Citywide Push to Improve Stroke Outcome
After months of holding meetings in churches, community and daycare centers, clinics and libraries – anywhere, really, where people regularly gather in D.C.’s seventh ward - the email that arrived in Shauna St. Clair’s inbox was proof the hard work was having an effect. A young woman wrote to offer her help in connecting St. Clair with other local community programs. She said: “I went to my mom’s house the other day and saw the stroke magnet up. So great work to bring awareness to this important topic!”
St. Clair and Chelsea Kidwell, MD, have mobilized an army of volunteers to get the word out that a stroke – a brain attack akin to a heart attack – can be successfully treated if a person is quickly seen in a hospital emergency room. They held 53 educational sessions in the seventh ward from July 2009 through this June, which reached more than 1,000 residents. And on September 1, they launched a yearlong push to reach black populations in all eight D.C. wards – an effort to reach one-fourth of District residents, about 150,000 people.
At least 500 stroke educational sessions held by 50 trainers in a variety of venues are planned. Media outreach will be extensive, including mass emails, facebook postings, public service announcements, and advertising on transit buses.
It’s known that stroke is the third leading cause of death and the leading cause of adult disability in the United States, and it has a disproportionate impact on underserved populations.
And it has been clear for more than a decade that use of a drug known as tissue plasminogen activator (tPA) can dissolve the blood clots responsible for 85 percent of strokes, and thus restore brain function – but only if given intravenously within a few hours of the attack.
But, overall, fewer than five percent of stroke patients get tPA in time. The situation is even worse in African Americans, who have two times the risk of stroke, are less likely to receive the care they need, and suffer worse outcomes compared to Caucasians, says Kidwell, professor of neurology and medical director of the Georgetown University Stroke Center.
Her mission, then, is to develop a community stroke education program that is culturally geared toward African Americans, with the goal of reducing disability and death from stroke. Called ASPIRE (Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities), the federally funded program is designed to produce a tried-and-true stroke intervention model that can be used in African American populations across the country. A recent program that targeted the Hispanic population in Texas has already doubled the rate of tPA use.
“We know that the type of stroke care people get in the United States depends at least in part on their race and socioeconomic status, and no one has done an intervention specifically in African American population to address barriers to vital stroke care,” says Kidwell.
“What better place to attempt to reduce these disparities than in the nation’s capital, where so many patients are coming from medically underserved communities?” she says.
So Kidwell, who is principal investigator for a $10 million grant, from the National Institutes of Health, designed a multi-part study aimed at improved stroke outcome in D.C., of which ASPIRE is the flagship project. The cooperative research grant involves physicians and scientists from twenty other local institutions, including GUMC’s clinical partner, Georgetown University Hospital.
To see what the barriers to tPA use were, and what effective intervention would look like in African-American populations, she and St. Clair launched their pilot program in one of the most economically disadvantaged areas in the district.
They found out that people need more culturally appropriate education about the stroke symptoms, and that there is a disconnect between intent and behavior – people who know what stroke symptoms still don’t call 911.
“A lot of people think they should wait it out, but they are not aware of the long term consequences,” says Kidwell. “Others may know they should call an ambulance but are reluctant to do so because they cannot pay for one. But while it is true that ambulances may be costly, it is the best option a person has to prevent disability, to reduce the chance that family members will have to care for you.”
Another difficulty discovered in the pilot was in getting stroke education sessions scheduled, says St. Clair, who began as ASPIRE project manager in March. She learned that trainers needed to be “present in the community. We found that in order to better connect with community members, we had to be willing to spend more time within the community, meet with community leaders, and attend local events,” she says.
On her daily walk to work, St. Clair experienced what a little personal attention can achieve.
“There is a great group of parking attendants on Georgetown’s campus. I always stop and talk with them about family etc. when heading to my office building,” she says. “One day, I went to their office around lunchtime with a laptop and a few giveaways and helped them learn about stroke. When we first started, most did not know a lot about stroke or signs of someone having a stroke yet several were well within the 45-65 age bracket that is three times more likely to have strokes in the district. Several had other risk factors as well. But by the end, I felt confident that each of them could identify stroke symptoms and access the best possible care.”
The experience led St. Clair to contact the transit union in D.C. and hold a successful stroke educational session, and she also turned to an unlikely place – daycare centers when parents meetings are held. “The person who ends up calling 911 may be a family member, so it is important to educate people of all ages.”
Donna Johnson, a nurse who works with the health ministry at New Macedonia Church, saw upfront how effective the stroke educational sessions can be. She said it was “well received and very helpful” as well as culturally appropriate, and that it was passed on virally to church members who had not attended.
“Since our church is located in a ward with some of the highest health disparities in the city, the need for stroke prevention and early recognition is critical,” Johnson says.
By Renee Twombly, GUMC Communications