Community stroke prevention_programs__an_overview.6

Volume 42 & Number 3 & June 2010 143

Community Stroke Prevention Programs:
An Overview
Elizabeth Kozub

ABSTRACT
Stroke is the third leading cause of death in the United States and is the leading cause of long-term
disability in the United States. Disparities in risk factor prevalence, stroke incidence, and mortality
exist across races and gender. Although healthcare providers may know the risk factors of stroke,
prevention of strokes and control of the major risk factors remain poor. In addition, the general
population lacks knowledge of the warning signs of strokes and the factors that put them at risk for
having a stroke. Stroke prevention programs have been found to be successful in increasing awareness
of the disease, but more prevention through reduction of modifiable risks is needed to lower the
incidence of strokes.

D
o you feel motivated to reduce one of the years of 1994 and 2004, with the actual number of
leading causes of death and disability in deaths declining to 6.8% (Rosamond et al., 2008).
your community? Stroke is the third lead- Disparities exist between races in the incidence of
ing cause of death and the leading cause of dis- stroke. Black men and Black women have a higher
ability in the United States (Rosamond et al., 2008). stroke incidence compared with White men and
The effects of a stroke can be devastating to the White women. The age-adjusted incidence rate of
individual and their families. Disparities exist in the stroke for Black men is 6.6/1,000 people, whereas for
incidence, mortality, and risk factors of stroke. How- White men, it is 3.6/1,000. Black women have a
ever, stroke prevention programs have been found to stroke incidence rate of 4.9/1,000; it is lower for
be effective in increasing an individual’s knowledge White women at 2.3/1,000 people (Rosamond et al.,
of stroke and to change a person’s behavior that puts 2008). The overall death rate for stroke is 50.0 per
them at higher risk for having a stroke. Yet, more 100,000, but again, disparities exist across races
needs to be done to reduce stroke risk factors, espe- (Rosamond et al., 2008). The death rate for Black
cially hypertension. This article provides the back- men is 74.9, whereas it is 48.1 for White men; the
ground for the human and economic cost of stroke, risk death rate for Black women is 65.5, whereas it is
factors and prevention efforts of stroke, and public 47.2 for White women (Rosamond et al., 2008).
knowledge deficits of strokes. In addition, stroke pre- Stroke is the leading cause of long-term disabil-
vention and awareness programs and cardiovascular ity, which can be experienced both physically and
risk reduction programs are examined, along with the mentally (American Heart Association, 2009). Of
need to tailor health messages. Finally, recommenda- stroke survivors, only 50%Y70% of people will
tions for neuroscience nurses are outlined. regain functional independence, whereas 15%Y30%
of people will be permanently disabled (Rosamond
et al., 2008). Because of these disabilities, 20% of
Human Cost of Stroke stroke survivors will require institutional care within
In the United States, there are almost 6 million people 3 months after their stroke (Rosamond et al., 2008.).
living with a stroke (Rosamond et al., 2008). Each The most prevalent disability after a stroke is
year, 795,000 people will have a stroke; 600,000 are hemiparesis or weakness on one side of the body.
new, and 185,000 are recurrent strokes (American Approximately 50% of people disabled by a stroke
Heart Association, 2009). Stroke causes 150,000 have some severity of hemiparesis, and 30% of sur-
deaths per year, with 54% of people dying before vivors are unable to walk without some assistance
they reach a hospital (Rosamond et al., 2008). The (Rosamond et al., 2008). Of those disabled by strokes,
death rate of strokes has fallen 24.2% between the 20% are dependent in their activities of daily liv-
ing, and another 20% have some form of aphasia
Questions or comments about this article may be directed to
(Rosamond et al., 2008). Compounded by the physi-
Elizabeth Kozub, RN MS CNRN CCRN, at ekozub1@jhmi.edu cal limitations, strokes secondarily impact people’s
or eikozub@gmail.com. She is a nurse clinician at the Neuro- mental health. Approximately, 35% of those physi-
science Critical Care Unit, Johns Hopkins Hospital, Baltimore, MD. cally disabled have depressive symptoms (Rosamond
Copyright B 2010 American Association of Neuroscience Nurses et al., 2008).

