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Developing a community-based stroke prevention intervention course in minority communities: the DC angels project.

ABSTRACT

Despite advances in stroke treatment in the United States, stroke remains the third leading cause of death among Americans and the leading cause of serious, long-term disability in the United States. About 780,000 Americans will have a new or recurrent stroke this year. Each year, about 60,000 more women than men have a stroke. African Americans have almost twice the risk of first-ever strokes compared with Whites. Minority populations are less likely to know all stroke symptoms and far less likely to know all heart attack symptoms. There are many benefits of early treatment of stroke, yet most minorities do not get this treatment because they do not recognize the warning signs, risk factors, and prevention of stroke. The objective of this intervention course was to increase the students' knowledge and awareness of stroke, warning signs, risk factors, and prevention. Developing community-based stroke prevention intervention courses in minority communities is a good strategy to reduce morbidity and mortality and help to eliminate health disparities in minority communities.

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Despite the advancement of stroke treatment in the United States, stroke remains the third leading cause of death and the leading cause of serious, long-term disability among adults. About 780,000 Americans will have a new or recurrent stroke this year, which means that someone will be having a stroke every 40 seconds. Also, every 3 to 4 minutes, someone dies of a stroke. Each year, about 60,000 more women than men have a stroke. Men's stroke incidence rates are greater than women's at younger ages but not at older ages. In 2008, the estimated direct and indirect cost of stroke in the United States was $65.5 billion (American Heart Association [AHA], 2008).

Minority communities and the poor are significantly affected by stroke; for example, African Americans have almost twice the risk of first-time strokes compared with Whites. African Americans have higher death rates for stroke compared with Whites. The 2006 prevalence of stroke in Black men is 3.9%; Black women, 4.1%; Mexican American, 2.1%; women, 3.8%; and Hispanics, 2.5%. Non-English Hispanics are less likely to know all stroke symptoms and far less likely to know all heart attack symptoms, compared with English-speaking Hispanics, non-Hispanic Blacks, and non-Hispanic Whites (AHA, 2008).

Minority populations usually have more than one risk factor for stroke such as high blood pressure, obesity, diabetes, cigarette smoking, high blood cholesterol, physical inactivity, and dietary factors. Many minorities lack knowledge and awareness of stroke warning signs, risk factors, and prevention. Increased knowledge of stroke warning signs and the need to call 911 is so important to timely administration of tissue plasminogen activator to patients experiencing acute ischemic stroke. Timely treatment should begin within 3 hours of symptom onset to reduce disability and death (Ellis, Wolff, & Wyse, 2009; Flaherty, Kleindorfer, & Kissela, 2004; Kleindorfer et al., 2005, 2008; Moser et al., 2006; Pancioli et al., 1998; Schneider et al., 2003; Yoon et al., 2001).

Stroke is a serious public health burden for residents here. Hospital discharge data for 2001-2002 show that stroke was a leading cause of hospitalization for residents in the District of Columbia (Department of Health, 2002). Vital statistics data show that stroke caused 4% of deaths in 2002. Heart disease and stroke rates are highest for African Americans compared with Whites and Hispanics (Centers for Disease Control and Prevention, 2007). According to the Behavioral Risk Factor Surveillance System (BRFSS) survey results, adults in the District of Columbia reported the following risk factors for heart disease and stroke in 2005: high blood pressure (27.1%) and high blood cholesterol (31.5%). In the 2006 BRFSS results, adults reported the following risk factors: overweight or obese (54.6%), diabetes (8.1%), current smoker (17.9%), overweight or obese (54.6%: body mass index greater than or equal to 25.0), and no physical exercise in the prior 30 days (22.1%). Implementation of effective stroke prevention strategies and the reduction in risk factors can have a significant impact on reducing the incidence of stroke in minority communities. It is estimated that about one half of all stroke could be prevented through stroke risk factor detection and management. Primary prevention is particularly important because more than 70% of strokes are first events (AHA, 2007; Brownstein et al., 2005; Kuhjda et al., 2006; Lutflyya, Cumba, McCullough, Barlow, & Lipsky, 2008). Many of these risk factors can be modified through heart healthy nutrition and physical activity (Covington, 2002).

