Education Strategies for Stroke Prevention
2013; Lippincott Williams & Wilkins; Volume: 44; Issue: 6_suppl_1 Linguagem: Inglês
10.1161/strokeaha.111.000396
ISSN1524-4628
AutoresBernadette Boden‐Albala, Leigh W. Quarles,
Tópico(s)Dementia and Cognitive Impairment Research
ResumoHomeStrokeVol. 44, No. 6_suppl_1Education Strategies for Stroke Prevention Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBEducation Strategies for Stroke Prevention Bernadette Boden-Albala, MPH, DrPH and Leigh W. Quarles, MPH Bernadette Boden-AlbalaBernadette Boden-Albala From the Division of Social Epidemiology, Departments of Health Evidence and Policy (B.B.-A., L.W.Q.) and Neurology (B.B.-A.), Mount Sinai School of Medicine, New York, NY. and Leigh W. QuarlesLeigh W. Quarles From the Division of Social Epidemiology, Departments of Health Evidence and Policy (B.B.-A., L.W.Q.) and Neurology (B.B.-A.), Mount Sinai School of Medicine, New York, NY. Originally published1 Jun 2013https://doi.org/10.1161/STROKEAHA.111.000396Stroke. 2013;44:S48–S51Stroke is a major public health burden in the United States, with indications that stroke is emerging as a global epidemic. Furthermore, there exists an appreciation that focus on clinical treatment alone will not significantly reduce the burden of stroke, including morbidity and mortality. Emphasis needs to shift to acknowledging the importance of behavioral change science. The focus of this monograph is to provide insight into considerations for the development of theory-based interventions for reduction of stroke through behavioral change.The Science of Behavioral Change is a complex endeavor, and addressing the lifestyle changes during the life course needed to reduce the burden of stroke remains a significant challenge. Areas of exploration include an understanding of the acquisition of vascular risk behaviors; identifying and testing mechanisms for changing existing behaviors; identifying strategies that optimally support the maintenance of health behaviors; and choosing the appropriate level for behavioral change (ie, individual change versus population level or structural change). Part of understanding behaviors includes making predictions about why people behave the way they do. Behavioral theory used in the design of interventions allows us to assess an individual's readiness to take action toward healthier behaviors. An accompanying theoretical platform, such as the transtheoretical model, provides the framework for the type of strategy or process needed to guide individual or system interventions through the stages of change, including action and maintenance.An important epidemiological feature of cerebrovascular disease concerns the sharp gradients in morbidity and mortality by race-ethnicity. Indeed, some of the earliest educational materials for stroke prevention have been suboptimal because of the generic nature of information without reference to place or culture. For example, trust is a concern among many African American and Hispanic communities and low-income populations. Effective interventions in minority communities have established trust by building relationships with community members and organizations. Successful community engagement strategies include engaging in conversation with the community to inform about the issues; designing curriculums to focus a dialogue; establishing collaborative leadership models; and sharing use of resources.1Other important components of any intervention design include a focus on health-literate materials and cultural tailoring. Examples of health-literate and cultural tailored educational materials include American Heart/American Stroke Association Power to End Stroke Program and the Massachusetts Department of Health Video.2For decades, a sense of nihilism permeated stroke research stemming from a clinical frustration about the lack of realistic stroke treatments, poor recovery prognosis, and the inability to change risk behaviors. However, literature exists to suggest individual level behavioral change is possible and that different modalities for change (ie, in-person, Web-based remote delivery) are successful. Even the most intractable behaviors, such as weight loss, have been successfully addressed with individual interventions. Appel et al3 demonstrated a significant decrease of ≥5% initial weight loss in 41% of participants randomized to in-person support group, 38% randomized to Web-based support, and 14% in control group ≥24 months.For cerebrovascular disease, further consideration is needed about specific types of behaviors and what types of strategies optimally achieve change. We suggest that interventions need to focus on 2 key areas of behavior