Copyright @ 2010 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

144 Journal of Neuroscience Nursing

risk ratios, hypertension is so important due to the
prevalence of the disease. The American Heart and
Stroke prevention remains a Stroke Association’s guidelines recommend that all
significant challenge despite adults should have a systolic blood pressure (SBP)
lower than 140 mm Hg and a diastolic blood pres-
our knowledge of modifiable sure (DBP) lower than 90 mm Hg (Goldstein et al.,
risk factors. 2006). However, the risk for stroke remains elevated
at blood pressures much lower than the recom-
mended guidelines, with the risk of stroke progress-
ing linearly beginning at an SBP of 115 mm Hg
Economic Cost of Stroke
and DBP of 75 mm Hg (Lawes, Bennett, Feigin, &
Although the human costs of stroke can be exten- Rodgers, 2004). Controlling blood pressure would
sive, the economic costs are also burdensome. The have broader implications than just preventing strokes:
estimated direct and indirect cost of strokes in the With every 20 mm Hg increase in SBP or 10 mm Hg
United States for 2008 is $65.5 billion (Rosamond increase in DBP above 120/80 mm Hg, the mortality
et al., 2008). Each lifetime cost of ischemic stroke, risk from heart disease and stroke doubles (National
including only direct costs, is $140,000 per case Heart, Lung, and Blood Institute, National High Blood
(Rosamond et al., 2008). For each hospitalization Pressure Education Program [NHLBI], 2004).
alone due to stroke, Medicare pays $6,363, total- A large segment of the U.S. population has hy-
ing $3.7 billion per year (Rosamond et al., 2008). pertension, yet most do not have their blood pres-
Disparities also exist in the cost of stroke by age sure adequately controlled. It is estimated that 73
and race. The cost per capita of stroke for Whites million Americans 20 years of age and older have
is lower than that for other minority groups. For high blood pressure, SBP 9140 mm Hg, and DBP
Whites, the per capita cost is $15,597, whereas it is 990 mm Hg, representing approximately 29% of all
$17,201 for Hispanics and $25,782 for Blacks (Brown adults (Rosamond et al., 2008). In addition, 37% of
et al., 2006). The cost of stroke is higher for His- adults have prehypertension (Ostchega, Dillon, Hughes,
panics and Blacks because of the higher stroke inci- Carroll, & Yoon, 2007). Of the 73 million Americans
dence in these groups and also because these groups with hypertension, 30% are not aware that they have
tend to have strokes earlier in life (Brown et al., 2006). the disease, 41% are not currently being treated for
hypertension by a healthcare provider, and 66% do
Stroke Risk Factors not have their blood pressure controlled (National
There are modifiable and nonmodifiable risk factors Heart, Lung, and Blood Institute, NHLBI, 2004).
of stroke. Nonmodifiable risk factorsVthose that you In addition to preventing and controlling hyperten-
cannot changeVinclude older age, gender (men have sion, other stroke prevention efforts focus on lifestyle
a higher risk of stroke compared with women), race behaviors by targeting modifiable risk factors, includ-
(Blacks and Hispanics have a higher stroke risk com- ing smoking, physical inactivity, and diet. Approxi-
pared with Whites), family history of stroke, and hav- mately 21% of all adults are current smokers, and
ing a low birth weight (Straus, Majumdar, & McAlister, smokers have a 1.8 times higher stroke risk compared
2002). Modifiable risk factorsVthose that you can with nonsmokers (Centers for Disease Control and
changeVare often tied to lifestyle behaviors. Mod- Prevention [CDC], 2008b; Goldstein et al., 2006).
ifiable risk factors for stroke include hypertension, Translating the higher stroke risk, 18% of all strokes
smoking, diabetes, hypercholesterolemia, physical in- can be attributed to cigarette smoking (Goldstein
activity, obesity, alcohol abuse, drug abuse, atrial fi- et al., 2006). Another important area for prevention
brillation, oral contraceptive use, and asymptomatic targets physical activity and weight. In 2006, only
carotid disease (Bronner, Kanter, & Manson, 1995; 31% of adults engaged in regular physical activity,
Rosamond et al., 2008; Straus et al., 2002). whereas 39% of adults did not engage in any physical
activity (CDC, 2008a). Physical inactivity increases
Stroke Prevention the risk of stroke by 2.7 times compared with those
The major prevention efforts of strokes are targeted individuals who are physically active (Straus et al.,
toward people’s modifiable risk factors. The most cru- 2002). To minimize the risk of stroke, adults should
cial risk factor of stroke is having hypertension, which have at least 30 minutes of moderate exercise each
is a factor in 70% of all strokes (Bronner et al., 1995). day and should maintain a normal body weight
Hypertension increases the risk of stroke two to four (Goldstein et al., 2006). Adults should also have a
times, depending on an individual’s age (Goldstein diet that is high in fruits, vegetables, and whole
et al., 2006). Although other risk factors have similar grains and lower in fat (Goldstein et al., 2006).



