In the Journals

Community-based intervention lowers BP in Hispanic patients with stroke

Bernadette Boden-Albala
Bernadette Boden-Albala

A culturally tailored, skills-based educational intervention helped lower BP 1 year after stroke in patients of Hispanic ethnicity, researchers reported in JAMA Neurology.

The intervention was not associated with significant BP reductions in the overall cohort of 552 patients (mean age, 65 years; 51% women) or in patients of non-Hispanic white or non-Hispanic black race.

“These findings provide evidence that educational/informational strategies alone may not be enough to promote successful vascular risk reduction, especially in different race-ethnic groups,” Bernadette Boden-Albala, DrPH, MPH, senior associate dean of research and program development, interim chair of the department of epidemiology, director, of the division of social epidemiology and professor of epidemiology and health promotion in neurology, dentistry and public health at NYU College of Global Public Health, told Cardiology Today. “Further, this study indicates that a skills-based approach may significantly enhance messaging and promote behavioral change, ultimately leading to secondary stroke prevention.”

For the DESERVE study, the researchers randomly assigned patients with mild or moderate stroke or transient ischemic attack to the community-based intervention or the usual care. The intervention consisted of engagement with a community health coordinator before discharge; receipt of a patient-paced workbook and video emphasizing patient-provider communication, medication adherence and accurate stroke risk perception with risk reduction skills; and follow-up calls from a coordinator at 72 hours, 1 month and 3 months. The usual care group received standard stroke treatment plus American Heart Association stroke pamphlets in English and Spanish.

“The study evolved as part of a partnership with community stroke survivor groups who were part of the SWIFT study,” Boden-Albala told Cardiology Today. “These community stroke survivors wanted us to focus on self-efficacy and specific actions that stroke survivors could take to prevent a recurrent stroke. They worked with us to specifically produce narratives focused on strategies for recovery and risk reduction. Especially among Hispanics, these narratives were entwined with messages of hope and recovery.”

Differences by ethnicity

The primary outcome was reduction in systolic BP at 1 year after discharge.

In the overall cohort, there was no significant difference in the primary outcome (beta = 2.5 mm Hg; 95% CI, –1.9 to 6.9), Boden-Albala and colleagues found.

However, although the study was not powered for subgroup analysis, among Hispanic patients, those assigned the intervention had a reduction in systolic BP 9.9 mm Hg greater than those assigned the usual care (95% CI, 1.8-18), the researchers wrote. The same was not true for non-Hispanic white patients (beta = 3.3 mm Hg; 95% CI, –4.1 to 10.7) and non-Hispanic black patients (beta = –1.6 mm Hg; 95% CI, –10.1 to 6.8).

“The current paradigm for risk reduction is focused on providing educational information on risk factors and the importance of reducing risk. The DESERVE study suggests that clinicians may need to incorporate action items and promote risk-reduction strategies incorporating aspects of self-efficacy,” Boden-Albala said in an interview. “The DESERVE study shifts the paradigm on vascular risk reduction for stroke. We will continue to refine the program and focus on some other areas, including shifting from self-management to family/friend networks.”

Managing risk

In a related editorial, Joosup Kim, PhD, and Amanda G. Thrift, PhD, both from the stroke and ageing research group in the department of medicine, School of Clinical Sciences at Monash Health, Monash University, Australia, wrote that the researchers “provide promising findings that a culturally tailored and evidence- and needs-based intervention may be beneficial in managing risk. We recommend that these elements are adopted for future studies. We further recommend that future trialists should investigate dose response of education to investigate the threshold for a positive effect and interrogate their data to identify potential reasons for disparities in effect according to age, sex, race/ethnic group, and/or presence of comorbidities.” – by Erik Swain

For more information:

Bernadette Boden-Albala, DrPH, MPH, can be reached at College of Global Public Health, New York University, 665 Broadway, 11th Floor, New York, NY 10012; email: bb109@nyu.edu.

