In this issue of the Journal of the American Heart Association (JAHA), Mannoh et al examined disparities in awareness of myocardial infarction (MI) and stroke symptoms among US‐ and foreign‐born adults. Their most important finding, that there are differences in awareness of MI and stroke symptoms by region of birth,¹ confirms and expands upon prior research² in several ways.

The authors used data from the National Health Interview Survey (NHIS) from 2014 and 2017 to evaluate self‐reported knowledge and awareness of MI and stroke by region of birth. Region of birth was categorized as Mexico/Central America/Caribbean, South America, Europe, Russia, Africa, the Middle East, the Indian subcontinent, Asia, Southeast Asia, and the United States. The authors also controlled for a range of potential confounders, including age, health insurance status, and access to a regular source of medical care. In addition, they considered the participants’ educational and socioeconomic status, as well as their atherosclerotic cardiovascular disease (ASCVD) risk factors and sex. This study provides several important insights, raises new questions, and hints at potential interventions that could aid in increasing knowledge and awareness of MI and stroke in certain foreign‐born populations.

The study’s primary finding is a disparity (ie, otherwise unexplained difference) in MI and stroke knowledge and awareness for US‐born and foreign‐born individuals. These differences were observed in both unadjusted and adjusted analyses in sociodemographic, educational attainment, and cardiovascular risk factors.

More specifically, awareness of both MI and stroke symptoms were highest among individuals born in the United States, slightly lower for individuals born in Europe and Russia, and lowest in individuals born in Asia for MI and in individuals born in the Indian subcontinent for stroke. What might explain these differences in awareness? The differences might reflect underlying differences in the prevalence of MI and stroke in each racial and ethnic group and geographic region. For example, a study by Hastings et al³ found that the leading cause of death for Asian Americans from 2003 to 2011 was cancer (accounting for 28.6% of total causes of death) with heart disease being second (accounting for 23.5% of the cause of death). Alternatively, the leading cause of death in both Russia and Europe is cardiovascular disease as referenced by the European cardiovascular disease statistics.⁴ Moreover, Manosh and colleagues found that ASCVD risk factors were more common among European‐ and Russian‐born residents of the United States than Asian‐born residents. Thus, it would be logical for Asian‐born residents in the United States to have lower awareness of MI and stroke symptoms than European‐ and Russian‐born individuals and this is what the authors found.

Alternatively, if we focus on the knowledge and awareness of Russian‐ and European‐born individuals relative to US‐born individuals, a different pattern emerges. Despite a high prevalence of cardiovascular disease in both Russia and Europe and a high prevalence of ASCVD risk factors in the interviewed sample from these countries, knowledge and awareness of MI and stroke were far lower for Russian‐ and European‐born respondents when compared to those born in the United States. The increased knowledge of US‐born individuals may partially be explained by the extensive advocacy and awareness efforts around MI and stroke in the United States over many years. The Centers for Disease Control and Prevention (CDC) and American Heart Association (AHA) have mounted significant media campaigns to increase knowledge and awareness of MI and stroke symptoms that may not have existed in Europe and Russia. This is also evident by the increase in knowledge and awareness of MI and stroke symptoms among US‐born individuals from 2014 to 2017 as demonstrated in this study by Mannoh et al.

It is also interesting to contemplate whether the differences that the authors observed in MI and stroke awareness by country of birth are necessarily disparities (unfair or unexplained differences) or whether they might simply be expected findings given risk‐factor profiles of the individuals within each region. European immigrants in the study had the highest hypertension prevalence and Russian immigrants had the highest current smoking and drinking prevalence, whereas Asian immigrants had the lowest coronary heart disease prevalence among all foreign‐born individuals; thus we might expect higher MI and stroke awareness in European and Russian immigrants and lower awareness in Asian immigrants, which is what the authors found. The higher prevalence of cardiovascular risk factors among those populations further demonstrates the idea that the observed differences in different regions are because of the different risk‐factor profiles as well as the mortality of that disease within the region. The study highlights the differences observed based on risk‐factor profile, further in the discussion section, specifically when looking at the highest prevalence of MI history in foreign‐born individuals. This was found in Russian immigrants who also had the highest knowledge prevalence of MI, therefore, suggesting that ASCVD risk factors and prevalence of a certain disease might affect a certain region’s knowledge and awareness of a disease.

