The difficulty of studying race-ethnic stroke rehabilitation disparities in a community

OBJECTIVE

Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data.

METHODS

As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot.

RESULTS

Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers.

CONCLUSIONS

Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed.

Mexican Americans Receive Less Intensive Stroke Rehabilitation Than Non-Hispanic Whites

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have worse neurological, functional, and cognitive outcomes after stroke. Stroke rehabilitation is important for good outcome. In a population-based study, we sought to determine whether allocation of stroke rehabilitation services differed by ethnicity.

METHODS

Patients with stroke were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project, TX, USA. Cases were validated by physicians using source documentation. Patients were followed prospectively for 3 months after stroke to determine rehabilitation services and transitions. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t tests or Wilcoxon rank-sum tests by ethnicity. Categorical baseline variables were compared using χ² tests. Ethnic comparisons of rehabilitation services were compared using χ² tests, Fisher's exact tests, and logistic regression.

RESULTS

Seventy-two subjects (50 MA and 22 non-Hispanic white [NHW]) were followed. Mean age, NHW-69 (SD 13), MA-66 (SD 11) years, sex (NHW 55% male, MA 50% male) and median presenting National Institutes of Health Stroke Scale did not differ significantly. There were no ethnic differences among the proportion of patients who were sent home without any rehabilitation services (P=0.9). Among those who received rehabilitation, NHWs were more likely to get inpatient rehabilitation (73%) compared with MAs (30%), P=0.016. MAs (51%) were much more likely to receive home rehabilitation services compared with NHWs (0%) (P=0.0017).

CONCLUSIONS

In this population-based study, MAs were more likely to receive home-based rehabilitation, whereas NHWs were more likely to get inpatient rehabilitation. This disparity may, in part, explain the worse stroke outcome in MAs.

The Association between Changes in Behavioral Risk Factors for Stroke and Changes in Blood Pressure

BACKGROUND

High blood pressure (BP) is the leading risk factor for stroke. Data on the association of physical activity (PA), fruit and vegetable (F&V) consumption, and dietary sodium with hypertension are lacking in Hispanic communities. In the current report, we provide data on the association between changes in these stroke behavioral risk factors and BP change.

METHODS

Participants were recruited from participating Catholic churches in Nueces County, Texas. BP was measured, and self-reported validated scales of F&V consumption, dietary sodium, and PA were collected at baseline and at 12 months. Linear mixed models were used to examine the associations between tertiles of improvement in the 3 behavior outcomes and BP change, adjusted for demographic characteristics. The association between the binary measure of at least 5 mmHg diastolic blood pressure (DBP) or 10 mmHg systolic blood pressure (SBP) reduction and behavior change was estimated with multilevel logistic regression models.

RESULTS

Of 586 participants, 66% were female and 82% were Mexican American (MA), and the mean age was 54 years. High compared with low change in PA was significantly associated with DBP change (P = .022), and high compared with low change in F&V intake was significantly associated with SBP change (P = .032). For the binary changes in DBP or SBP, there was a borderline association of PA (P = .054); all other variables were not associated (P > .10).

CONCLUSIONS

PA and F&V consumption are potential stroke prevention targets in predominantly MA populations.

A Multicomponent Behavioral Intervention to Reduce Stroke Risk Factor Behaviors: The Stroke Health and Risk Education Cluster-Randomized Controlled Trial

BACKGROUND AND PURPOSE

The Stroke Health and Risk Education Project was a cluster-randomized, faith-based, culturally sensitive, theory-based multicomponent behavioral intervention trial to reduce key stroke risk factor behaviors in Hispanics/Latinos and European Americans.

METHODS

Ten Catholic churches were randomized to intervention or control group. The intervention group received a 1-year multicomponent intervention (with poor adherence) that included self-help materials, tailored newsletters, and motivational interviewing counseling calls. Multilevel modeling, accounting for clustering within subject pairs and parishes, was used to test treatment differences in the average change since baseline (ascertained at 6 and 12 months) in dietary sodium, fruit and vegetable intake, and physical activity, measured using standardized questionnaires. A priori, the trial was considered successful if any one of the 3 outcomes was significant at the 0.05/3 level.

