A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025)

Camila Pantoja-Ruiz; Karashash Menlibayeva; Wasana Kalansooriya; Eva S Emmett; Evelyn Lim; David Wyatt; Yanzhong Wang; Amal R Khanolkar; Ajay Bhalla; C D A Wolfe; Matthew D L O'Connell; Iain J Marshall

doi:10.1159/000552798

A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025)

Camila Pantoja-Ruiz
, Karashash Menlibayeva
, Wasana Kalansooriya
, Eva S Emmett
, Evelyn Lim
, David Wyatt
, Yanzhong Wang
, Amal R Khanolkar
, Ajay Bhalla
, C D A Wolfe
, Matthew D L O'Connell
, Iain J Marshall

Research output: Contribution to journal › Article › peer-review

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Abstract

BACKGROUND: Ethnic minority groups experience higher stroke risk than majority groups. While overall stroke incidence has declined, it is unclear whether recent prevention strategies have narrowed ethnic inequalities. We systematically reviewed last decade trends on ethnic inequalities in stroke incidence.

METHODS: We systematically reviewed observational studies (2015-2025) reporting first-ever stroke incidence by ethnicity in adults globally. We searched MEDLINE, Embase, and Scopus; assessed bias using ROBINS-E; reported narratively using PRISMA-2020 and conducted random-effects meta-analysis for Black versus White populations in North America.

RESULTS: Twenty-six publications from 22 studies across high-income countries were included. Five studies had low risk of bias; six had some concerns, twelve were high or very high risk of bias. Black populations in the US experienced higher stroke incidence versus White populations (pooled incidence rate ratio=1.62; 95% CI 1.18-2.22), with persistent and, in some repeated-wave registries, widening inequalities in the US and UK. Aboriginal and Torres Strait Islander peoples in Australia and Māori in New Zealand showed two- to threefold excess incidence with widening gaps observed across successive survey waves. Asian and Middle Eastern populations and Hispanic/Latino populations showed heterogeneous patterns. Adjustment for socioeconomic status and cardiovascular risk factors only partially reduced inequalities.

CONCLUSIONS: Ethnic inequalities in stroke incidence persist and and show widening in some long-running registry populations, particularly among Black, Aboriginal and Torres Strait Islander, and Māori populations. Cardiovascular risk factors only partly explain these inequalities, indicating that additional unmeasured drivers are also at play. While improved detection and treatment of hypertension and diabetes remains necessary, it is insufficient on its own; reducing inequalities will also require investigation of these upstream determinants and population-based prevention strategies that address structural barriers to equitable care. Evidence from low- and middle-income countries is urgently needed.

Original language	English
Number of pages	27
Journal	Neuroepidemiology
Early online date	2 Jun 2026
DOIs	https://doi.org/10.1159/000552798
Publication status	E-pub ahead of print - 2 Jun 2026

Bibliographical note

Copyright © 2026 The Author(s). Published by S. Karger AG, Basel. This article is licensed under the Creative Commons Attribution 4.0 International License (CC BY) (https://karger.com/Services/OpenAccessLicense). Usage, derivative works and distribution are permitted provided that proper credit is given to the author and the original publisher.

Data Access Statement

All data analysed in this study are derived from previously published studies, which are cited within the article and its supplementary materials. No new individual-level data were collected. The datasets generated during the current study (including extracted data and risk-of-bias assessments) are available from the corresponding author on request.

Funding

This project is funded by the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research (NIHR202339) and is supported by the NIHR Applied Research Collaboration (ARC) South London at King’s College Hospital NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

ethnicity
race
health inequalities
stroke
incidence

Access to Document

10.1159/000552798Licence: CC BY 4.0

A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025)
Copyright © 2026 The Author(s). Published by S. Karger AG, Basel. This article is licensed under the Creative Commons Attribution 4.0 International License (CC BY) (https://karger.com/Services/OpenAccessLicense). Usage, derivative works and distribution are permitted provided that proper credit is given to the author and the original publisher.
Accepted author manuscript, 4.71 MBLicence: CC BY 4.0

Cite this

Pantoja-Ruiz, C., Menlibayeva, K., Kalansooriya, W., Emmett, E. S., Lim, E., Wyatt, D., Wang, Y., Khanolkar, A. R., Bhalla, A., Wolfe, C. D. A., O'Connell, M. D. L., & Marshall, I. J. (2026). A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025). Neuroepidemiology. Advance online publication. https://doi.org/10.1159/000552798

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abstract = "BACKGROUND: Ethnic minority groups experience higher stroke risk than majority groups. While overall stroke incidence has declined, it is unclear whether recent prevention strategies have narrowed ethnic inequalities. We systematically reviewed last decade trends on ethnic inequalities in stroke incidence.METHODS: We systematically reviewed observational studies (2015-2025) reporting first-ever stroke incidence by ethnicity in adults globally. We searched MEDLINE, Embase, and Scopus; assessed bias using ROBINS-E; reported narratively using PRISMA-2020 and conducted random-effects meta-analysis for Black versus White populations in North America.RESULTS: Twenty-six publications from 22 studies across high-income countries were included. Five studies had low risk of bias; six had some concerns, twelve were high or very high risk of bias. Black populations in the US experienced higher stroke incidence versus White populations (pooled incidence rate ratio=1.62; 95\% CI 1.18-2.22), with persistent and, in some repeated-wave registries, widening inequalities in the US and UK. Aboriginal and Torres Strait Islander peoples in Australia and Māori in New Zealand showed two- to threefold excess incidence with widening gaps observed across successive survey waves. Asian and Middle Eastern populations and Hispanic/Latino populations showed heterogeneous patterns. Adjustment for socioeconomic status and cardiovascular risk factors only partially reduced inequalities.CONCLUSIONS: Ethnic inequalities in stroke incidence persist and and show widening in some long-running registry populations, particularly among Black, Aboriginal and Torres Strait Islander, and Māori populations. Cardiovascular risk factors only partly explain these inequalities, indicating that additional unmeasured drivers are also at play. While improved detection and treatment of hypertension and diabetes remains necessary, it is insufficient on its own; reducing inequalities will also require investigation of these upstream determinants and population-based prevention strategies that address structural barriers to equitable care. Evidence from low- and middle-income countries is urgently needed.",

