Background: Hypertension is the most important modifiable stroke risk factor, but blood pressure (BP) remains poorly controlled after stroke, especially among Black and Hispanic patients. We tested the feasibility of TASC (Telehealth After Stroke Care), a post-acute stroke care model integrating nurse-supported home BP telemonitoring, tailored infographics, and multidisciplinary team video visits. Methods: Acute stroke patients with hypertension were randomized at discharge to usual care or usual care with TASC. Usual care patients received video visits with primary care and stroke. TASC included a tablet and monitor to wirelessly transmit BP data to the electronic health record, with telenursing support, tailored infographics to explain BP readings, and pharmacist visits. Outcomes assessment was blinded. Feasibility outcomes included recruitment, randomization, adherence, and retention. Systolic BP from baseline to 3 months after discharge was evaluated using generalized linear modeling. Results: Fifty patients (64±14 years; 36% women‚ 44% Hispanic, 32% Black, 54% ≤high school education, 30% private insurance), and 75% of all eligible were enrolled over 6.3 months. Baseline systolic BP was similar in both (TASC n=25, 140±19 mm Hg; usual care n=25, 142±19 mm Hg). At 3 months, adherence to video visits (91% versus 75%, P =0.14) and retention (84% versus 64%, P =0.11) were higher with TASC. Home systolic BP declined by 16±19 mm Hg from baseline in TASC and increased by 3±24 mm Hg in usual care ( P =0.01). Among Black patients, systolic BP control (<130 mm Hg) improved from 40% to 100% with TASC versus 14% to 29%, and among Hispanic patients, from 23% to 62% with TASC, versus 33% to 17% in usual care. Conclusions: Enhancing post-acute stroke care with home BP telemonitoring is feasible to improve hypertension in an underserved setting and should be tested in a definitive randomized clinical trial. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04640519.

Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol’s pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial ( CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.

Background and Purpose—: 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. Methods—: 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. Results—: 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. Conclusions—: HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities. Clinical Trial Registration—: URL: https://clinicaltrials.gov . Unique identifier: NCT01497886.

The prevalence of hypertension continues to rise in low- and middle-income- countries (LMICs) where scalable, evidence-based interventions (EBIs) that are designed to reduce morbidity and mortality attributed to hypertension have yet to be fully adopted or disseminated. We sought to evaluate evidence from published randomized controlled trials using EBIs for hypertension control implemented in LMICs, and identify the WHO/ExpandNet scale-up components that are relevant for consideration during “scale-up” implementation planning. Systematic review of RCTs reporting EBIs for hypertension control implemented in LMICs that stated “scale-up” or a variation of scale-up; using the following data sources PubMed/Medline, Web of Science Biosis Citation Index (BCI), CINAHL, EMBASE, Global Health, Google Scholar, PsycINFO; the grey literature and clinicaltrials.gov from inception through June 2021 without any restrictions on publication date. Two reviewers independently assessed studies for inclusion, conducted data extraction using the WHO/ExpandNet Scale-up components as a guide and assessed the risk of bias using the Cochrane risk-of-bias tool. We provide intervention characteristics for each EBI, BP results, and other relevant scale-up descriptions. Thirty-one RCTs were identified and reviewed. Studies reported clinically significant differences in BP, with 23 studies reporting statistically significant mean differences in BP (p < .05) following implementation. Only six studies provided descriptions that captured all of the nine WHO/ExpandNet components. Multi-component interventions, including drug therapy and health education, provided the most benefit to participants. The studies were yet to be scaled and we observed limited reporting on translation of the interventions into existing institutional policy (n = 11), cost-effectiveness analyses (n = 2), and sustainability measurements (n = 3). This study highlights the limited data on intervention scalability for hypertension control in LMICs and demonstrates the need for better scale-up metrics and processes for this setting. Registration PROSPERO (CRD42019117750).

The age-adjusted incidence of a first ischemic stroke is higher among black and Hispanic individuals compared with persons of white race/ethnicity,¹ yet they are less likely to use ambulance services, which is associated with delayed hospital arrival and ineligibility for intravenous tissue plasminogen activator use for acute stroke.² Outcomes are largely dependent on patient recognition of stroke symptoms and immediate presentation in the emergency department.³ Stroke preparedness, or the ability to recognize that a stroke is occurring and appropriately call 911, is poor among black individuals and Hispanic individuals compared with whites and may be partly responsible for some of the racial/ethnic disparities observed in acute stroke treatment.^4,5 Most community stroke preparedness interventions have been evaluated with short-term outcomes of behavioral intent, despite the tendency for these effects to decay over time.

Owing to their enormous capacity to improve health and save lives, public health researchers and practitioners have worked on developing effective frameworks for the optimization of health promotion strategies. A multilevel focus, as exemplified by the Socio-Ecological Model (SEM), is one common denominator among these frameworks. The SEM highlights important social and ecological influences on health behavior by delineating the different levels of influence. These include public policy, organizational, community, interpersonal, and intrapersonal levels, which, when considered during the development of health promotion campaigns—especially those that focus on health education—strengthen the influence of that campaign on targeted behaviors. However, the SEM lacks a complimenting framework for understanding the role of conventional and unconventional approaches to health education; that is, how to design a health education intervention that considers both the context, such as the social and ecological levels of influence, and the best approaches for developing and delivering the health education in a manner that optimizes its effectiveness in today’s modern and increasingly diverse world. Addressing this gap, the current article presents an integrative Multisensory Multilevel Health Education Model (MMHEM), which incorporates three key domains—(1) Art (innovativeness/creativity), (2) Culture (cultural tailoring), and (3) Science (evidence-based), while promoting the importance of considering the socio-ecological levels of influence on targeted behaviors. Using a successful health education intervention, called the Hip Hop Stroke, we deconstruct the Multisensory Multilevel Health Education Model and discuss its potential role as a guide for developing public health education interventions.