Danny R. Rose, Jr., MD

Brown DL, Conley KM, Sánchez BN, Resnicow K, Cowdery JE, Sais E, et al. A Multicomponent Behavioral Intervention to Reduce Stroke Risk Factor Behaviors: The Stroke Health and Risk Education Cluster-Randomized Controlled Trial. Stroke. 2015
Despite ample evidence regarding the importance modifiable risk factors for stroke prevention, optimal implementation of appropriate community interventions to promote positive lifestyle modifications remains uncertain. This is a particular concern for ethnic minority populations such as African Americans and Hispanic-Latinos, which have a higher prevalence of poorly controlled blood pressure and a greater burden of stroke. Given that these groups tend to have less favorable diet and exercise profiles and poorer access to preventative services, the need for developing culturally sensitive community preventative programs has been stressed. As a faith-based community intervention was feasible in studies centering on Protestant churches in the African-American community, Brown et al. used a similar approach, targeting 10 Catholic parishes within the Diocese of Corpus Christi, Texas.

The study randomized 10 Catholic churches and included 760 subjects, divided into control group and intervention groups. The intervention group received a one-year individual level program with culturally sensitive self-help materials focused on healthy eating, physical activity and blood pressure control, as well as newsletters, motivational interviewing calls and a 2 hour workshop on supportive peer counseling. Interventions were also done on the cluster level, promoting availability of lower sodium foods and fruits and vegetables at parish functions and programs to encourage healthy eating and physical activity. The control subjects received skin cancer awareness materials or sunblock at 3 and 9 months to maintain contact every three months, including assessments. Subjects were assessed during home visits for baseline and 12-month follow-up data, and with an interim 6-month telephone assessment. All three evaluations included validated questionnaires addressing dietary intake and physical activity. At baseline and 12 months, assessments included an average of recent blood pressure measurements, a fasting lipid panel, glucose and glycosolated hemoglobin, height and weight, waist circumference, a BP medication adherence question, and Self-Determination Theory measures. There were no significant baseline differences between the intervention and control groups. Over half of the subjects (56.3%) completed the baseline, 6 month and 12 month assessments, with about a quarter of subjects (25.8%) completing only the baseline and 12 month assessments; 28 subjects (3.7%) completed only the baseline and 6 month assessments.

There were significant improvements with the intervention for 2 of the 3 co-primary outcomes (decreased dietary sodium intake, p=0.04, and increased dietary fruit and vegetable intake, p=0.04). There was no impact on moderate or greater intensity physical activity. Similarly, there was no effect on systolic BP, a secondary outcome. Total dietary and saturated fat intake decreased in the intervention group, which was statistically significant after adjusting for age, sex, education and social desirability. There was no intervention effect for the remaining biological exploratory outcomes. Assessment of the Self-Determination Theory related outcomes, designed to measure perceived competence and motivation to adopt lifestyle modifications, showed a significant increase in perceived competence to eat more fruits and vegetables (p=0.01) and decrease in subjects reporting lack of motivation for dietary change (p=0.05). Self-reported adherence to the interventions was also assessed, with 74 percent of subjects completing at least one motivational call, 63 percent reporting having read at least one newsletter, 80 percent using the healthy eating guide and 55 percent using the exercise guide.

The outcomes of this study mirror similar community interventions finding a relatively modest effect of the intervention on risk factor modification. This and similar studies are subject to the inherent limitations of self-report and and the authors’ discussed their disappointment at the relatively low adherence rate in their study with respect to the interventions. Similar community and population-based risk factor intervention studies that utilize resource intensive, multi-faceted approaches to promote lifestyle modification tend to have only modest results, highlighting the complexity of the problem and what is likely a considerable amount of social and cultural underpinnings of poor diet and lack of physical activity. Additional studies are needed to identify and implement resource efficient programs for promoting healthier lifestyle choices. These programs should ideally involve a collaborative effort between healthcare providers, community leaders and government officials.