It is also interesting to note that women from all regions (US‐born individuals and foreign‐born individuals) had higher recommended knowledge and awareness of MI and stroke than men. This finding is surprising as the incidence of both MI and stroke are higher in men than in women.⁵ The differences in knowledge and awareness between men and women despite the higher incidence of cardiovascular disease in men could be partially explained by long recognized differences in how men and women view and access health care. According to the paper published by Mansfield in 2003 on “Why he won’t go to the doctor”,⁶ men are less likely to seek help for their medical problems and learn about information related to their health, owing to what they believe are underlying social constraints on gender roles and their view of masculinity. In addition, the differences in the awareness level of men and women could also be explained by the increased focus on MI prevalence and awareness in women owing to previous incidences of misdiagnosis and mismanagement of MI in women.⁷

It is also important to comment on the potential implications of the National Health Interview Survey and its associated methodology. The National Health Interview Survey is administered through a face‐to‐face interview and is offered in both English and Spanish. Typically, 1 adult and 1 child are selected from each household, as the representative of that particular unit, and participate in a face‐to‐face interview. English proficiency is assessed by asking participants to read a question that states “How well do you speak English?” and respond by reading an answer from the categories listed (very well, well, not well, etc) before conducting the survey. This method of establishing the interviewee’s English proficiency is imperfect, as an individual’s ability to read a language does not necessarily correlate with their comprehension level. Many of the populations included in the current study do not speak English or Spanish as a first language and the survey is administered only in English and Spanish. Thus, it is difficult to interpret whether differences in MI and stroke awareness are truly due to differences in knowledge or to a lack of comprehension of the questions themselves. This argument, however, is not true for all populations included in this study, because the percentage of MI and stroke knowledge and awareness was still lower in the Mexican‐born participants even though the test was offered in Spanish as well. However, it is still an argument that warrants further investigation.

Moving forward, further research is needed to examine the interplay between region of birth, language, disease prevalence, knowledge, and access. Further research should also consider conducting surveys that are administered in multiple languages to minimize the role of English proficiency and comprehension in evaluating MI and stroke knowledge and awareness. It would also be extremely useful to study whether between‐region differences in MI and stroke knowledge continue to decrease over time; a related question is how time residing in the United States may affect the differences in knowledge observed for region of birth.

In conclusion, Mannoh and colleagues highlight important differences in awareness of MI and stroke symptoms both across racial and ethnic groups born in the United States and by region of birth for immigrants to the United States. The study raises many important questions about why such differences exist and the potential impact of the differences on health outcomes. The study highlights that prevalence of MI and stroke in the region of origin and individual ASCVD risk factors do not always correlate with knowledge and awareness. Further research is needed to understand the reasons for the differences that were observed, including the role of English comprehension. In the meantime, it would be beneficial for the government, private entities, and community organizations to consider outreach and educational efforts targeting immigrants to improve awareness of MI and stroke symptoms.

This work is supported in part by US National Institute on Aging to Dr Cram (R01AG058878).

Dr Cram received salary support as a 2020–2021 Health and Aging Policy Fellow at Columbia University. Dr Aboueisha has no disclosures to report.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

For Sources of Funding and Disclosures, see page 3.

See Article by Mannoh et al.

在本期美国心脏协会杂志 (JAHA)中，Mannoh 等人研究了美国和外国出生的成年人对心肌梗塞 (MI) 和中风症状的认识差异。他们最重要的发现是，出生地区对 MI 和中风症状的认识存在差异¹以多种方式证实并扩展了先前的研究²。

作者使用了 2014 年和 2017 年全国健康访谈调查 (NHIS) 的数据来评估出生地区自我报告的 MI 和中风知识和意识。出生地区分为墨西哥/中美洲/加勒比、南美洲、欧洲、俄罗斯、非洲、中东、印度次大陆、亚洲、东南亚和美国。作者还控制了一系列潜在的混杂因素，包括年龄、健康保险状况和获得常规医疗服务的机会。此外，他们还考虑了参与者的教育和社会经济地位，以及他们的动脉粥样硬化性心血管疾病 (ASCVD) 风险因素和性别。这项研究提供了几个重要的见解，提出了新的问题，

该研究的主要发现是美国出生和外国出生的个人在 MI 和中风知识和意识方面存在差异（即无法解释的差异）。在社会人口学、教育程度和心血管危险因素的未调整和调整分析中都观察到了这些差异。

更具体地说，在美国出生的人对 MI 和中风症状的认识最高，在欧洲和俄罗斯出生的人略低，在亚洲出生的人对 MI 和出生在印度次大陆的中风的人的认识最低。什么可以解释这些意识上的差异？这些差异可能反映了每个种族和民族以及地理区域中 MI 和中风患病率的潜在差异。例如，Hastings 等人的一项研究³发现 2003 年至 2011 年亚裔美国人的主要死因是癌症（占总死因的 28.6%），其次是心脏病（占死因的 23.5%）。或者，俄罗斯和欧洲的主要死因是欧洲心血管疾病统计数据所引用的心血管疾病。⁴此外，Manosh 及其同事发现，在欧洲和俄罗斯出生的美国居民中，ASCVD 风险因素比在亚洲出生的居民中更为常见。因此，与欧洲和俄罗斯出生的人相比，在美国出生的亚洲居民对心肌梗死和中风症状的认识较低是合乎逻辑的，这就是作者的发现。

或者，如果我们关注俄罗斯和欧洲出生的个体相对于美国出生的个体的知识和意识，就会出现不同的模式。尽管俄罗斯和欧洲的心血管疾病患病率很高，并且这些国家的受访样本中 ASCVD 危险因素的患病率也很高，但与俄罗斯和欧洲出生的受访者相比，俄罗斯和欧洲出生的受访者对 MI 和中风的了解和认识要低得多。出生在美国。美国出生个体的知识增加可能部分归因于多年来在美国对 MI 和中风的广泛宣传和宣传工作。疾病控制与预防中心 (CDC) 和美国心脏协会 (AHA) 开展了重要的媒体宣传活动，以提高对欧洲和俄罗斯可能不存在的 MI 和中风症状的认识和认识。Mannoh 等人的这项研究表明，2014 年至 2017 年美国出生的人对 MI 和中风症状的认识和认识的增加也证明了这一点。

思考作者观察到的 MI 和出生国卒中意识的差异是否必然是差异（不公平或无法解释的差异），或者考虑到每个区域内个体的风险因素概况，它们是否可能只是预期的结果也很有趣. 研究中欧洲移民的高血压患病率最高，俄罗斯移民的当前吸烟和饮酒患病率最高，而亚洲移民的冠心病患病率最低；因此，我们可能预期欧洲和俄罗斯移民对 MI 和中风的认识较高，而亚洲移民的认识较低，这正是作者的发现。这些人群中心血管危险因素的较高流行进一步表明，不同地区观察到的差异是由于该地区不同的危险因素概况以及该疾病的死亡率。该研究强调了基于风险因素概况观察到的差异，在讨论部分中进一步讨论，特别是在研究外国出生个体中 MI 病史的最高患病率时。这在同样具有最高 MI 知识患病率的俄罗斯移民中发现，因此表明 ASCVD 危险因素和某种疾病的患病率可能会影响某个地区的疾病知识和意识。