A good strategy is to develop a community-based stroke prevention course at historically Black colleges and universities and Hispanic-serving colleges and universities. Students can gain knowledge and awareness of stroke warning signs, risk factors, and prevention so that they can empower their communities locally, nationally, and internationally.

Program Description

To address stroke disparities in minority communities, an assistant professor at a historically Black college and university decided to develop a stroke prevention intervention course (Table 1), The DC Angels Project. The program offers the course every semester to students interested in the implementation of stroke prevention in the community. The purpose of the course is to increase knowledge and awareness of stroke, stroke warning signs, and stroke prevention in minority communities. The goal of The DC Angels Projects course is to educate students about stroke warning signs, risk factors, and prevention so that they can educate future generations in their families and communities. This can be accomplished by meeting the following objectives: (a) teaching minority communities about stroke and stroke warning signs, (b) educating minority communities about stroke risk factors and stroke prevention, (c) discussing the importance of knowing your genetic medical history and risk for stroke, (d) creating stroke champions to develop and implement culturally sensitive stroke prevention educational interventions in minority communities, (e) empowering minority communities to decide to engage in health-promoting behaviors to reduce their risk for stroke, and (f) measuring the effectiveness of the community-based stroke prevention intervention by using a pretest-posttest design evaluation.

The Implementation of the DC Angels Stroke Prevention Project in the Community

After educating students about stroke prevention in the course, students developed a culturally sensitive PowerPoint presentation to present to the community. The source for the educational material came from the National Institutes of Neurological Disorders and Stroke (NINDS; 2007) Brain Basics and the AHA (2008) Power to End Strokes campaign. A pretest was given to participants prior to the educational intervention followed by a posttest. Participants received educational materials to take to their families and heart healthy cookbooks, and blood pressure screening and referral were provided (Summers et al., 2009). The investigators and trainers went to various venues to provide the educational intervention starting in 2007.

The stroke prevention educational intervention targeted high-risk-area residents here and used venues such as churches, group homes, community centers, and community organizations. After participating in the stroke prevention workshop, two participants who took the stroke prevention workshop were able to call 911 when recognizing the symptoms, which saved two people's lives. Two students received the stroke ambassadors' awards for their 2-year outstanding community service. The DC Angels Project addresses the health disparities in Table 2.

Evaluation

Course Evaluation Methods

The stroke prevention course evaluations methods include community projects, culturally sensitive stroke prevention PowerPoint presentation, a genetic family medical history analysis, stroke simulation in the laboratory, and stroke prevention in the community paper:

Community Project Evaluation

The theoretical approach is based on the social cognitive theory (Bandura, 1977) and the stages of change (Prochaska, DiClemente, & Norcross, 1992). A multisite quasi-experimental design was used to increase minority community's knowledge and awareness about stroke, warning signs, risk factors, and prevention to empower minority communities to decide to engage in health-promoting behaviors to reduce their risk for stroke. The data collection survey instrument for the pretest and posttest evaluation was the BRFSS from the Centers for Disease Control and Prevention (2007). A convenience sample of 3 men and 13 women participated in the study. Of the participants, 85% were Black, 12% were White, and 3% were other. Most participants had master's (34%), bachelor's (19%), and associate degrees (25%), and 19% had a high school diploma.

Most participants in this study perceived their health status as good (56%) and very good (31%). The Wilcoxon matched-pairs signed rank test was used to get the mean scores for knowledge of health-promoting behaviors for stroke (z = 0.00, p = 1.00), knowledge of risk factors for stroke (z = 0.316, p = .752), and warning signs of stroke (z = -0.137, p = .891).

