Stroke Preparedness Intervention Research Articles

Design of a school-based stroke preparedness intervention: challenges in acute diseases recognition

Abstract Background Timely activation of emergency medical services (EMS) by bystanders is important and it can improve outcomes of acute diseases such as stroke in Europe. Since there are no effective interventions addressing the complexity of help-seeking behaviour in the event of stroke, this study describes the development of the Czech “HOBIT” programme, which educates secondary school children to correctly activate the EMS. Methods Intervention Mapping was used to guide the development of the intervention using theory and evidence, as well as principles of co-creation. A needs assessment was completed by reviewing the evidence and interviewing stroke survivors. It identified sub-behaviours and their determinants. The information obtained was utilised to select the methods of behaviour change and their practical applications. In the last phase, the intervention tools were created. Results The needs assessment revealed stroke recognition and assessment as well as ambulance call as the main behaviours that must be done for EMS activation. Risk perception, outcome expectations, social influences, knowledge, and skills were revealed as important determinants of above behaviours. Modelling was selected as a method for the behaviour change. Based on discussions with 157 children aged 11-15, the format of an entertainment-education video was chosen. Incorporation of the modelling parameters (engagement, transplantation, identification) into the video was assessed during discussions with 15 children (scored >4 on the 5-point scale). As a result, a 5-minute entertainment video, modelling an acute stroke with a child as the main bystander was created. Conclusions The innovative educational video teaches children to correctly activate the EMS in stroke by modelling a real-life situation. Our results enable future projects to build on our findings to create the intervention for supporting behaviours in acute events that cannot be trained by direct experience. Key messages • Using the systematic approach built on co-creation with stakeholders is a significant foundation for the development of an effective intervention to improve timely activation of the EMS in stroke. • The current paper provides a comprehensive roadmap to help health promoters approach structured planning for behaviour change in acute diseases response.

Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan

Acute stroke treatment rates in the US lag behind those in other high-income nations. To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis. This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023. Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted. The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type. In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30). This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage. ClinicalTrials.gov Identifier: NCT036455900.

Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention.

Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.

A Community-Engaged Stroke Preparedness Intervention in Chicago.

BackgroundWe evaluated a community‐engaged stroke preparedness intervention that aimed to increase early hospital arrival and emergency medical services (EMS) utilization among patients with stroke in the South Side of Chicago, Illinois.Methods and ResultsWe compared change in early hospital arrival (<3 hours from symptom onset) and EMS utilization before and after our intervention among patients with confirmed ischemic stroke at an intervention hospital on the South Side of Chicago with concurrent data from 6 hospitals in nonintervention communities on the North Side of Chicago and 17 hospitals in St Louis, Missouri. We assessed EMS utilization for suspected stroke secondarily, using geospatial information systems analysis of Chicago ambulance transports before and after our intervention. Among 21 497 patients with confirmed ischemic stroke across all sites, early arrival rates at the intervention hospital increased by 0.5% per month (95% CI, −0.2% to 1.2%) after intervention compared with the preintervention period but were not different from North Side Chicago hospitals (difference of −0.3% per month [95% CI, −0.12% to 0.06%]) or St Louis hospitals (difference of 0.7% per month [95% CI, −0.1% to 1.4%]). EMS utilization at the intervention hospital decreased by 0.8% per month (95% CI, −1.7% to 0.2%) but was not different from North Side Chicago hospitals (difference of 0.004% per month [95% CI, −1.1% to 1.1%]) or St Louis hospitals (difference of −0.7% per month [95% CI, −1.7% to 0.3%]). EMS utilization for suspected stroke increased in the areas surrounding the intervention hospital (odds ratio [OR], 1.4; 95% CI, 1.2–1.6) and in the South Side (OR, 1.2; 95% CI, 1.1–1.3), but not in the North Side (OR, 1.0; 95% CI, 0.9–1.1).ConclusionsFollowing a community stroke preparedness intervention, early hospital arrival and EMS utilization for confirmed ischemic stroke did not increase. However, ambulance transports for suspected stroke increased in the intervention community compared with other regions.RegistrationURL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02301299.

