Todd S. Harwell

Public Education Strategies to Increase Awareness of Stroke Warning Signs and the Need to Call 911

Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. We implemented a 20-week public education campaign to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older before and after the intervention to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up (67% to 83%). Awareness increased significantly among both men and women and younger and older respondents. There was no significant change in the proportion of respondents indicating that they would call 911 if they witnessed someone having a stroke (74% to 76%). However, after the campaign, an increased proportion of respondents indicated that they would call 911 if they experienced sudden speech problems (51% to 58%), numbness or loss of sensation (41% to 51%), or paralysis (46% to 59%) that would not go away. Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911.

Do Persons With Diabetes Know Their (AIC) Number

PURPOSE The objective of this study was to compare self-reported knowledge about Al C testing with information from the medical record. METHODS A telephone survey was conducted among patients with diabetes in a rural fee-for-service practice and a community health center. Self-reported information regarding Al C testing, the last Al C value, and perceived blood glucose control was compared with the most current Al C value documented in the medical record. RESULTS Seventy five percent of survey respondents reported having 1 or more Al C tests in the past year, which generally agreed with information from their medical records. However, only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last Al C on the medical record. Among those with a documented Al C value, half described their blood glucose as very well controlled. The last Al C value, however, was <7.0% in only half of those respondents. CONCLUSIONS Persons with diabetes were aware of their previous Al C testing but did not interpret the values accurately in relation to their own glycemic control. If clinicians expect patient knowledge and understanding of glycemic control measures to improve outcomes of care, patient education will need to emphasize the meaning of these values.

Effectiveness of a Lifestyle Intervention Program Among Persons at High Risk for Cardiovascular Disease and Diabetes in a Rural Community

PURPOSE To evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in a rural community. METHODS In 2008, the Montana Diabetes Control Program worked collaboratively with Holy Rosary Healthcare to implement an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (N = 101). Participants set targets to reduce fat intake and increase physical activity (> or = 150 mins/week) in order to achieve a 7% weight loss goal. FINDINGS Eighty-three percent (n = 84) of participants completed the 16-session core program and 65 (64%) participated in 1 or more after-core sessions. Of those completing the core program, the mean participation was 14.4 +/- 1.6 and 3.9 +/- 1.6 sessions during the core and after core, respectively. Sixty-five percent of participants met the 150-min-per-week physical activity goal during the core program. Sixty-two percent achieved the 7% weight loss goal and 78% achieved at least a 5% weight loss during the core program. The average weight loss per participant was 7.5 kg (range, 0 to 19.7 kg), which was 7.5% of initial body weight. At the last recorded weight in the after core, 52% of participants had met the 7% weight loss goal and 66% had achieved at least a 5% weight loss. CONCLUSION Our findings suggest that it is feasible to implement a group-based DPP in a rural community and achieve weight loss and physical goals that are comparable to those achieved in the DPP.

Cardiovascular disease and risk factors in Montana American Indians and non-Indians

BACKGROUND Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. OBJECTIVE To compare CVD and risk factors in American Indian and non-Indian populations in Montana. METHODS Adult American Indians (n=1000) living on or near Montanas seven reservations and non-Indian (n=905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS Indians aged > or =45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18-44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged > or =45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged > or =45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). CONCLUSIONS Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

Implementing a State-Based Cardiovascular Disease and Diabetes Prevention Program

OBJECTIVE To evaluate weight loss and cardiometabolic risk reduction achieved through an adapted Diabetes Prevention Program intervention among adults at high risk for cardiovascular disease (CVD) and diabetes. RESEARCH DESIGN AND METHODS Eight health care facilities implemented a group-based lifestyle intervention beginning in 2008. Participants attended 16 weekly core sessions followed by 6 monthly after core sessions. RESULTS A total of 1,003 participants were enrolled, 816 (81%) completed the core and 578 (58%) completed the after core. Of participants completing the core and after core, 45 and 49% achieved the 7% weight loss goal, respectively. There were significant improvements in blood pressure, fasting glucose, and LDL cholesterol among participants completing the intervention. CONCLUSIONS Our findings indicate it is feasible for state-coordinated CVD and diabetes prevention programs to achieve significant weight loss and improve cardiometabolic risk.

