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Stroke Prevention Education in the Hispanic Community
The Hispanic population is the fastest growing minority population in the United States. Little research has been done to assess the stroke risk in the Hispanic population, which has a higher prevalence of hypertension, diabetes, alcohol use, and physical inactivity. Healthcare professionals therefore are faced with the management and education of a cultural group with unfamiliar health beliefs. To decrease the risk of stroke, a culturally sensitive program that combines education and risk identification is needed. This article identifies the development of a stroke education and screening program for Hispanics.
Providing health education has been identified as one of the most important steps toward modifying risk factors and minimizing disease. Primary prevention education about the risk factors and warning signs of stroke is believed to reduce its incidence and severity. Progress in stroke prevention and treatment will depend, at least in part, on education of the community at large regarding both risk factor reduction and the need for timely implementation of appropriate therapy (Stern et al., 1999). Improving community knowledge of stroke risk factors and stroke symptoms is a critical factor in improving access to preventive stroke treatments and acute stroke interventions (DeLemos, Atkinson, Croopnick, Wentworth, & Akins, 2003). But what if the information provided as part of the education is not pertinent? What if it doesn’t make sense? Would it still modify risk factors and minimize disease?
It is important not only that all ethnic groups have access to health education but also that the information is pertinent, not simply translated into their native language, in order to change behavior. The Hispanic population is the fastest growing minority group in the United States. Even though this population shares a common language, it is made up of people from various countries. Lack of education predisposes many Hispanics to disproportionate morbidity and mortality (Council on Scientific Affairs, 1995). Simply translating current written education information into Spanish does not address the cultural differences that increase the risk of stroke in Hispanics. As the Hispanic population ages, the stroke burden will be felt with increasing intensity (Smith, Risser, Lisabeth, Moye, & Morgenstern, 2003). The American Heart Association (AHA) admits that efforts to control stroke in the Hispanic population are far from adequate (AHA, 1999).
Stroke is one of the leading causes of death for Hispanic men and women in the United States. One out of every four deaths in Hispanic males and one out of every three deaths in Hispanic females in the United States is attributed to stroke or heart disease (AHA, 1998). The few research studies available that have examined stroke in Hispanics have found a higher occurrence of hemorrhagic strokes and stroke deaths in this population (Ayala et al., 2002; Smith et al., 2003). The age at which strokes occur varies between Hispanics and non-Hispanics, with strokes occurring more frequently in a younger population (69%) when compared with non-Hispanics (61%).
Numerous risk factors for stroke are more prevalent in Hispanics. Hispanics are more likely to have hypertension. The Third National Health and Nutrition Examination Survey found hypertension in 72% of Hispanics with stroke compared with 66% in non-Hispanics (Frey, Jahnke, & Bulfinch, 1998). This finding also can explain the increase in the risk for hemorrhagic stroke in this population. Diabetes is another risk factor more frequently occurring in the Hispanic population (36%) than non-Hispanics (17%). The National Institute of Diabetes and Digestive and Kidney Disease reports that 30% of Hispanic adults have diabetes, but as many as half of them are not aware of it (Bassett, 2002). Obesity not only is another more frequently occurring stroke risk factor in the Hispanic population, but also is associated with diabetes mellitus. Hispanics lead a more sedentary lifestyle; as a result, obesity is more common in this population than in the non-Hispanic population. The Third National Health and Nutrition Examination Survey reported that 65% of Mexican American men and 74% of Mexican American women participate in little or no leisure time physical activity (Bassett, 2002). Finally, there is a reported greater frequency of alcohol use in Hispanics (37%) than in non-Hispanics (23%; Staub, 2000). Alcohol consumption is specifically correlated to intercerebral hemorrhages. The risk of intercerebral hemorrhages in those who use alcohol is 3.3–6.5 times greater (Staub & Morgenstern, 2000). Risk factors that are less strongly correlated with the Hispanic population include gender, smoking, and cardiac disease.