Disclosures: The authors, Kim and Thrift report no relevant financial disclosures.

Bernadette Boden-Albala
Bernadette Boden-Albala

A culturally tailored, skills-based educational intervention helped lower BP 1 year after stroke in patients of Hispanic ethnicity, researchers reported in JAMA Neurology.

The intervention was not associated with significant BP reductions in the overall cohort of 552 patients (mean age, 65 years; 51% women) or in patients of non-Hispanic white or non-Hispanic black race.

“These findings provide evidence that educational/informational strategies alone may not be enough to promote successful vascular risk reduction, especially in different race-ethnic groups,” Bernadette Boden-Albala, DrPH, MPH, senior associate dean of research and program development, interim chair of the department of epidemiology, director, of the division of social epidemiology and professor of epidemiology and health promotion in neurology, dentistry and public health at NYU College of Global Public Health, told Cardiology Today. “Further, this study indicates that a skills-based approach may significantly enhance messaging and promote behavioral change, ultimately leading to secondary stroke prevention.”

For the DESERVE study, the researchers randomly assigned patients with mild or moderate stroke or transient ischemic attack to the community-based intervention or the usual care. The intervention consisted of engagement with a community health coordinator before discharge; receipt of a patient-paced workbook and video emphasizing patient-provider communication, medication adherence and accurate stroke risk perception with risk reduction skills; and follow-up calls from a coordinator at 72 hours, 1 month and 3 months. The usual care group received standard stroke treatment plus American Heart Association stroke pamphlets in English and Spanish.

“The study evolved as part of a partnership with community stroke survivor groups who were part of the SWIFT study,” Boden-Albala told Cardiology Today. “These community stroke survivors wanted us to focus on self-efficacy and specific actions that stroke survivors could take to prevent a recurrent stroke. They worked with us to specifically produce narratives focused on strategies for recovery and risk reduction. Especially among Hispanics, these narratives were entwined with messages of hope and recovery.”

Differences by ethnicity

The primary outcome was reduction in systolic BP at 1 year after discharge.

In the overall cohort, there was no significant difference in the primary outcome (beta = 2.5 mm Hg; 95% CI, –1.9 to 6.9), Boden-Albala and colleagues found.

However, although the study was not powered for subgroup analysis, among Hispanic patients, those assigned the intervention had a reduction in systolic BP 9.9 mm Hg greater than those assigned the usual care (95% CI, 1.8-18), the researchers wrote. The same was not true for non-Hispanic white patients (beta = 3.3 mm Hg; 95% CI, –4.1 to 10.7) and non-Hispanic black patients (beta = –1.6 mm Hg; 95% CI, –10.1 to 6.8).

“The current paradigm for risk reduction is focused on providing educational information on risk factors and the importance of reducing risk. The DESERVE study suggests that clinicians may need to incorporate action items and promote risk-reduction strategies incorporating aspects of self-efficacy,” Boden-Albala said in an interview. “The DESERVE study shifts the paradigm on vascular risk reduction for stroke. We will continue to refine the program and focus on some other areas, including shifting from self-management to family/friend networks.”

Managing risk

In a related editorial, Joosup Kim, PhD, and Amanda G. Thrift, PhD, both from the stroke and ageing research group in the department of medicine, School of Clinical Sciences at Monash Health, Monash University, Australia, wrote that the researchers “provide promising findings that a culturally tailored and evidence- and needs-based intervention may be beneficial in managing risk. We recommend that these elements are adopted for future studies. We further recommend that future trialists should investigate dose response of education to investigate the threshold for a positive effect and interrogate their data to identify potential reasons for disparities in effect according to age, sex, race/ethnic group, and/or presence of comorbidities.” – by Erik Swain

For more information:

Bernadette Boden-Albala, DrPH, MPH, can be reached at College of Global Public Health, New York University, 665 Broadway, 11th Floor, New York, NY 10012; email: bb109@nyu.edu.

Disclosures: The authors, Kim and Thrift report no relevant financial disclosures.