Abstract WP221: Very Brief Intervention Improves Stroke Response in a Randomized Trial: Stroke Ready Very Brief Intervention

Introduction: Stroke pre-hospital delay has not improved over time. Hypothesis: Stroke Ready, a very brief (5 minute), theory based, peer-led, stroke preparedness intervention, will increase stroke response compared with a control intervention. Methods: We performed a randomized, single-blind controlled trial among adults in Flint, MI. The stroke preparedness intervention group received a Stroke Ready pamphlet and action plan, while the control group received stroke prevention materials - both delivered during a one-to-one interaction with a trained peer educator. Research staff, blinded to group intervention assignment, assessed baseline and immediate post-intervention outcomes. Primary outcome was change in stroke response (behavioral intent to call 911) using a community-modified stroke action test (range 0-12). Secondary outcome was change in stroke symptom recognition (range 0-8). We conducted descriptive analyses and used a linear regression model to evaluate the effect of the intervention on stroke response after adjustment for pre-intervention intent, age, education, race, marital status, history of stroke, stroke in someone they know and psychological constructs. Results: We enrolled 129 participants (74 intervention; 55 control). Mean age was 60 years (SD 14); 61% were women, 89% were African American and 19% were not high school graduates. Intervention participants had greater improvement in stroke response than control participants (figure 1), which remained after full adjustment (improvement in average score for stroke response was 1.7 higher in intervention participants than control participants, 95% CI 0.9-2.5, p&lt;0.0001). There was no difference in stroke symptom recognition (figure 1). Conclusion: The Stroke Ready very brief intervention increased stroke response. This new approach using a very brief, one-to-one interaction with trained peer educators is a promising, scalable, intervention to increase stroke response.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention

BackgroundLess than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. ObjectiveWe evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. MethodsUsing the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%. ResultsThe cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY. ConclusionII was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

Stroke Ready: a multi-level program that combines implementation science and community-based participatory research approaches to increase acute stroke treatment: protocol for a stepped wedge trial

BackgroundPost-stroke disability is common, costly, and projected to increase. Acute stroke treatments can substantially reduce post-stroke disability, but few patients take advantage of these cost-effective treatments. Practical, cost-efficient, and sustainable interventions to address underutilized acute stroke treatments are currently lacking. In this context, we present the Stroke Ready project, a stepped wedge design, multi-level intervention that combines implementation science and community-based participatory research approaches to increase acute stroke treatments in the predominately African American community of Flint, Michigan, USA.MethodsGuided by the Tailored Implementation of Chronic Disease (TICD) framework, we begin with optimization of acute stroke care in emergency departments, with particular attention given to our safety-net hospital partners. Then, we move to a community-wide, multi-faceted, stroke preparedness intervention, with workshops led by peer educators, over 2 years. Measures of engagement of the safety-net hospital and the feasibility and sustainability of the implementation strategy as well as community intervention reach, dose delivered, and satisfaction will be collected. The primary outcome is acute stroke treatment rates, which includes both intravenous tissue plasminogen activator, and endovascular treatment. The co-secondary outcomes are intravenous tissue plasminogen activator treatment rates and the proportion of stroke patients who arrive by ambulance.DiscussionIf successful, Stroke Ready will increase acute stroke treatment rates through emergency department and community level interventions. The stepped wedge design and process evaluation will provide insight into how Stroke Ready works and where it might work best. By exploring the relative effectiveness of the emergency department optimization and the community intervention, we will inform hospitals and communities as they determine how best to use their resources to optimize acute stroke care.Trial registrationClinicalTrials.gov Trial Identifier NCT03645590.