Physical violence, intimate partner violence, and emotional abuse among adult American Indian men and women in Montana

BACKGROUND Little is known about the experience of American Indian communities relative to physical violence (PV), intimate partner violence (IPV), and emotional abuse. METHODS A random sample of adult American Indians living on or near the seven Montana reservations were interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 2001 (N = 1,006). Victimization from physical violence was defined as PV or sexual assault committed by any person. Respondents who reported experiencing PV and who reported that the perpetrator was a current or former spouse, boyfriend, girlfriend, or date were categorized as experiencing IPV. Emotional abuse was defined as fear for ones safety or being controlled by another individual. RESULTS Nine, one, and twelve percent of men reported experiencing PV, IPV, and emotional abuse in the past year, respectively. Five percent of women reported PV in the past year, 3% reported IPV, and 18% reported emotional abuse. Men who reported PV in the past year were more likely to be younger and report more days of physical and mental health problems in the past month. Women reporting PV in the past year were more likely to be younger and have more days with mental health problems in the past month. Few men (7%) or women (12%) reported ever being assessed for PV or safety. CONCLUSIONS Recent PV, IPV, and emotional abuse are prevalent for both American Indian men and women. Strategies to increase screening for PV and effective interventions for violence are needed.

Adapted Diabetes Prevention Program Lifestyle Intervention Can Be Effectively Delivered Through Telehealth

Purpose The purpose of this study was to assess the feasibility of delivering an adapted group-based version of the Diabetes Prevention Program’s (DPP) lifestyle intervention through telehealth video conferencing. Methods In 2009, the Montana Department of Public Health and Human Services in collaboration with Holy Rosary Heathcare implemented the DPP lifestyle intervention, which was provided to an on-site group in 1 community and simultaneously through telehealth to a second group in a remote frontier community. Participants obtained medical clearance from their primary care physician and were eligible if they were overweight and had 1 or more of the following risk factors: prediabetes, impaired glucose tolerance/impaired fasting glucose (IGT/IFG), a history of gestational diabetes (GDM) or the delivery of an infant >9 pounds, hypertension, or dyslipidemia. Results A total of 13 and 16 eligible adults enrolled in the on-site and the telehealth program, and 13 (100%) and 14 (88%) participants completed the 16-week program, respectively. Both the on-site and telehealth groups achieved high levels of weekly physical activity and there were no significant differences between groups. Over 45% of on-site and telehealth participants achieved the 7% weight loss goal with the average weight loss per participant greater than 6.4 kg in both groups. Conclusions Our findings suggest that it is feasible to deliver an adapted group-based DPP lifestyle intervention through telehealth resulting in weight loss outcomes similar to the original DPP.

Smoking cessation and prevention: An urgent public health priority for American Indians in the Northern Plains

Objective. The purpose of this study was to compare the prevalence of cigarette smoking and smoking cessation among American Indians living on or near Montanas seven reservations to those of non-Indians living in the same geographic region. Methods. Data for Montana Behavioral Risk Factor Surveillance System (BRFSS) respondents (n = 1,722) were compared to data from a BRFSS survey of American Indians living on or near Montanas seven reservations in 1999 (n = 1,000). Respondents were asked about smoking and smoking cessation as well as cardiovascular disease (CVD) and selected risk factors. Quit ratios were calculated for both groups. Results. American Indians were more likely to report current smoking (38%) than non-Indians (19%; p<0.001). Thirty-seven percent of Indian respondents with CVD risk factors reported current smoking, compared with 17% of non-Indians with CVD risk factors. However, there was no significant difference in reported smoking rates between Indians (21%) and non-Indians (27%) with a history of CVD. Indian smokers were more likely to report quitting for one or more days in the past year (67%), compared with non-Indians (43%). Quit ratios were significantly lower among Indians (43%) than among non-Indians (65%). Conclusions. High smoking rates in Indians, particularly among those with other CVD risk factors, demonstrate an urgent need for culturally sensitive smoking cessation interventions among Northern Plains Indians and highlight the need for the Surgeon Generals focus on smoking in minority populations.

Factors associated with achieving a weight loss goal among participants in an adapted Diabetes Prevention Program

AIMS To assess the factors associated with achieving the 7% weight loss goal among participants enrolled in an adapted Diabetes Prevention Program (DPP). METHODS Adults at high-risk (N=989) for CVD and diabetes were enrolled in the lifestyle intervention. Multiple logistic regression analyses were used to identify factors associated with achieving the weight loss goal. RESULTS Overall 37% of participants achieved the weight loss goal. Participants who were older, male, had a lower baseline BMI, self-monitored their fat and caloric intake more frequently, and who achieved higher levels of physical activity were more likely to achieve the weight loss goal compared to participants without these characteristics. In multivariate analyses more frequent self-monitoring of fat and caloric intake and higher levels of weekly physical activity were the only factors independently associated with participant achievement of the weight loss goal. CONCLUSIONS In a real-world translation of the DPP lifestyle intervention participants who achieved the weight loss goal were more likely to have monitored their dietary intake frequently and increased their physical activity markedly both in a dose-response relationship. Our findings highlight the importance of supporting participants in lifestyle interventions to initiate and maintain dietary self-monitoring and increased levels of physical activity.

Impact of Media on Community Awareness of Stroke Warning Signs: A Comparison Study

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms.