Culturally Tailored Stroke Education Lowers BP in Secondary Stroke Prevention

Pauline Anderson

November 02, 2018

A culturally tailored, skills-based educational strategy targeting stroke survivors reduced systolic blood pressure (SBP) within a year compared to usual care, but it was statistically significant only among Latino patients, new research shows.

"There's evidence that providing skills-based action items in addition to information is likely to reduce blood pressure, especially among Hispanic populations," study author Bernadette Boden-Albala, DrPH, professor of epidemiology and health promotion in neurology, dentistry, and public health, College of Global Public Health, New York University, New York City, told Medscape Medical News.

"We need to kind of shift and rethink the way we ask patients and their family members to reduce risk."

The study was published online October 8 in JAMA Neurology.

Hidden Burden

Stroke is a "huge burden" for patients, their families, and the healthcare system, said Boden-Albala.

The burden is particular onerous for Hispanic and African American patients, who are two to three times more likely to suffer a stroke and die compared to non-Hispanic white patients, she said.

Racial/ethnic disparities persist in secondary prevention, largely owing to cultural and behavioral factors.

The skills-based approach represents a "paradigm shift" in stroke prevention, said Boden-Albala. Prior approaches, she said, just focused on providing education, information, and resources on risk factors, such as hypertension and diabetes.

"Skills-based interventions are able to translate that education or information into actions that patients and families can take" to reduce stroke risk, said Boden-Albala.

The new study included 552 participants who had suffered a stroke or transient ischemic attack (TIA). In general, the strokes were mild (mean National Institutes of Health Stroke Scale score at admission: 2.9 for the intervention group and 3.4 in the usual-care group).

About a third of participants had already suffered a stroke or TIA, and most had a history of overweight or obesity or hypertension. At baseline, the mean SBP was almost 140 mmHg. There was little variation in SBP between race/ethnic groups.

Participants were randomly assigned to receive usual care (standard stroke treatment and an American Heart Association stroke pamphlet in English or Spanish) or the intervention known as Discharge Educational Strategies for Reduction of Vascular Events (DESERVE).

Importance of Friends and Family

DESERVE is a skills-based behavioral intervention delivered by a community health coordinator. In addition to participating in an interactive educational session before being discharged, patients receive a workbook and video that emphasizes three areas.

These include patient-physician communication, medication adherence, and risk perception. With risk perception, the aim was to increase patients' understanding of their "actual risks" of having a secondary event, said Boden-Albala.

The intervention group also received follow-up calls at 72 hours, 1 month, and 3 months to enhance patient-physician communication strategies, to clarify medication regimens, and to provide social support to motivate behavior change.

Researchers worked with various racial/ethnic stroke survival communities to develop the type of intervention that members of that group would best respond to.

The primary outcome was the difference in SBP reduction between baseline (predischarge) and after 12 months.

At study end, the mean reduction in SBP was 7.0 mmHg in the intervention group and 4.3 mmHg in the usual-care group. In models adjusted for study site and interaction between trial arm and race/ethnicity, there was a nonsignificant between-group difference of 2.5 mmHg (95% confidence interval [CI], −1.9 to 6.9; P = .16).

However, among Hispanics, there was almost a 10-mmHg difference in mean reduction in SBP in the intervention group compared with usual-care participants (decrease of 7.7 mmHg in the intervention arm vs an increase of 2.1 mmHg in the usual-care arm; significant difference of 9.9; 95% CI, 1.8 - 18.0).

The reduction in SBP in Hispanic individuals translates to almost a 40% risk reduction for secondary stroke events, write the authors.

There are two main factors that may explain why the Hispanic population responded so well to the intervention, said Boden-Albala.

"It may be that Latinos, which is the fastest growing minority group in US, have the most issues in terms of patient-physician communications, and so in a way they're the low-hanging fruit."

In addition, Latinos in the intervention group had "very, very strong friend and family networks," said Boden-Albala.

Family and friends of Latinos tended to gather at the hospital and were more likely to participate in discussions of stroke risk reduction, she said.

Clinically Significant?

In earlier research, the investigators examined the role of social networks and found "a very strong relationship between who your social networks are and reduction of blood pressure," said Boden-Albala.

Such networks, she said, may explain why the intervention had a greater impact on Latinos.

"We think that this skills-based approach capitalized on these networks," she said.