Overall, participants did not know most of the warning signs and risk factors for stroke and stroke prevention. Longer term educational intervention is needed to increase knowledge and awareness of stroke warning signs, risk factors, and prevention in minority communities.

There continue to be significant disparities in stroke morbidity and mortality in minority communities. It is very important to educate minority communities about stroke warning signs, risk factors, and prevention. Culturally sensitive health communication is important to reduce stroke disparities in minority communities.

Key Findings

Lessons Learned About Community-Based Stroke Prevention: Challenges

Maintaining participants in the educational intervention over time is important to empower them to make lifestyle changes. Continuous funding is also a major factor to continue to provide the stroke prevention intervention to minority communities.

Benefits and Results

A major benefit of the community-based stroke intervention prevention course is the creation of stroke champions in minority communities locally, nationally, and internationally. Community empowerment and health behavior change in minority community are other major benefits. Healthy family and community environments are very important. Reduced disability and death and increase quality of life in a minority community are major parts of the long-term stroke prevention educational intervention.

Discussion and Next Steps

Results from the community project indicated that most people lacked knowledge and awareness of stroke, stroke warning signs, risk factors, and prevention. Long-term educational interventions are needed to increase the knowledge and awareness of stroke warning signs, risk factors, and prevention. Stroke prevention programs should be implemented to educate minority communities. One hundred forty students at a historically black college and university have completed the program since 2007. They indicated a great desire to implement the program in their communities. Culturally sensitive stroke prevention educational interventions are important in reducing morbidity and mortality in minority communities.

Stroke Prevention Resources in the Community

American Heart Association. (2008). Heart disease and stroke statistical update. Available from www.americanheart.org

American Heart Association. (2006). Power to end stroke campaign. Available from www.americanheart.org

American Stroke Association. www.strokeassociation.org

Brain Attack Coalition: www.stroke-site.org

The National Institutes of Neurological Disorders and Stroke (2008). Brain basics. Available from www.ninds.nih.gov

National Stroke Association: www.stroke.org

References

American Heart Association. (2007). Heart disease and stroke statistical update. Dallas, TX: Author.

American Heart Association. (2008). Heart disease and stroke statistical update. Dallas, TX: Author.

American Heart Association. (2009). Get with the guidelines and stroke. Retrieved from www.americanheart.org

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191-215.

Brownstein, J., Bone, L., Dennison, C., Hill, M., Kim, M., & Levine, D. (2005). Community health workers as interventionists in the prevention and control of heart disease and stroke. American Journal of Preventive Medicine, 29(5S1), 128-133.

Centers for Disease Control and Prevention. (2007). National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System. Atlanta, GA: Author.

Covington, C. (2002). Correlates and risk factors associated with coronary heart disease and the likelihood of engaging in health promoting behaviors among women (Doctoral dissertation, Howard University). Dissertation Abstracts' International, 1-241.

Department of Health. (2002). District of Columbia cardiovascular health program. Government of the District of Columbia. Retrieved from the DC State Center for Health Statistics 2001, 2002 DC Department of Health Web site: https://www.doh.dc.gov

Ellis, C., Wolff, J., & Wyse, A. (2009). Stroke awareness among low literacy Latinos living in the South Carolina low country. Journal of Immigrant and Minority Health, 11, 1577-1920.

Ignatavicius, D., & Hausman, K. (2009). Care of critically ill patients with neurologic problems (7th ed.). New York: Elsevier.

Kleindorfer, D., Alwell, K., Khoury, J., et al. (2005). Temporal trends, in emergency department arrivals" times for acute ischemic stroke: A population-based study Abstract presented at the 30th International Conference on Stroke and Cerebral Circulation, New Orleans, LA.

Kleindorfer, D., Miller, R., Sailor-Smith, S., Moomaw, C. J., Khoury, J., & Frankel. (2008). The challenges of community-based research: The Beauty Shop Stroke Education Project. Stroke, 39(8), 2331-2335.