Additional stroke prevention efforts focus on con- school or lower education, and those in poor to fair
trolling other diseases besides hypertension. Control health had the poorest knowledge of stroke symp-
of blood sugar for patients with diabetes, treatment of toms and warning signs (Reeves et al., 2002).
high cholesterol, anticoagulation treatment of chronic In addition to the Michigan study, knowledge of
atrial fibrillation (with warfarin or aspirin depending stroke risk factors and warning signs has also been
on the patient’s condition), and carotid endarterecto- extensively studied in the Cincinnati, Ohio, region,
mies are all recommended treatments to reduce stroke where the population is representative of the United
risk (Goldstein et al., 2006). Treatment of high chol- States Bin terms of age, sex, race, educational level,
esterol is especially important due to its high preva- and economic status[ (Schneider et al., 2003). Sim-
lence. Approximately 17% of the adult population have ilar to the results found in the Michigan study, it was
high cholesterol, which increases the risk of stroke found that those older than 75 years old, male in-
by 1.8Y2.6 times (CDC, 2008c; Straus et al., 2002). dividuals, and those with lower education had lower
In addition, individuals with asymptomatic carotid knowledge of stroke (Pancioli et al., 1998; Schneider
disease can reduce their stroke risk by 50% by having et al., 2003).
a carotid endarterectomy performed (Goldstein et al.,
2006).
Stroke Prevention and Awareness Programs
In addition to preventing stroke, it is also crucial to
Public Knowledge Deficits of Stroke educate the public on symptom recognition and the
Although stroke risk factors are well known and need to seek emergency treatment of stroke. Prompt
understood by healthcare practitioners, the general treatment may reduce the severity of injury to the
population often lacks this understanding. In a sur- brain and reduce the chances of dying from stroke
vey of more than 2,500 Michigan adults, 80% could (Helgason & Wolf, 1997). There have been several
list at least one stroke risk factor, and only 27.9% could stroke prevention and awareness programs docu-
list three risk factors (Reeves, Hogan, & Rafferty, mented in the literature that aim to increase knowl-
2002). The most commonly listed risk factors were edge of stroke symptom recognition, to reduce the
hypertension (32.3%), smoking (29.2%), physical modifiable risk factors of stroke, or a combination of
inactivity (25.9%), and diet (24.5%; Reeves et al., both strategies.
2002). Twenty percent of those surveyed were un- One of the simpler stroke prevention and aware-
able to list a single correct risk factor (Reeves et al., ness programs used a 12-minute slide and audio
2002). The National Institute of Neurological Dis- presentation to educate individuals on what stroke is,
orders and Stroke has established the hallmark warn- the different types of stroke, the warning signs of
ing signs of stroke. These warning signs include stroke, and the risk factors of stroke (Stern, Berman,
sudden numbness or weakness, particularly on one Thomas, & Klassen, 1999). The study found that
side of the body; sudden confusion; sudden diffi- after individuals watched the movieVwhether or not
culty speaking or understanding speech; sudden they had a 45-minute discussion afterwardVand re-
trouble seeing, especially in one eye; sudden and gardless of gender, race, age, or educational status,
unexplained trouble with walking, dizziness, or loss there were significant gains in stroke knowledge.
of balance or coordination; or sudden severe head- Knowledge gain scores increased by 10.8% from
ache with no known cause (National Institute of Neu- 68.5% to 79.4% immediately after the program (Stern
rological Disorders and Stroke, 2008). Michigan et al., 1999). However, participants were never fol-
adults were also surveyed about their knowledge lowed up after the program to determine if the knowl-
of stroke warning signs. Seventy percent of adults edge gained remained with participants.
were able to list at least one symptom of a stroke, Another stroke prevention program aimed to deter-
with only 14% able to list three symptoms (Reeves mine whether a community stroke screening could
et al., 2002). The most commonly listed warning have positive effects 3 months after the screening. The
signs were weakness or numbness (45.7%), confu- stroke screening program included a stroke risk as-
sion, difficulty speaking (29.9%), and trouble walking sessment, blood pressure and cholesterol measure-
(23.5%; Reeves et al., 2002). However, there re- ments, carotid bruit detection, and atrial fibrillation
mains confusion between the signs of stroke and screening (DeLemos, Atkinson, Croopnick, Wentworth,
having a heart attack. Over 9% of those surveyed & Akins, 2003). During the screening process, indi-
listed shortness of breath as a warning sign of stroke, viduals were educated on the risk factors of stroke,
and another 9% listed pain in the chest or arm (Reeves the warning signs of stroke, and the need to call 911
et al., 2002). This study also found that older persons immediately if they or someone they knew was pos-
(more than 75 years old), Blacks, those with high sibly having a stroke (DeLemos et al., 2003). The