Boden-Albala said the reason SBP increased in Hispanic patients may be that standard stroke care "doesn't really address" barriers to risk reduction experienced by this population.

Among non-Hispanic white and black participants, there were no significant differences in mean reduction of SBP between trial arms.

In blacks, both those in the intervention group and the usual-care group experienced moderate decreases in SBP (5.8 mmHg and 6.7 mmHg, respectively).

Whites in the intervention group experienced a large reduction in SBP (9.6 mmHg); their counterparts in the usual-care group also experienced a moderate reduction (6.6 mmHg).

Boden-Albala emphasized that although there wasn't a statistically significant difference between intervention and usual care, "some would argue that almost a 3-mmHg decrease of SBP is still clinically significant."

The median age of the participants in the intervention group was 63.3 years; in the usual-care group, the median age 65.9 years. To address the significant difference in mean age between the two groups, the researchers conducted sensitivity analyses to adjust for age. The results were similar to those in the main analysis.

Better Response in Men

Men seemed to respond to the intervention better than women, something the investigators intend to explore further. Boden-Albala surmised that male stroke survivors tend to have a social network in place.

"Men with stroke are more likely to be supported by family; women are more likely to be discharged to nursing homes," she said.

When examining whether there was a dose-response relationship in the intervention group, the researchers found that the reduction in SBP was greater for those who received all three calls about lowering blood pressure than it was for those who received fewer calls. However, these differences were not statistically significant.

The impact of receiving more calls was particularly evident among blacks, although the study wasn't powered to uncover racial differences. "This is something we are trying to explore further," said Boden-Albala. "We need greater numbers to look at some of these nuances, which I think are very important."

The study results suggest that "we have to think carefully about culturally tailoring" stroke prevention "narratives" and messaging, said Boden-Albala.

She noted that the messages conveyed to Latinos, in addition to being about recovery and risk reduction, tended to have more of a spiritual component and were "more about hope," she said.

The study provides "reasonable evidence that culturally appropriate programs do work," said Boden-Albala. "It also provides some evidence that we probably need to shift our approach and not just think about providing information" but also about "differential uptake of action" between different racial/ethnic groups, she added.

Now, researchers need to determine how to "optimize" or refine this skills-based intervention, she said.

The authors note that DESERVE and other culturally tailored, skills-based interventions could lead not only to significant reductions in racial/ethnic disparities in stroke incidence and recurrence but also to major healthcare savings.

Promising Findings

Although there have been numerous studies on the management of risk factors after stroke, this new one is among only a few to target disadvantaged populations, say the authors of an accompanying editorial.

In an interview with Medscape Medical News, editorialist Amanda G. Thrift, PhD, stroke and aging research, Department of Medicine, School of Clinical Sciences, Monash University, Victoria, Australia, who has researched the impact of education on behavioral changes in stroke patients, said the study provides "promising findings" that a culturally tailored and evidence- and needs-based intervention may be beneficial in managing stroke risk.

"The authors have done all the right things by asking the community how they want to be educated about this," she said.

Although Thrift said she thinks the educational approach used in the study "is likely to work," she has a few concerns.

One concern is that there was a significant difference in only one group.

"This always raises a few concerns about potential statistical power," said Thrift. "It might be a chance finding."

The rise in blood pressure among Hispanic participants who received usual care "actually might be the thing that is driving why the intervention was successful in that group and not in the others," she said.

It's possible that outliers among Hispanic participants influenced the results — perhaps for some of them, baseline blood pressure was closer to 200 mgHg instead of the mean of 139 mmHg, said Thrift.

"The higher the blood pressure is, the more likely it is to drop by a significant amount," she said.

She would have liked to have seen some kind of illustration "to show the spread of blood pressure" across the groups.

What would have made Thrift "absolutely sure" that this educational approach was working was if the authors had provided information on such things as the proportion in the different groups who were receiving antihypertensive medications, as well as information on adherence to such medications and the lifestyle interventions that were followed, she said.

Thrift stressed that although experts are well versed on how to prevent stroke, "it's getting people to take more responsibility for their own health that is the big barrier at the moment."

The study was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Dr Boden-Albala has disclosed no relevant financial relationships. Dr Thrift was supported by a National Health and Medical Research Council (Australia) fellowship. She and her coauthor received grant funding from the National Health and Medical Research Council (Australia) in the past 5 years.

JAMA Neurology. Published online October 8, 2018. Abstract, Editorial

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