modification: stroke preparedness and stroke prevention. With the emergence of tissue-type plasminogen activator in 1996, there has been an emphasis on reducing stroke morbidity and mortality through increased action during acute stroke.4 Being prepared to take action requires individuals to be able to recall and recognize stroke warning signs, learn how to call 911, facilitate a dialogue about stroke, and navigate the emergency department so appropriate stroke codes are activated. Preparedness behavior may be best characterized by achieving competency skills that require short-term interventions with reinforcement.4Several interventions have actively addressed preparedness with mixed success in different populations (Table). One study reported that widespread acute stroke education was associated with a 10% decrease in the proportion of stroke patients presenting within 3 hours of symptom onset.5 Morgenstern group demonstrated that an aggressive, multilevel stroke educational intervention program can be effective in promoting behavioral change.6 They reported an increase in intravenous tissue-type plasminogen activator treatment from 1.38% to 5.75% among all cerebrovascular event patients in the intervention community (P=0.01) compared with a change from 0.49% to 0.55% in the comparison community (P=1.00).6Table. Summary of Major Primary, Secondary Prevention, and Preparedness Stroke InterventionsStudyIntervention StrategiesOutcome MeasuresStroke preparedness Temple Foundation Stroke Project6Community level social marketing campaign lCommunity level acute stroke parameters KIDS8Community engagedCulturally tailored moduleDissemination to parentsPrepost 3-dimensional knowledge preparedness, stroke physiology, and risk factors school children and parents HIP HOP Stroke9–11School basedCulturally tailored,Hip Hop SongCartoonsDissemination to parentsPrepost (3 mo) knowledge in preparedness and risk factors school children and parents Beauty shop12Community engagedTrain the trainerFocus on African American womenKnowledge of stroke warning signs, preparedness and risk factors SWIFT13,14,22RCTStroke and TIA patientsCulturally tailoredHospital basedMultimediaInteractive group sessionsMotivational interviewingPatient narrativesBraceletsMeasurement of individual acute stroke parameters in recurrent events SWIFT communityStroke-free community basedRandomized community organizationsFree risk factor screeningMultimediaInteractive group sessionsMotivational interviewingPatient narrativesPrepost (1 y) knowledge in preparedness, and risk factors in multiethnic adults ASPIRE15City-wideTrain the trainerCommunity engagedGroup sessions/health fairsUse of bracelets, magnetsAcute stroke messages on busesComparison of city-wide prepost intervention acute stroke parametersPrimary stroke prevention SHARE16Community engagedCulturally tailoredChurch-based, video, motivational interview, Partner supportReduction in vascular risk factors, including BPChange in lifestyle behaviorsSecondary stroke prevention PROTECT17Structural integration of care with systematic evidence based, disease management programNurse focusedHospital discharge treatment and adherence rates ICARUSS18RCT systems modelShared care-specialist and general practitionerNurse coordinatorEducation and clinical communicationReduction in vascular risk factors, including BPChange in lifestyle behaviors including physical activity SUSTAIN19Structural interventionChronic care model with care managerPoststroke dischargeGroups sessions, self -instructionMeasurement of BP at 6 mo after dischargeLifestyle and adherence measuresCost Analysis PROTECT DC20RCT Community health worker hospital-based initiation of secondary prevention strategiesReduction in vascular risk factors including BP at 1 yMortality DESERVERCTMild stroke and TIA patientsDischarge strategyCulturally tailored and bilingual staffCommunity health workersChronic care modelPatient-based educational videosSkill-based focusReduction in vascular risk factors including BP at 1 yChange in lifestyle behaviors, including physical activityLifestyle and adherence measuresDifference in recurrent stroke eventsCost analysis PRAISE21RCTSelf-identified strokeCommunity-based peer education workshops vs. usual careCulturally tailored and bilingual staffFlexible participant schedulingReduction in vascular risk factors, including BP at 1 y FURRThERRCTCulturally tailoredFamily-friend support networks, family-based counselingMeasurement of BP at 1 y in stroke patients and family networksBP indicates blood pressure; RCT, randomized controlled trial; and TIA, transient ischemic attack.Other programs have focused on the basis of theory, educational interventions to improve