Year: 2017
Type: review
Abstract: S ocial and behavioral factors, also termed social determi- nants of health, are increasingly established risk factors for incident and recurrent stroke, both ischemic and hemorrhagic stroke, yet improvement in addressing these factors remains insufficient. 1There is a lack of clarity on who should share in accountability for reducing risk (eg, patients, providers, or health systems) and what interventions are practical, cost-effective, and scalable. 2For the purpose of this review, we will use the definition of an intervention as a set of actions with a coherent objective to bring about change or produce identifiable outcomes. 3We first review the published literature to summarize the relevant research on previous behavioral interventions for prevention of stroke and other related conditions, the theoretical frameworks underpinning these behavioral interventions, and then propose a new conceptual model for more effective implementation of social and behavioral interventions for stroke prevention.Successful implementation will require adequately addressing the known inherent barriers to behavioral interventions and the ambiguity of financial responsibility and accountability among the various stakeholders.Because new tools, such as digital phenotyping, social network analysis, machine learning, and gamification, have emerged for facilitating, measuring, and improving existing behavioral interventions, a promising new paradigm in behavioral change has emerged. Behavioral Interventions in StrokeTable 1 categorizes the various behavioral interventions by operational level, risk factor targets, and tactics that range from the simple (eg, provider referral for behavior change program) to the complex (eg, multifaceted, multidomain intervention). 4 Table 2 summarizes the prior interventions specific to stroke prevention covered in 3 major systematic Cochrane reviews.Because the evidence suggests that modifiable risk factors are often not effectively managed after a stroke or transient ischemic attack, the first review sought to identify interventions for improving control of 6 major modifiable risk factors 5 of blood pressure, lipids, atrial fibrillation, diabetes mellitus, body mass index, and general medication adherence.Twenty-six studies of reasonable quality involving 8021 participants with ischemic stroke, hemorrhagic stroke, or nonspecified pathogenesis through April 2013 in the United States, Canada, Europe, Asia, and Australia were identified for inclusion.The majority were conducted in primary care or community settings and were of 3-to 12-month duration.Eleven studies involved educational or behavioral interventions for participants, and 15 studies involved predominantly organizational interventions.Changes to the organization of healthcare services were associated with meaningful improvements in systolic and diastolic blood pressure, blood pressure target achievement, and body mass index.Examples of organizational interventions include professional role revision (eg, nonphysician staff involvement in prevention clinics), multidisciplinary team collaboration (eg, primary and secondary care team coordination), and integrated care services (eg, disease and case management programs after screening, education, treatment, and surveillance protocols).The effects of these interventions on changes in blood lipids, diabetes mellitus management, medication adherence, or the occurrence of stroke and other cardiovascular events were equivocal.Overall, changes to healthcare delivery services that addressed patient education or behavior in isolation without changes to the organization of care delivery were not associated with clinically significant changes in modifiable risk factors for stroke.The second review analyzed the effectiveness of multidimensional, nonpharmacologic interventions used in cardiac rehabilitation, including aerobic training, dietary advice or nutritional strategies, verbal or written patient education, and lifestyle counseling delivered by health professionals or other personnel and compared these with usual care in preventing secondary vascular events and reducing vascular risk after index stroke or transient ischemic attack. 6nly 1 study was identified that met inclusion criteria involving 48 participants in a 10-week pilot cardiac rehabilitation program for poststroke patients and showed that patients after stroke had a significantly greater improvement in standardized cardiac risk score.The third review focused on physical fitness training for mostly ambulatory stroke patients and included 58 trials with a total of 2797 participants at all stages of care after stroke up through February 2015.
Source: Stroke
Authors: Joel Salinas, Lee H. Schwamm
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2612496085