The American Stroke Association, National Stroke Association, National Institute of Neurological Disorders and Stroke, and other major health organizations have emphasized educating the public about the signs and symptoms and risk factors of stroke. These organizations have used television, videotape, newspapers, educational pamphlets, and health seminars to disseminate their message. Community stroke screening is a prevention strategy commonly used to identify and educate those at risk (DeLemos et al., 2003). Collecting baseline data about patients’ stroke knowledge can help to determine the effectiveness of programs and adjust them to target specific populations and emphasize particular facts (Kothari et al., 1997). With the differences in stroke risk factors between Hispanics and non-Hispanics, it is important to focus on those areas pertinent to this population. Spending time on the education of those risk factors that are not applicable can turn away a population of individuals already suspicious of healthcare professionals and guarded about the use of Western medicine. Curanderos, or providers of folk medicine, are used quite frequently by Hispanic patients because of their low cost, shared language, and accessibility. To show the need for a culturally sensitive education program in this population, a training project was developed with assistance from the National Institute on Disability and Rehabilitation Research. Objectives were developed to ensure that the project maintained its cultural sensitivity. Project objectives included the following:
The first phase of the training project was dedicated to conducting focus groups to ensure that the content presented in the program was relevant and understandable. A preliminary English and Spanish slide show presentation about stroke, stroke risk factors, and prevention was presented to the focus groups. After input had been received from the focus groups about the presentation content and length, the slide show was modified and the next phase of the project began. A 20-item, multiple-choice questionnaire, the Stroke Knowledge Questionnaire, was developed to assess each participant’s stroke knowledge base (Figure 1). A second questionnaire, the Lifestyle Questionnaire, was also developed. This questionnaire was intended to ascertain the participants’ medical and lifestyle histories to be used later in the program (Figure 2). The program also included a stroke risk assessment screening. The risk assessment screening included cardiac rhythm assessment, blood pressure measurement, carotid bruit assessment, and blood glucose measurement.
After the program was finalized, the last phase of the project began. The project coordinator was responsible for contacting community organizations that served Hispanics in the Chicago area. The goal was to arrange one educational program per month in a Hispanic neighborhood. By presenting the educational session in Hispanic neighborhoods, the aim was to increase participation by those who normally do not venture outside their community because of lack of transportation or language barriers. The Northwestern University institutional review board approved the program.
Each participant who arrived at the educational program was asked to sign a consent form. After consent was obtained, participants were asked to complete the Stroke Knowledge Questionnaire. If the group had difficulty reading, the project coordinator read each question and the answers to the group, without revealing the correct answer. After completing the Stroke Knowledge Questionnaire, participants were asked to complete the Lifestyle Questionnaire. Participants then viewed a 30-minute slide show presentation narrated in Spanish. The show included the different types of stroke, stroke risk factors, and ways to decrease stroke risk. The methods to decrease stroke risk included cultural issues such as diet, sedentary lifestyle, hypertension, diabetes mellitus, and medical management. Following the slide show presentation, the participants underwent a Stroke Risk Assessment Screening. At this time the participants were also told how they could reduce their own risk factors based on the Risk Assessment Screening results and the answers to their Lifestyle Questionnaire. Each program lasted between 1 and 2 hours depending on the size of the group.
During the 24-month period between September 2001 and August 2003, 177 persons participated in the program at 10 different sites. Sites included the Chicago Department of Public Health, the Erie Community Church, the Erie House, the Hermosa Community Center, Latino Family Services, Our Lady of the Resurrection Hospital, the Pilsen-Little Village Mental Health Center, the Puerto Rican Parade Committee, the St. Elizabeth Hospital Programa Cielo, and the Swedish Covenant Hospital. Results from the Lifestyle Questionnaire showed 125 (71%) of the participants spoke Spanish and 52 (29%) spoke English as their primary language. Responses to the question on the country of origin or race revealed that 69 (39%) of the participants were Mexican, 21 (12%) Puerto Rican, 21 (12%) South American, 29 (16%) Caucasian, 10 (6%) African American, and 5 (3%) Asian; 122 (2%) did not answer the question. Other personal information on project participants showed that 113 (64%) were female and 42 (24%) were male; 12% did not answer the question. The mean age was 52 years; the median age was 53 years.