intent to call 911 for stroke among children.7–9 The Kids Identifying and Defeating Stroke (KIDS) was a pilot, randomized, controlled trial to encourage calling 911 for witnessed stroke among middle-school children and their parents.8 A comparison of knowledge change between intervention and control students was P<0.001 for each of the 3 individual domains of stroke pathophysiology, stroke symptom knowledge, and stroke preparedness. Unfortunately, dissemination of this knowledge was suboptimal because of poor parental response.8 Similarly, the Hip Hop Stroke intervention, with its timely music and catchy phrases, demonstrated improved stroke knowledge and behavioral capability to activate emergency services at 3-month follow-up.9 A larger randomized trial of Hip Hop is ongoing in New York City.10,11 The community placed health-literate beauty shop intervention in African American women improved knowledge of stroke warning signs and calling 911, and this knowledge was sustained for ≥5 months.12 Although these studies have focused on increased knowledge and behavioral intent (ie, will call 911), data from the Stroke Warning and Information and Faster Treatment Study (SWIFT) specifically measured preparedness outcomes in a randomized group of 1200 stroke and transient ischemic attack (TIA) patients.13 SWIFT found that ≥45% of stroke/TIA patients randomized to health-literate educational materials; and 46% of stroke/TIA patients randomized to intensive inpatient intervention returned to the emergency department within 4.5 hours of recurrent stroke onset. This is compared with 18% at baseline and 20% in an urban control group.14 The data also suggested that after-stroke reinforcement may be as effective as hospital interventions.14 The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) study is a multidimensional program aimed at community, hospital, and emergency medical services for acute stroke preparedness targeted to increased intravenous tissue-type plasminogen activator usage in underserved black communities in the DC metro area.15 A pilot feasibility study of 1 DC ward reported preintervention mean and median time to arrival of 1600 minutes (27.0 hours) and 890 minutes (14.8 hours), respectively. After the intervention, mean and median time to arrival was 1423 minutes (23.7 hours) and 815 minutes (13.6 hours), respectively. In addition to this modest decrease in overall arrival times, an increased proportion of cases arriving in the 4.5-hour group was noted (pre 25% versus post 28%; P=NS).15Behavioral strategies focused on both primary and secondary preventions may be more complex. Indeed, prevention requires a different set of skills and actions taken during the life course. Primary prevention programs focused on prevention of hypertension, diabetes mellitus, and increased healthy behaviors are relevant for reduction of all cardiovascular risk and will not be addressed here. The Stroke Health and Risk Education study is an educational intervention study aimed at primary stroke prevention for Mexican Americans and non-Hispanic whites using a community-based participatory research approach.16 Vascular risk reduction is a critical target in the prevention of secondary stroke, as demonstrated in the evidence-based guidelines. Strategies include modification of lifestyle behaviors and medication adherence targets. Motivation and reinforcement may be 2 key components for successful and sustainable lifelong interventions. With regard to intervention design, 2 distinctly different approaches to secondary prevention of stroke have emerged: (1) community engaged, and (2) structural. Behavioral economics suggest that we can compel action through structure. A focus on structural interventions include the integration of behavioral strategies, such as medication adherence into existing structures or systems allowing for process evaluations and use of quality indicators to test success of implementation.As a structural intervention, the Preventing Recurrence of Thromboembolic Events through Coordinated Treatment (PROTECT) study included integration of a quality initiative program, which mandated documentation of discharge medications among stroke/TIA patients.17 This discharge intervention demonstrated success in increasing adherence to stroke discharge medications during the first year after stroke and reported 90-day adherence rates of 100% antithrombotics, 99% statins, 92% angiotensin-converting enzyme, 99% statins, 80% thiazides.17 The primary aim of the Integrated Care for the Reduction of Secondary Stroke (ICCARUS) study was to promote the management of vascular risk factors through ongoing patient contact and education via the