Kuhajda, M., Cornell, C., Brownstein, J., Littleton, M., Stalker, V., Bittner, V., et al. (2006). Training community health worker to reduce health disparities in Alabama's black belt: The Pine Apple Heart Disease and Stroke Project, Family and Community Health, 29(2), 89-102.

Lutflyya, M. N., Cumba, M. T., McCullough, J. E., Barlow, E. L., & Lipsky, M. S. (2008). Disparities in adult African American women's knowledge of heart and stroke symptomatology: An analysis of 2003-2005 behavioral risk factor surveillance survey data. Journal of Women Health (Larchmt), 17(5), 805-813.

Moser, D., Kimble, L., Alberts, M., Alonza, A., Croft, J., Dracup, K., et al. (2006). Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke. A scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. Circulation, 114, 168 182.

National Institute of Neurological Disorders and Stroke. (n.d.). Stroke risk factors and symptoms. Retrieved from www. ninds.nih.gov

National Institute of Neurological Disorders and Stroke. (2006). Brain basics. Retrieved from www.ninds.gov

Pancioli, A. M., Broderick, J., Kothari, R., Brott, T., Tuchfarber, A., Miller, R., et al. (1998). Public perceptions of stroke warning signs and knowledge of potential risk factors. JAMA, 279, 1288-1292.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47, 1102-1114.

Schneider, A. T., Pancioli, A. M., Khoury, J. C., Rademacher, E., Tuchfarber, A., Miller, R., et al. (2003). Trends in community knowledge of the warning signs and risk factors for stroke. JAMA, 289, 343 346.

Summers, D., Leonard, A., Wentworth, D., Saver, J., Simpson, J., Spilker, J., et al. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40, 2911-2944.

Yoon, S. S., Heller, R. F., Levi, C., Wiggers, J., & Fitzgerald, P. E. (2001). Knowledge of stroke risk factors, warning symptoms and treatment among Australian urban population. Stroke, 32, 1926-1930.

Questions or comments about this article may be directed to Carolyn Frances Covington, PhD, at c_covington@howard.edu. She is the DC Angels Project director and principle investigator and an assistant professor in the Division of Nursing at Howard University, Washington, DC

Joyce A. King, PhD, is a coinvestigator and an instructor at the Rowan-Cabarrus Community College, Concord, NC

Irnise Fennell, BSN RN, is a research assistant and a clinical IM at The Johns Hopkins Hospital, Baltimore, MD.

Chanel Jones, BSN RN, is a research assistant at the Medical Surgical/Oncology Department, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA.

Charmaine Hutchinson, MSN RNC FNP, is a research coordinator and an instructor at the Division of Nursing, Howard University, Washington, DC.

Annette Evans, MHR, is a research assistant at the Division of Nursing, Howard University, Washington, DC.
TABLE 1. Stroke Prevention in the
Community Course Outline

Stroke disparities in minority communities

Stroke champions' role in stroke prevention in
minority communities

Risk factors for stroke and stroke prevention

Etiology and pathophysiology

Clinical manifestations of a stroke

Diagnostic studies

Collaborative care of stroke patients

Nursing management of stroke patients

Ambulatory and home care

Theoretical approaches for stroke prevention

Methodological approaches in stroke prevention in
the community

Ways to enhance nutrition and physical activity in
children to prevent obesity

Stroke prevention and health policy

Stroke prevention resources in the community

TABLE 2. The DC Angels Projects

Annual Heart Disease and Stroke Prevention workshop
for the community

Heart disease prevention in the community

Ways to enhance nutrition and physical activity in
children to prevent obesity

Stroke prevention education in the community
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Article Details
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Author:Covington, Carolyn Frances; King, Joyce A.; Fennell, Irnise; Jones, Chanel; Hutchinson, Charmaine; E
Publication:Journal of Neuroscience Nursing
Article Type:Clinical report
Geographic Code:1USA
Date:Jun 1, 2010
Words:2672
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