RESULTS

Of 801 subjects who consented, 760 completed baseline data assessments, and of these, 86% completed at least one outcome assessment. The median age was 53 years; 84% subjects were Hispanic/Latino; and 64% subjects were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 cups per day [95% confidence interval: 0.08, 0.42], P=0.002), a greater decrease in sodium intake (-123.17 mg/d [-194.76, -51.59], P=0.04), but no difference in change in moderate- or greater-intensity physical activity (-27 metabolic equivalent-minutes per week [-526, 471], P=0.56).

CONCLUSIONS

This multicomponent behavioral intervention targeting stroke risk factors in predominantly Hispanics/Latinos was effective in increasing fruit and vegetable intake, reaching its primary end point. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01378780.

Abstract T P387: Stroke Health and Risk Education Project: main results

Objective: The Stroke Health and Risk Education (SHARE) Project is a cluster-randomized, faith-based, culturally-sensitive, theory-based behavioral intervention trial to reduce key stroke risk factor behaviors.

Methods: Ten Catholic churches in Corpus Christi, Texas were randomized to intervention or control group. Subjects were enrolled as friend or family partners who provided reciprocal support to each other. The intervention group received a 1-year multicomponent intervention that included self-help materials (physical activity guide with pedometer, healthy eating guide, blood pressure management photonovella, and motivational short film), 2 tailored newsletters, 5 motivational interviewing counseling calls, and a peer partnership support workshop. Multilevel modeling, accounting for clustering within pairs and parishes, was used to test treatment differences in the average of two measures of change since baseline (ascertained at 6 and 12 months), using standardized questionnaires, in dietary sodium, dietary fruit and vegetable intake, and physical activity of moderate or greater intensity. The primary endpoint was met if any one of the three outcomes was significant based on a pre-specified p-value threshold of 0.05/3.

Results: Of 801 subjects who consented, 760 completed baseline data assessments. The median age was 52; 84% were Hispanic, the remainder were non-Hispanic whites; 64% were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 (95% CI: 0.08, 0.42) cups per day, p = 0.002), a greater decrease in sodium intake (-123.17 (-194.76, -51.59) mg/day, p=0.04), but no difference in change in moderate or greater intensity physical activity (-27.47 (-526.32, 471.38) MET-minutes per week, p=0.56).

Conclusion: This cluster-randomized trial was effective in increasing fruit and vegetable intake among Hispanic and non-Hispanic white Catholic parishioners, reaching its primary endpoint. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts.

Stroke Health and Risk Education (SHARE): design, methods, and theoretical basis

BACKGROUND

Stroke is a disease with tremendous individual, family, and societal impact across all race/ethnic groups. Mexican Americans, the largest subgroup of Hispanic Americans, are at even higher risk of stroke than European Americans.

AIM

To test the effectiveness of a culturally sensitive, church-based, multi-component, motivational enhancement intervention for Mexican Americans and European Americans in reducing stroke risk factors.

METHODS

Participants enroll in family or friendship pairs, from the same Catholic church in the Corpus Christi Texas area, and are encouraged to change diet and physical activity behaviors and provide support for behavior change to their partners. Churches are randomized to either the intervention or control group. Goal enrollment for each of the 10 participating churches is 40 participant pairs. The intervention consists of self-help materials (including a motivational short film, cookbook/healthy eating guide, physical activity guide with pedometer, and photonovella), five motivational interviewing calls, two tailored newsletters, parish health promotion activities and environmental changes, and a peer support workshop where participants learn to provide autonomy supportive counseling to their partner. SHARE's three primary outcomes are self-reported sodium intake, fruit and vegetable intake, and level of physical activity. Participants complete questionnaires and have measurements at baseline, six months, and twelve months. Persistence testing is performed at 18 months in the intervention group. The trial is registered with clinicaltrials.gov (NCT01378780).