值得注意的是，来自所有地区的女性（美国出生的个人和外国出生的个人）对 MI 和中风的推荐知识和意识都高于男性。这一发现令人惊讶，因为男性心肌梗死和中风的发病率均高于女性。⁵尽管男性心血管疾病的发病率较高，但男性和女性在知识和意识方面的差异可以部分解释为长期以来公认的男性和女性在看待和获得医疗保健方面的差异。根据曼斯菲尔德 2003 年发表的关于“他为什么不去看医生”的论文，⁶男性不太可能因医疗问题寻求帮助，也不太可能了解与健康有关的信息，因为他们认为社会对性别角色和他们对男子气概的看法存在潜在的限制。此外，男性和女性意识水平的差异也可以解释为，由于以前发生过女性 MI 误诊和管理不善的事件，人们越来越关注女性的 MI 患病率和意识。⁷

评论国家健康访谈调查及其相关方法的潜在影响也很重要。全国健康访谈调查通过面对面访谈进行，以英语和西班牙语提供。通常，从每个家庭中选择 1 名成人和 1 名儿童，作为该特定单元的代表，并参加面对面的访谈。英语水平是通过要求参与者阅读一个问题来评估的，上面写着“你的英语说得怎么样？” 在进行调查之前，通过阅读列出的类别中的答案（非常好、好、不好等）做出回应。这种确定受访者英语水平的方法是不完善的，因为个人阅读语言的能力不一定与他们的理解水平相关。当前研究中包括的许多人群的第一语言不是英语或西班牙语，调查仅以英语和西班牙语进行。因此，很难解释 MI 和卒中意识的差异究竟是由于知识差异还是由于对问题本身缺乏理解。然而，这一论点并不适用于本研究中的所有人群，因为即使测试也以西班牙语提供，墨西哥出生的参与者的 MI 和中风知识和意识的百分比仍然较低。然而，这仍然是一个值得进一步调查的论点。很难解释 MI 和卒中意识的差异究竟是由于知识差异还是由于对问题本身缺乏理解。然而，这一论点并不适用于本研究中的所有人群，因为即使测试也以西班牙语提供，墨西哥出生的参与者的 MI 和中风知识和意识的百分比仍然较低。然而，这仍然是一个值得进一步调查的论点。很难解释 MI 和卒中意识的差异究竟是由于知识差异还是由于对问题本身缺乏理解。然而，这一论点并不适用于本研究中的所有人群，因为即使测试也以西班牙语提供，墨西哥出生的参与者的 MI 和中风知识和意识的百分比仍然较低。然而，这仍然是一个值得进一步调查的论点。因为即使测试也以西班牙语提供，墨西哥出生的参与者的 MI 和中风知识和意识的百分比仍然较低。然而，这仍然是一个值得进一步调查的论点。因为即使测试也以西班牙语提供，墨西哥出生的参与者的 MI 和中风知识和意识的百分比仍然较低。然而，这仍然是一个值得进一步调查的论点。

展望未来，需要进一步研究来检验出生地区、语言、疾病流行、知识和获取途径之间的相互作用。进一步的研究还应考虑进行以多种语言进行的调查，以尽量减少英语水平和理解在评估 MI 和中风知识和意识中的作用。研究 MI 和卒中知识的区域间差异是否会随着时间的推移而继续减少也非常有用；一个相关的问题是，在美国居住的时间如何影响出生地区所观察到的知识差异。

总之，Mannoh 及其同事强调了美国出生的种族和族裔群体以及移民到美国的出生地区在对 MI 和中风症状的认识方面的重要差异。该研究提出了许多重要问题，即为什么存在这种差异以及这些差异对健康结果的潜在影响。该研究强调，起源地区 MI 和中风的患病率以及个体 ASCVD 风险因素并不总是与知识和意识相关。需要进一步研究以了解所观察到的差异的原因，包括英语理解的作用。同时，这对政府、私人实体、

这项工作得到了美国国家老龄化研究所对 Cram 博士 (R01AG058878) 的部分支持。

Cram 博士在哥伦比亚大学担任 2020-2021 年健康与老龄化政策研究员时获得了薪水支持。Aboueisha 博士没有披露要报告的信息。

本文所表达的观点不一定是编辑或美国心脏协会的观点。

有关资金来源和披露信息，请参见第 3 页。

见 Mannoh 等人的文章。