Abstract TMP73: The Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS) Study: Primary Results

Introduction: Early hospital arrival after stroke increases access to proven treatments and improves outcomes. We hypothesized that a community-engaged stroke preparedness intervention to overcome barriers to early activation of 9-1-1 would increase early hospital arrival and emergency medical services (EMS) use after stroke in high-risk neighborhoods in Chicago. Methods: We partnered with stakeholders in a South Side Chicago community with a high stroke incidence and in close proximity to a primary stroke center to develop a community stroke preparedness intervention. The intervention was delivered by “stroke promoters”, trained lay persons from the target neighborhood who utilized in-person discussions to overcome barriers and obtain stroke preparedness pledges as measured by “Pacts to Act FAST”. We applied an interrupted time-series analysis at the target hospital to study the effects of the intervention on EMS utilization and hospital arrival within 3 hours of symptom onset among patients with confirmed ischemic stroke. We compared these results to 6 North Side Chicago stroke centers and 17 St. Louis stroke centers as concurrent controls. Results: During a 12-month period, 242 stroke promoters distributed &gt;110,000 educational materials, participated in 167 community events, and registered 39,975 Pacts to Act FAST, reaching 19.4% of residents in the target South Side neighborhoods. Early arrival increased (0.5%/month post-intervention; p=0.124 for slope change) at the target hospital but was not different compared to North Side hospitals (p=0.560) or St. Louis hospitals (p=0.072). The effect on early arrival was significant among patients &lt;66 years old (0.8%/month increase; p=0.036), men (1.2%/month increase; p=0.026), and African-Americans (0.9%/month increase; p=0.037). No effect was observed on EMS use. Conclusions: Using a community-engaged approach to deliver a stroke preparedness intervention in Chicago, we observed a modest increase in early hospital arrival after confirmed stroke, which was more pronounced in younger, male, and African-Americans patients. Future efforts should consider improving message penetration and sustainability using novel personal approaches such as social media.

Abstract WP240: Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS): Exploring Stroke Knowledge, Self-Efficacy, and Trust in the Healthcare System in Chicago

Introduction: In a segregated city like Chicago with distinct neighborhood characteristics, a discrepancy between neighborhoods in stroke knowledge, self-efficacy, and trust in the medical system could impact stroke outcomes. Methods: As part of a study which implemented a culturally-tailored stroke preparedness intervention targeting South (S) Side Chicago communities, individuals attending community health events were recruited in S neighborhoods and North (N) Side neighborhoods pre- and one-year post-intervention to assess stroke knowledge, self-efficacy, and trust. Independent stand-alone pre- and post-sample cohorts were purposefully recruited to match demographics. Survey outcomes included knowledge (assessed via Stroke Action Test, STAT), self-efficacy (Likert scale), trust (Health Care Trust Survey), and stress (Likert). Zip codes divided subjects into S/N neighborhoods. Two-sample t-tests compared cohorts, and interactions between race/ethnicity-time and neighborhood-time were tested, with multivariable linear regression when statistically (p&lt;0.05) significant. Results: We recruited 364 subjects pre-intervention (S=199, N=165) and 363 subjects post-intervention (S=198, N=165) who were well-matched in race/ethnicity, sex, and education, though the post-group was slightly younger (p=0.04). Unadjusted analysis revealed increases post-intervention in stroke knowledge (p=0.07), self-efficacy (p&lt;0.0001), trust (p&lt;0.0001), and stress scores (p&lt;0.0001). After adjusting for race/ethnicity, gender, and age, the N post-group had greater gains in knowledge (N: 4.0, p=0.02 vs. S: 0.7, p=0.69), self-efficacy (N: 2.3, p&lt;0.0001 vs. S: 0.7, p&lt;0.0001), trust (N: 0.8, p&lt;0.0001 vs. S: -0.1, p=0.20) and stress (N: -0.3, p&lt;0.0001 vs. S: -0.1, p=0.04). Conclusions: The observed gains in stroke knowledge, self-efficacy, trust, and stress, greater in the North Side of Chicago, could signal overall improved public health messaging around stroke recognition and treatment, but could also point to socioeconomic factors that may have disproportionately benefited North Side residents. Further focused research to understand neighborhood factors which influence stroke awareness and action is necessary.