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AU - Pantoja-Ruiz, Camila

AU - Menlibayeva, Karashash

AU - Kalansooriya, Wasana

AU - Emmett, Eva S

AU - Lim, Evelyn

AU - Wyatt, David

AU - Wang, Yanzhong

AU - Khanolkar, Amal R

AU - Bhalla, Ajay

AU - Wolfe, C D A

AU - O'Connell, Matthew D L

AU - Marshall, Iain J

N1 - Copyright © 2026 The Author(s). Published by S. Karger AG, Basel. This article is licensed under the Creative Commons Attribution 4.0 International License (CC BY) (https://karger.com/Services/OpenAccessLicense). Usage, derivative works and distribution are permitted provided that proper credit is given to the author and the original publisher.

PY - 2026/6/2

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N2 - BACKGROUND: Ethnic minority groups experience higher stroke risk than majority groups. While overall stroke incidence has declined, it is unclear whether recent prevention strategies have narrowed ethnic inequalities. We systematically reviewed last decade trends on ethnic inequalities in stroke incidence.METHODS: We systematically reviewed observational studies (2015-2025) reporting first-ever stroke incidence by ethnicity in adults globally. We searched MEDLINE, Embase, and Scopus; assessed bias using ROBINS-E; reported narratively using PRISMA-2020 and conducted random-effects meta-analysis for Black versus White populations in North America.RESULTS: Twenty-six publications from 22 studies across high-income countries were included. Five studies had low risk of bias; six had some concerns, twelve were high or very high risk of bias. Black populations in the US experienced higher stroke incidence versus White populations (pooled incidence rate ratio=1.62; 95% CI 1.18-2.22), with persistent and, in some repeated-wave registries, widening inequalities in the US and UK. Aboriginal and Torres Strait Islander peoples in Australia and Māori in New Zealand showed two- to threefold excess incidence with widening gaps observed across successive survey waves. Asian and Middle Eastern populations and Hispanic/Latino populations showed heterogeneous patterns. Adjustment for socioeconomic status and cardiovascular risk factors only partially reduced inequalities.CONCLUSIONS: Ethnic inequalities in stroke incidence persist and and show widening in some long-running registry populations, particularly among Black, Aboriginal and Torres Strait Islander, and Māori populations. Cardiovascular risk factors only partly explain these inequalities, indicating that additional unmeasured drivers are also at play. While improved detection and treatment of hypertension and diabetes remains necessary, it is insufficient on its own; reducing inequalities will also require investigation of these upstream determinants and population-based prevention strategies that address structural barriers to equitable care. Evidence from low- and middle-income countries is urgently needed.

AB - BACKGROUND: Ethnic minority groups experience higher stroke risk than majority groups. While overall stroke incidence has declined, it is unclear whether recent prevention strategies have narrowed ethnic inequalities. We systematically reviewed last decade trends on ethnic inequalities in stroke incidence.METHODS: We systematically reviewed observational studies (2015-2025) reporting first-ever stroke incidence by ethnicity in adults globally. We searched MEDLINE, Embase, and Scopus; assessed bias using ROBINS-E; reported narratively using PRISMA-2020 and conducted random-effects meta-analysis for Black versus White populations in North America.RESULTS: Twenty-six publications from 22 studies across high-income countries were included. Five studies had low risk of bias; six had some concerns, twelve were high or very high risk of bias. Black populations in the US experienced higher stroke incidence versus White populations (pooled incidence rate ratio=1.62; 95% CI 1.18-2.22), with persistent and, in some repeated-wave registries, widening inequalities in the US and UK. Aboriginal and Torres Strait Islander peoples in Australia and Māori in New Zealand showed two- to threefold excess incidence with widening gaps observed across successive survey waves. Asian and Middle Eastern populations and Hispanic/Latino populations showed heterogeneous patterns. Adjustment for socioeconomic status and cardiovascular risk factors only partially reduced inequalities.CONCLUSIONS: Ethnic inequalities in stroke incidence persist and and show widening in some long-running registry populations, particularly among Black, Aboriginal and Torres Strait Islander, and Māori populations. Cardiovascular risk factors only partly explain these inequalities, indicating that additional unmeasured drivers are also at play. While improved detection and treatment of hypertension and diabetes remains necessary, it is insufficient on its own; reducing inequalities will also require investigation of these upstream determinants and population-based prevention strategies that address structural barriers to equitable care. Evidence from low- and middle-income countries is urgently needed.

KW - ethnicity

KW - race

KW - health inequalities

KW - stroke

KW - incidence

UR - https://karger.com/ned/article/doi/10.1159/000552798/950125/A-Systematic-Review-and-Meta-analysis-of-Ethnic

U2 - 10.1159/000552798

DO - 10.1159/000552798

M3 - Article

C2 - 42228643

SN - 0251-5350

JO - Neuroepidemiology

JF - Neuroepidemiology

ER -

A Systematic Review and Meta-analysis of Ethnic Inequalities in Stroke Incidence Patterns and Trends in High-Income Countries (2015-2025)

Abstract

Bibliographical note

Data Access Statement

Funding

UN SDGs

Keywords

Access to Document

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