program found 113 out of the 400 individuals screened the 7 smokers were attempting to quit (Willoughby
to be at high risk for stroke, which included those et al., 2001).
participants who had at least one or more modifi- Another mechanism for stroke awareness is using
able risk factor for stroke (DeLemos et al., 2003). advertising to raise public awareness. Previous studies
The stroke screening program had positive results have reported that mass media campaigns have been a
for educating individuals about the warning signs of powerful source of stroke information. In 1995, 24%
stroke. Individual knowledge gains included stroke of those surveyed said television was the most com-
symptom recognition (59% baseline to 94% im- mon source of stroke information, followed by news-
mediately after program to 77% at 3 months) and papers (21%), magazines (19%), and doctors (18%;
knowing to call 911 if stroke symptoms develop Pancioli et al., 1998). In 2000, those surveyed relied
(47% baseline to 98% at 3 months; DeLemos et al., more on television for their source of stroke in-
2003). Although the goal of the study was to information, with approximately 32% of the participants
crease participant knowledge, a minor effect of the (up from 24% in 1995; Schneider et al., 2003). In an-
program was also influencing some participants’ other approach, Silver, Rubini, Black, and Hodgson
behaviors. Of the people participating in the program, (2003) compared different mass media strategies to
27% made a lifestyle change, only 9% saw a doctor determine which was the most effective in raising
despite the emphasis for physician follow-up, and 64% stroke awareness. They found that use of television
of the participants did not make any lifestyle change. had significant positive changes in people’s ability
No one stopped smoking 3 months after the program to name stroke warning signs; however, newspapers
(DeLemos et al., 2003). This program had positive did not produce any change in knowledge (Silver
knowledge changes lasting up to 3 months after- et al., 2003). An interesting finding was that the
ward, with having minor effects in people changing comparison community had a decrease in stroke
their lifestyle. knowledge, which draws into question whether or
Another stroke prevention program found posi- not the survey methods were adequate or if in fact
tive behavioral changes after a nurse-led stroke screen- the comparison community really did have a de-
ing program. This comprehensive stroke screening crease in knowledge over 2 years (Silver et al., 2003).
program of 107 participants included an in-depth With the use of television, there was an increase in
risk assessment; a detailed action plan; and health stroke knowledge across all education levels, with
counseling by a registered nurse, including ways to the largest effect on those with at least a college edu-
reduce their individual risk factors for stroke and cation (Silver et al., 2003). However, individuals over
instructions to call 911 if they experience any symp- the age of 65 did not experience any stroke knowl-
toms of a stroke (Willoughby, Sanders, & Privette, edge changes by the television education (Silver et al.,
2001). A dietitian and a pharmacist were also avail- 2003).
able to answer any questions participants may have
had related to their area of expertise. Participants
were then surveyed at 1, 3, and 6 month to assess Cardiovascular Risk Reduction Programs
for their stroke knowledge. The screening program A lot can be learned from cardiovascular risk re-
participants had knowledge gains from baseline that duction programs that could be adapted for use in
carried through the 6-month assessment for knowl- stroke prevention programs. Worldwide, there have
edge of where in the body stroke occurs (52% been many community programs implemented to
baseline to 98% at 6 months), the warning signs reduce mortality and morbidity from cardiovas-
of stroke (42%Y80% baseline to 68%Y100% at 6 cular disease by reducing modifiable risk factors.
months; varying percentage based on the warning These programs include the North Karelia Project in
sign, with severe headache being lowest and diz- Finland, the Bootheel Heart Health Program in
ziness and loss of balance being the highest), and Missouri, the Stanford Three-City and Five-City Proj-
action that should be taken if you have any symptoms ects, the Minnesota Heart Health Program, and the
of stroke (41% at baseline to 100% at 6 months; Pawtucket Heart Health Program in Rhode Island
Willoughby et al., 2001). After the screening pro- (Brownson et al., 1996; Carleton, Lasater, Assaf,
gram, many participants made changes in their life- Feldman, & McKinlay, 1995; Luepker et al., 1996;
style based on their modifiable risk factors for stroke; Papadakis & Moroz, 2008; Sarti, Vartiainen, Torppa,
54% changed to a low-fat and low-cholesterol diet, Tuomilehto, & Puska, 1994; Vartiainen et al., 2000;
34% had increased awareness and monitoring of Winkleby, Taylor, Jatulis, & Fortmann, 1996). Some
their cholesterol, 33% of participants began exer- of these programs have been more effective than
cising, 23% began weight loss measures, 11% im- others, but they all target disease reduction through
proved blood pressure monitoring, and 4 out of education, health screenings, mass media campaigns,