Abstract 170: Paramedic-Suspected Stroke Increased after Implementing a Community-Engaged Stroke Preparedness Intervention in Chicago

Introduction: Emergency medical services (EMS) utilization for acute stroke is associated with improved stroke care and outcomes. We evaluated whether a community-engaged stroke preparedness intervention would increase EMS use for suspected stroke. Methods: The Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS) study was conducted in a South Side Chicago neighborhood with proximity to a primary stroke center. In early 2016, CEERIAS implemented a community-engaged stroke preparedness intervention delivered by trained laypersons from the target community who taught peers about the importance of calling 9-1-1 for acute stroke. Paramedic impressions of all EMS calls were obtained from the municipal EMS provider agency serving the study neighborhood. Using ArcGIS 10.5.1 and ArcGIS Pro 2.1.2 (Esri Inc., Redlands, CA), EMS run locations were geolocated, and Getis-Ord Gi* analysis was used to identify hot spots for EMS-suspected stroke. Statistical hot and cold spots are defined as areas where there is &lt;1% chance of case clusters occurring by chance. Results: A total of 274,773 EMS runs were successfully geolocated in the 13.5 month pre-CEERIAS intervention period, and 267,061 in the 12.5 month post-CEERIAS intervention period. The study hospital’s neighborhood changed from a cold spot to a hot spot for EMS-suspected stroke (Figure). In the hot spot region adjacent to the study hospital, EMS use for suspected stroke increased 2.2-fold (p&lt;0.001) post-CEERIAS compared to pre-CEERIAS. Overall EMS utilization and EMS utilization for stroke were similar pre- and post-CEERIAS elsewhere in the city. Conclusions: A community-engaged stroke preparedness intervention was associated with an increase in EMS use for suspected stroke in targeted neighborhoods of Chicago. Further studies should investigate the effect on stroke outcomes and dissemination strategies to broaden the impact of this intervention.

Development and Preliminary Results of a Community-Partnered Stroke Preparedness Intervention in Chicago (P1.001)

Development and Preliminary Results of a Community-Partnered Stroke Preparedness Intervention in Chicago (P1.001)

Improving Community Stroke Preparedness in the HHS (Hip-Hop Stroke) Randomized Clinical Trial.

Deficiencies in stroke preparedness cause major delays to stroke thrombolysis, particularly among economically disadvantaged minorities. We evaluated the effectiveness of a stroke preparedness intervention delivered to preadolescent urban public school children on the stroke knowledge/preparedness of their parents. We recruited 3070 fourth through sixth graders and 1144 parents from 22 schools into a cluster randomized trial with schools randomized to the HHS (Hip-Hop Stroke) intervention or attentional control (nutrition classes). HHS is a 3-hour culturally tailored, theory-based, multimedia stroke literacy intervention targeting school children, which systematically empowers children to share stroke information with parents. Our main outcome measures were stroke knowledge/preparedness of children and parents using validated surrogates. Among children, it was estimated that 1% (95% confidence interval [CI], 0%-1%) of controls and 2% (95% CI, 1%-4%; P=0.09) of the intervention group demonstrated optimal stroke preparedness (perfect scores on the knowledge/preparedness test) at baseline, increasing to 57% (95% CI, 44%-69%) immediately after the program in the intervention group compared with 1% (95% CI, 0%-1%; P<0.001) among controls. At 3-month follow-up, 24% (95% CI, 15%-33%) of the intervention group retained optimal preparedness, compared with 2% (95% CI, 0%-3%; P<0.001) of controls. Only 3% (95% CI, 2%-4%) of parents in the intervention group could identify all 4 letters of the stroke FAST (Facial droop, Arm weakness, Speech disturbance, Time to call 911) acronym at baseline, increasing to 20% at immediate post-test (95% CI, 16%-24%) and 17% at 3-month delayed post-test (95% CI, 13%-21%; P=0.0062), with no significant changes (3% identification) among controls. Four children, all in the intervention group, called 911 for real-life stroke symptoms, in 1 case overruling a parent's wait-and-see approach. HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities. URL: https://clinicaltrials.gov. Unique identifier: NCT01497886.