integrated care reduction of secondary stroke model, involving collaboration between a specialist stroke service, a hospital coordinator, and a patient's general practitioner.18 At 12 months after stroke, systolic blood pressure decreased in the integrated care group and increased in controls (P=0.04).18 The Families Understanding Risk Reduction through Educational Reinforcement (FURRThER) pilot study uses family and friend networks as a structural platform for vascular risk reduction. The ongoing Systematic Use of Stroke Averting Interventions (SUSTAIN) program seeks to improve the delivery of secondary stroke preventive services after hospital discharge. This care intervention includes group clinics, self-management support, report cards, decision support through care guides and protocols, and coordination of ongoing care.19There is an ongoing concern that vascular risk reduction programs have not been widely implemented or successful in reducing risk factors outside of a trial setting because interventions have not included community infrastructure or addressed behavioral barriers to vascular risk factor reduction, including health literacy, patient physician communication, and risk perception. There are numerous ongoing studies that have integrated components of community engagement into secondary stroke prevention. PROTECT DC piloted the use of community health workers as vehicles for reducing disparities in risk control after stroke.20 Prevent Recurrence of All Inner-City Strokes Through Education (PRAISE) a community-based peer education workshop versus usual care among self-identified stroke survivors, demonstrated significant improvements in blood pressure control in intervention versus control groups.21 The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study of mild stroke and TIA patients, currently underway, incorporates a chronic care model of vascular risk management strategies with emphasis on integration of skills related to risk perception, medication adherence, and patient/physician communication.This is an exciting time for behavioral interventions in stroke. As indicated above, there are a substantial number of interventions currently underway. Each of these trials will add unique information and ultimately inform optimal strategies for both stroke prevention and stroke preparedness. Key issues surrounding intervention design that still need to be resolved include cost, optimal reinforcement strategies, and the appropriate use of usual care for testing behavioral interventions because even educational brochures systematically distributed can be considered an intervention. Furthermore, given the burden of disparities in stroke, it may be that although these interventions equalize the field, the disparities gradient continues to exist. Indeed, equalizing the playing field is a good first step but not enough, and continued work identifying mechanisms and designing strategies addressing disparities will be critical. Finally, dissemination and implementation of successful intervention strategies must be underwritten so that what is successful in a few communities can be disseminated to all.Sources of FundingThis work was supported by the following grants: NIH NINDS P50 NS049060 P3, NIH NIMHD 7U24MD006961, NIH NINDS RO1 NS072127, and NIH NINDS U54NS057405 P1.DisclosuresNone.FootnotesCorrespondence to Bernadette Boden-Albala, MPH, DrPH, Division of Social Epidemiology, Department of Health Evidence and Policy, Mount Sinai School of Medicine, 1 Gustave Levy Place, box 1077, New York, NY 10032. E-mail [email protected]References1. Horowitz CR, Robinson M, Seifer S. Community-based participatory research from the margin to the mainstream: are researchers prepared?Circulation. 2009; 119:2633–2642.LinkGoogle Scholar2. Wall HK, Beagan BM, O'Neill J, Foell KM, Boddie-Willis CL. 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Clark M and Gropen T (2014) Advances in the Stroke System of Care, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-014-0355-9, 17:1, Online publication date: 1-Jan-2015. Boden-Albala B, Edwards D, St. Clair S, Wing J, Fernandez S, Gibbons M, Hsia A, Morgenstern L and Kidwell C (2014) Methodology for a Community-Based Stroke Preparedness Intervention, Stroke, 45:7, (2047-2052), Online publication date: 1-Jul-2014. June 2013Vol 44, Issue 6_suppl_1 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.000396PMID: 23709728 Manuscript receivedDecember 7, 2012Manuscript acceptedFebruary 26, 2013Originally publishedJune 1, 2013 Keywordsstrokehealth educationbehavioral interventionTIAPDF download Advertisement SubjectsBehavioral/Psychosocial Treatment
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