and individual and community empowerment. As the will cause a 14% decline in overall mortality due to
risk factors for stroke and cardiovascular disease over- stroke (National Heart, Lung, and Blood Institute,
lap, a joint program to address both programs could NHLBI, 2004). In addition, a decrease in SBP by
be implemented simultaneously. 10 mm Hg or DBP by 5 mm Hg is associated with a
30%Y40% decrease in stroke risk, depending on the
Tailoring Health Messages age of the individual (Lawes et al., 2004).
To reduce the prevalence of hypertension, inter-
As programs are developed to alter an individual’s
ventions targeted at the modifiable risk factors for
health knowledge and behavior, the information com-
the diseaseVwhich are also risk factors for strokeV
municated to the individual is extremely important. If
should be the primary focus. The major risk factors
the targeted individual is not kept in focus during the
for hypertension include overweight and obesity, physi-
development of information to be communicated and
cal inactivity, and smoking (National Heart, Lung, and
disseminated, the information is less likely to alter
Blood Institute, NHLBI, 2004). Other risk factors in-
the person’s behavior or attitude (Hawkins, Kreuter,
clude excessive sodium intake, low potassium intake,
Resnicow, Fishbein, & Dijkstra, 2008; Noar, Benac,
excessive alcohol consumption, and having ineffec-
& Harris, 2007). However, when health information
tive coping mechanisms for stress (National Heart,
is specifically developed for a specific individual or
Lung, and Blood Institute, NHLBI, 2004). Exam-
group, the information is more effective in changing
ples of programs that can be implemented to target
their attitude, their perceived susceptibility to the
overweight and obesity may include augmenting die-
disease or condition, their self-efficacy, and their pro-
tary changes by offering free or discounted nutrition
cesses of changing (Noar et al., 2007). Tailored health
and cooking classes. In addition to teaching par-
messages may increase the attention and processing
ticipants how to cook their favorite meals healthier,
of the health message and Balter the psycho-social
these classes may also emphasize healthier choices
constructs thought to directly influence behavior[
for snacks and ways to be a more Bhealth-conscious[
(Hawkins et al., 2008, p. 457). In addition, it has
consumer at the grocery store. Other program ideas
been found that printed materials tailored toward
targeting physical inactivity may be to start a walking
preventative behaviorsVsuch as smoking cessation, die-
club with your employer or within your community,
tary changes, and preventative screening behaviorsV
establish an adult soccer/softball/kickball league, or
are the most successful in altering a person’s be-
negotiate with the local schools to allow their gym
havior (Noar et al., 2007). Finally, it is possible to
facilities to remain open during the afternoon and eve-
deliver tailored messages aimed at the entire popu-
ning time for community members to use for exercise.
lation. To achieve individual personal relevance of
Programs do not need to start on a grand scale; they
the material, different messages may need to be
can begin in your local neighborhood, school dis-
transmitted for different subsets of the population
trict, or town.
(Noar et al., 2007).
There are several key points that are useful in
program development for population-based cardio-
Recommendations vascular disease risk factor reduction programs.
To reduce the burden of stroke on our population Nurses, pharmacists, nutritionists, physicians, social
and society, population-based efforts should be fo- workers, and health educators are key healthcare
cused on reducing the prevalence of modifiable risk workers in stroke program awareness and prevention
factors. Although it is important for stroke preven- implementation. A multidisciplinary approach should
tion programs to raise awareness of the disease and be taken to increase the knowledge of the community,
to educate people of the warning signs of stroke, augment the physical and social environments, in-
primary and secondary prevention efforts should corporate community participation, and produce
focus on reducing the risk factors that contribute healthy policy changes. In addition, it is important to
most to causing stroke. Specifically, prevention and be mindful of the community that you are working
treatment of hypertension should be a primary focus. with and the communities involved with similar pro-
Also, smoking, elevated cholesterol, physical inactiv- grams. McLaren, Ghali, Lorenzetti, and Rock (2007)
ity and obesity, and anticoagulation treatment of pa- argued and showed evidence that too often commu-
tients with atrial fibrillation should also be targeted. nity health workers will replicate a program without
The importance in control of hypertension cannot taking into consideration the target community. The
be understated. A modest reduction in blood pres- context of the environment (including social, phys-
sure can significantly reduce the risk of stroke and ical, economic, political, and cultural) is just as im-
decrease overall stroke mortality. It is estimated that portant as the intervention (McLaren et al., 2007).
a 5 mm Hg decrease of SBP in the entire population Finally, when evaluating the effectiveness of an