Abstract TP288: Development and Preliminary Results of a Community Partnered Stroke Preparedness Intervention in Chicago

Objective: Delayed recognition and hospital arrival after acute stroke leads to worse outcomes. Given multi-level barriers to calling 9-1-1 for stroke, we sought to develop a community-partnered stroke preparedness intervention in Chicago’s underserved communities (where EMS use is low, despite high stroke incidence and mortality) tailored to neighborhood and cultural needs and barriers. Methods: As part of the CEERIAS study, we recruited local laypersons to serve as community promoters for a training program that sought to instruct them on delivering targeted messages to their communities. Each half-day training session was facilitated by CEERIAS study investigators, and consisted of a mix of didactic material on stroke statistics relevant to South Side communities, hospital-based tours of the “stroke patient journey,” role playing and tailored strategies for community messaging based on aim 1 focus group findings, and distribution of stroke education materials, “Pact to Act FAST” pledge cards, and website (www.ceerias.com) instructions. Results: We conducted 21 training sessions for 242 community promoters (81 African-American [AA] males, 133 AA females, 4 Hispanic males, 5 Hispanic females, 3 Caucasian males, 16 Caucasian females) between October 2015 and May 2016. Since training, these community promoters have distributed &gt;110,000 educational materials including FAST cards and magnets and participated in 167 community events. A total of 38,221 Pact to Act FAST pledges have been registered (Figure), 80.3% of which registered in South Side Chicago zip codes (Figure). Conclusions: A community-partnered stroke preparedness campaign was effective in increasing stroke awareness in underserved minority communities, as noted by the high volume of Pact to Act FAST pledges. Data on 9-1-1 calls for stroke and early arrival after stroke at neighborhood hospitals will be analyzed to assess effect of the intervention.

Hip Hop Stroke: Statewide Dissemination and Implementation of an Evidence-based Stroke Preparedness Intervention

Hip Hop Stroke: Statewide Dissemination and Implementation of an Evidence-based Stroke Preparedness Intervention

Internet Stroke Preparedness for African American Women.

African American women exhibit low stroke awareness and may benefit from experiential and lay language description of stroke symptoms. The purpose of this pilot study was to examine the effect of an online stroke preparedness intervention for identification of stroke symptoms and appropriate action in response to suspected stroke and estimate effect sizes for a larger study. A quasi-experimental nonequivalent comparison group design was used to randomized 44 women to intervention (n = 23) or wait-list control group (n = 21). Data were analyzed with Friedman and Wilcoxon signed rank tests and Cochran-Mantel-Haenszel statistics to examine intervention effect on (1) self-efficacy to recognize stroke and know what to do in the event of stroke, (2) awareness of stroke symptoms, and (3) behavioral intent to call 911 for suspected stroke. Effect size estimates were calculated by converting z scores to r. Significant intervention effect was found for self-efficacy to know what to do in the event of stroke, ability to identify stroke symptoms presented in written vignettes, and ability to identify correct action in response to symptoms presented in written vignettes. Small to medium effect sizes were obtained. No improvement was found for ability to name stroke symptoms. Behavioral intent to call 911 for stroke in someone else was high, but significantly fewer women would call 911 for themselves. Experiential depictions of stroke symptoms in an online format showed preliminary effectiveness to improve stroke awareness among African American women.

Development and Validation of a Bilingual Stroke Preparedness Assessment Instrument.

Stroke preparedness interventions are limited by the lack of psychometrically sound intermediate end points. We sought to develop and assess the reliability and validity of the video-Stroke Action Test (video-STAT) an English and a Spanish video-based test to assess people's ability to recognize and react to stroke signs. Video-STAT development and testing was divided into 4 phases: (1) video development and community-generated response options, (2) pilot testing in community health centers, (3) administration in a national sample, bilingual sample, and neurologist sample, and (4) administration before and after a stroke preparedness intervention. The final version of the video-STAT included 8 videos: 4 acute stroke/emergency, 2 prior stroke/nonemergency, 1 nonstroke/emergency, and 1 nonstroke/nonemergency. Acute stroke recognition and action response were queried after each vignette. Video-STAT scoring was based on the acute stroke vignettes only (score range 0-12 best). The national sample consisted of 598 participants, 438 who took the video-STAT in English and 160 who took the video-STAT in Spanish. There was adequate internal consistency (Cronbach α=0.72). The average video-STAT score was 5.6 (SD=3.6), whereas the average neurologist score was 11.4 (SD=1.3). There was no difference in video-STAT scores between the 116 bilingual video-STAT participants who took the video-STAT in English or Spanish. Compared with baseline scores, the video-STAT scores increased after a stroke preparedness intervention (6.2 versus 8.9, P<0.01) among a sample of 101 black adults and youth. The video-STAT yields reliable scores that seem to be valid measures of stroke preparedness.