The results of the Lifestyle Questionnaire are presented in Table 1. Of the 177 participants, 65% reported that they had never had a stroke, 6% had a previous stroke, and 31% were unsure or did not respond. When queried about family history, 40% reported they had never had someone in their family with a stroke or TIA, 28% did have a family member with a stroke, 15% were unsure, and 17% did not answer the question. When asked whether they exercised, 51% answered yes, 33% answered no, and 16% did not respond. In regard to smoking, 81% responded no and 6% responded yes. For alcohol use, 66% of the participants reported not drinking, 22% admitted to drinking, and 13% did not answer the question. When responding to the question of diabetes, 12% admitted to having diabetes mellitus and 73% answered no. On the Stroke Knowledge Questionnaire, of the possible perfect score of 20, the mean pretest score was 13.42 and the mean posttest score was 14.86. Paired students’ t tests were performed to compare the change from the pretest score with the posttest score. The means were statistically significant (t = –3.63, p < .001).
Project results showed that a culturally sensitive educational program could improve knowledge of stroke risk factors, warning signs, and lifestyle changes. Targeting risk factors specific to the Hispanic population allows for the group to identify potential lifestyle changes. In the Lifestyle Questionnaire, the unusually large number of participants who were unsure of whether they or someone in their family had ever had a stroke is consistent with the reported lack of knowledge of what stroke is and its symptoms. Most participants responded that a stroke occurred in the heart. The unusually large number of participants who reported exercising was further questioned by the project coordinator because this result was not consistent with the review of the literature that found Hispanics to be more sedentary than non-Hispanics. A large portion of participants responding yes to the exercise question considered walking in their everyday activities or simply working outside of the home a form of exercise. With this additional information, the education program was altered to emphasize that aerobic exercise for 20–30 minutes, 2–3 times a week is the best type of exercise to prevent stroke. The responses on alcohol use were also not consistent with literature reports. When participants were questioned further, it was determined that the large number of older female participants contributed to this negative result. Also noted was underreporting by participants secondary to the stigma associated with alcohol use. One participant reported no alcohol use, but when further questioned, she reported drinking six beers every evening. This same reasoning may explain the small percentage of participants who reported a diagnosis of diabetes mellitus. Because the blood glucose measurement was random and not fasting, only one participant had a random blood glucose level of over 300. This person had no previous history of diabetes mellitus. The small percentage of participants who reported heart disease and a history of smoking is consistent with the review of the literature.
Based on feedback from participants and the experience of presenting the education program in the community, there are several recommendations for modifying the program for future use. Because of literacy issues and time constraints, questionnaires to obtain baseline stroke knowledge should be limited to 10 questions or fewer to improve compliance and enable staff to spend more time with participants in the risk assessment screening. Participants in this project came for the free Stroke Risk Assessment Screening and felt more comfortable asking personal questions during that time. Because of healthcare barriers and lack of health insurance, providing free health screenings as part of the educational program can not only increase attendance but also personalize the information presented and improve compliance. The slide show or education piece of the program should be eliminated, however. Because of the stroke information provided during the education piece of the program, the participants knew what questions to ask during the risk-assessment screening. Another knowledge deficit coincidentally identified during this educational project was the lack of knowledge about medications. Few patients were able to answer the Lifestyle Questionnaire question regarding medication names, dosage, and frequency. During this project, participants were given an index card and instructed to write the name, dosage, and frequency of their medications and carry the card with them at all times. This would prevent any problems in medication management especially because many participants received medical care at clinics where different physicians may see them at each visit or in the event of an emergency. Also, this would avoid confusion with a non-English-speaking healthcare provider.
When any educational material or program are being developed to meet the needs of the Hispanic population, it is important to understand not only the language but also the cultural differences, which include customs and healthcare beliefs. Simply translating existing material into Spanish does not address the lack of education or barriers to healthcare access already experienced by some Hispanics. Creating information that addresses these cultural differences will begin to meet the needs of a growing minority population and prevent the long-term disability associated with stroke.
This work was supported by the Rehabilitation Research and Training Center on Enhancing the Quality of Life of Stroke Survivors, a grant awarded from the U.S. Department of Education, National Institute of Disability and Rehabilitation Research (H133B9080021).
About the Author
Sylvia A. Duraski, MS RN CS CRRN-A, is a nurse practitioner at the Rehabilitation Institute of Chicago, Chicago, IL. Address correspondence to her at 345 E. Superior Street, Chicago, IL 60611, or to her e-mail address Sduraski@rehabchicago.org.
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