intervention, it is crucial to have comparison com- to be a continued partnership and collaboration with
munities. Without comparison, it is impossible to the community.
determine if any changes in risk factors or mortality As neuroscience nurses specializing in the
is due to the program or due to secular changes. unique needs and challenges of stroke patients, we
Although you may feel energized to start and are at a pivotal position to reduce the number of
develop your own specific program targeting stroke people affected by this debilitating disease. We have
prevention, it is important not to neglect the work the expert knowledge and opportunity to teach others
that may be already being done around you. There in our communities ways to reduce their risk of
are many programs being implemented by local and having a stroke and how to improve their overall
state health departments that target cardiovascular health. Collectively, we can have a huge impact with-
disease. For instance, Florida’s Department of Health out relinquishing all of our free time. It can be as
partnered with the American Heart Association, Florida easy as volunteering once per month or every other
Affiliate, and the Florida Cardiovascular Health Coun- month in a stroke community screening program or
cil to develop and implement the Florida Heart starting a walking group in your neighborhood. The
Disease and Stroke Prevention Program since 2003 important piece is that we must put our knowledge
(Florida Department of Health, 2008). In addition, the to work in reducing the death and disability from
Department of Health and Human Services funds stroke.
Preventative Health and Health Services Block
Grants to all the 50 states, District of Columbia, and
U.S. territories (CDC, 2008d). The states determine
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