Abstract W MP72: Sleep and Timing of Recurrent Events in a Mild Stroke Population: Results of the SWIFT Study

Sleep is an important contributor to cardiovascular disease; we have previously reported it is a risk factor for incident vascular events. It is thought that sleep apena may be the primary mechanism through which sleep disturbance is associated with vascular events. Little is known, however, about the association between sleep and recurrent events. The aim of this analysis was to determine the association between sleep problems and the risk of recurrent vascular events in an elderly, multiethnic population. This analysis uses data from SWIFT, a randomized clinical trial conducted in northern Manhattan designed to test a stroke preparedness intervention. Sleep was measured with the MOS sleep scale. MOS is a 12 item questionnaire that produces 8 validated scales. We report results using the snoring (1 question), shortness of breath during sleep (1 question), and sleep problem index 2 (9 questions) scales. Outcomes were collected prospectively through active surveillance. We used Cox Models to test whether our measures of sleep were associated with an increased hazard of having a recurrent event. SWIFT randomized 1193 stroke participants: mean age 63 years +- 15.14; 50% female; 17% black, 51% Hispanic, 26% white, 6% other. In models adjusted for treatment assignment, race, age, gender, education, marital status and baseline measures of hypertension, diabetes, smoking and NIH stroke scale the sleep problems index 2 was associated with an increased hazard of a first recurrent stroke or TIA (HR=1.91, p-value=0.02), whereas our measures of snoring (HR=1.20, p-value=0.43) and shortness of breath during sleep (HR=1.39, p-value=0.46) were not. The same pattern of results held for a composite measure of first recurrent stroke, TIA, MI or vascular death: sleep problems index 2 (HR=1.97, p-value=0.003), snoring (HR=1.10, p-value=0.62) and shortness of breath during sleep (HR=1.59, p-value=0.18). Our results highlight the contribution of sleep to the risk of recurrent vascular events in a population of mild and moderate stroke/TIA survivors. Importantly, this result is not driven by snoring or trouble breathing at night and is independent of hypertension, smoking and diabetes.

Methodology for a community-based stroke preparedness intervention: the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities Study.

Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multilevel program using a community-engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia. This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue-type plasminogen activator utilization for acute ischemic stroke. Phase 1 included (1) enhancement of focus of emergency medical services on acute stroke; (2) hospital collaborations to implement and enrich acute stroke protocols and transition District of Columbia hospitals toward primary stroke center certification; and (3) preintervention acute stroke patient data collection in all 7 acute care District of Columbia hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted, reaching >10,256 participants; 3289 intervention evaluations were performed, and 19,000 preparedness bracelets and 14,000 stroke warning magnets were distributed. Phase 3 included an evaluation of emergency medical services and hospital processes for acute stroke care and a year-long postintervention acute stroke data collection period to assess changes in intravenous tissue-type plasminogen utilization. We report the methods, feasibility, and preintervention data collection efforts of the ASPIRE intervention. http://www.clinicaltrials.gov. Unique identifier: NCT00724555.

Abstract T MP71: Evaluation of a Community-Wide Stroke Preparedness Intervention: Results of the ASPIRE Study

Background: Lack of education about stroke preparedness and needed action, particularly in underserved communities may prevent seeking timely care. Aim: To evaluate the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project. Methods: ASPIRE is a multi-level program [individual/community, hospital, EMS] using a community-engaged approach to stroke preparedness targeted to underserved black DC communities. The aim is to decrease acute stroke (AS) presentation times and increase intravenous tissue plasminogen activator (IV tPA) use. Phase 1 included 1) Enhancement of EMS focus on AS; 2) Implementation/enrichment of AS protocols to move DC hospitals to Primary Stroke certification; 3) Pre-intervention (PRE) AS patient data collection in all 7 acute care DC hospitals; 4) Focus group/survey identification of barriers to emergency stroke care to create a culturally tailored intervention. Phase 2 was a 1 year city-wide intervention. Phase 3 was 1 year post-intervention (POST) acute stroke data collection to assess changes in IV tPA use and AS presentation time. We compare PRE vs. POST AS parameters among ischemic stroke cases that arrived within 168 hours of stroke onset, excluding hospital transfers (n=84). We performed logistic regression models for AS arrival ≤ 3 hours. Results: Phase 1 identified 687 ischemic stroke cases, 85% black, 58% women; 56% ≥ 65 yrs. Phase 2 conducted 531 community interventions for 10,256+ participants; performed 3,289 intervention evaluations; distributed 19,000 preparedness bracelets and 14,000 stroke warning magnets. In Phase 3, we identified 684 ischemic stroke cases, 79% black, 58% women; 56% ≥ 65 yrs. We report significant increases in AS arrival time ≤ 3 hours (14% to 27%; p&lt;0.0001) and in IV tPA use (4% to 9%; p&lt;0.001). In a logistic model, significant predictors of ED arrival ≤ 3 hours included (OR; 95% CI): POST vs. PRE (1.8; 1.4 - 2.4); White vs. Black (2.0; 1.8 -2.8); Male (1.3: 1.0 -1.8); and EMS (3.6: 2.5 - 5.0). Conclusion: ASPIRE shows significant success increasing the proportion of AS arrivals to ED ≤ 3 hours and increasing IV tPA utilization. Culturally tailored community interventions can be effective in increasing stroke preparedness in underserved urban communities.

Abstract T MP70: Dense Households and Weak Social Networks Increase Risk of Recurrent Vascular Events

Background: Social isolation is associated with increased vascular events post stroke, but the role of living arrangements versus social networks on stroke outcomes has not been well explored. We aim to characterize these associations overall and by race-ethnicity. Methods: The Stroke Warning Information and Faster Treatment (SWIFT) study tested a stroke preparedness intervention on arrival times for stroke/TIA recurrence to the ED. Stroke/TIA patients able to consent were prospectively recruited and randomized. Baseline data collection included demographics, medical history, socioeconomic status (SES), and social support networks. Living arrangements were categorized as living alone, living with one or 2 people, or living with three or more people (dense household). Weak social support networks defined as 4 or less family or friend visits in past week. Participants were followed for a mean of 2.9 years. An outcome of vascular event was defined as stroke, TIA, MI, or death post enrollment. Multivariate logistic regression models examined the relationship between vascular outcomes, living arrangements and social support networks adjusting for demographics, health and SES. Results: Between 2005 and 2009 1193 participants were enrolled: mean age 63 years; 51% Hispanics, 26% whites, and 17% Blacks; 50% female; and 42% &lt; high school education. Over 24% lived alone, 23% lived with spouse/partner only, and 21% lived in dense households. In adjusted logistic models, post stroke vascular events were associated with dense households [RR 1.5 (95% CI: 1.1 - 1.9)], and weak family networks [RR 1.9 (95% CI: 1.4 - 2.8)]. Stratifying by race-ethnicity, the results remained significant for Hispanics where dense households [RR 1.9 (95% CI: 1.3 - 2.6)], weak family networks [RR 2.8 (95% CI: 1.5 - 5.1)], and weak friend networks [RR 1.5 (95% CI: 1.0 - 2.5)] increased vascular events post stroke. Conclusion: Living in dense households can increase risk of vascular events post stroke, while stronger social support networks can decrease this risk especially among Hispanic stroke survivors. Future research is needed to explore the mechanism of these associations and to identify possible racial/ethnic tailored interventions based on living arrangements and social networks.