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Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention.
This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019).
Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected
Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain
Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US
Social inequities affecting minority populations after Hurricane Katrina led to an expansion of the environmental justice literature after large-scale floods [
Houston is not only ranked among the most flood-impacted urban centers in the United States but also has some of the highest national stroke mortality rates, significantly affecting minority health [
Minority populations are receptive to the use of mobile health (mHealth) technology for health interventions; however, racial differences in technology use and internet access persist [
Studies have shown that ongoing public education on stroke symptoms improves stroke recognition [
There are limited data regarding the practice of community engagement in stroke systems of care in flood-prone areas [
The purpose of this study was to implement Stomp Out Stroke, a hybrid multimedia education and health screening paradigm, serving a population disproportionately affected by Hurricane Harvey flooding. We hypothesize that the Stomp Out Stroke structure identifies and provides targeted health interventions, fulfilling specific needs, stratified by race and ethnicity. Multiple coastal cities in the Southern
Stomp Out Stroke is a prospective observational study and a collaborative public education initiative, which was implemented by the Vascular Neurology Program at the McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth) as part of the Joint Commission–Certified Integrated Stroke Healthcare System at Memorial Hermann Health System. Both institutions are located in the 2.1 square mile Texas Medical Center, topographically distributed within the 100-year and 500-year floodplains due to Brays Bayou, a slow-moving river that borders the health care district [
Stomp Out Stroke flow process.
Recruitment for participation in Stomp Out Stroke occurred exclusively via web-based platforms. Both the Texas Medical Center and the Texas Heart Institute provided location information, types of activities, and links to the registration website [
Evidence-based protocols for primary stroke prevention were followed using the US Preventive Services Task Force Guide to Clinical Preventive Services [
Houston is the fourth largest city in the United States, with a 2018 population estimate of 2.3 million people [
Stomp Out Stroke was divided into five zones: central, stage and entertainment, healthy brain, stroke recovery, and children’s. Each zone had health education and screening stations and was staffed by a volunteer coordinator and co-coordinator. Family-friendly activities and entertainment, including local multicultural dance groups, were included throughout the program (
To address disparities in stroke literacy due to language barriers, bilingual health care providers and students were recruited as volunteers to assist in registration or check-in and to conduct health screenings or risk assessments in Spanish, simplified Chinese, and Vietnamese.
Assessment of impact was determined through the completion of onsite health screenings and stroke risk assessments. Each health screening consisted of vascular risk factor counseling, risk modification strategies, and recommended primary care provider follow-up. At the end of each screening, participants received printed educational materials and a give-away item (value <US $5). Automated blood pressure monitors (HEM-7222-ITZ; Omron Healthcare, Inc) were used to obtain a single measure. Additional health screenings included bone density, carotid ultrasound, BMI, serum lipids, and hemoglobin A1c. The 10-year stroke risk was calculated utilizing a modified Framingham stroke risk profile assessment tool, which contains age, sex, and baseline measurements of cerebrovascular risk factors, including systolic blood pressure, use of antihypertensive medications, current smoking status, presence of cardiovascular disease, current or prior atrial fibrillation, and diabetes mellitus (
Institutional review board approval was obtained at the McGovern Medical School at UTHealth to collect voluntary onsite and web-based registration data (HSC-MS-15-0813—UT Stroke Team Community Outreach Program). The UTHealth Institute for Stroke and Cerebrovascular Diseases has an archive of past Stomp Out Stroke events, detailing the evolution of the program before the study period [
Sociodemographic characteristics were summarized using frequency and percentage or median and IQR for nonnormal distributions. Comparisons by racial group or ethnicity (Asian, Black or African American, Hispanic, or non-Hispanic White) were conducted using the Kruskal-Wallis (for age) or chi-square test. A
Summary of sociodemographic characteristics: 2018 and 2019 Stomp Out Stroke registrants (N=1401).
Variable | Value | |
Age in years (n=1381), median (IQR) | 45.0 (36-57) | |
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Female | 973 (70) |
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Male | 417 (30) |
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Married | 770 (55.68) |
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Not married | 613 (44.32) |
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Hispanic | 449 (32.05) |
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Black or African American | 359 (25.62) |
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Non-Hispanic White | 331 (23.63) |
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Asian | 191 (13.63) |
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Other, two, or more races | 49 (3.5) |
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American Indian, Alaska Native, Native American, or Pacific Islander | 5 (0.36) |
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Unknown | 17 (1.21) |
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White | 234 (52.12) |
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Black or African American | 9 (2) |
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American Indian, Alaska Native, Native American, or Pacific Islander | 8 (1.78) |
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Asian | 3 (0.67) |
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Other, two, or more races | 136 (30.3) |
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Unknown | 59 (13.29) |
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No | 882 (63.5) |
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Yes | 507 (36.5) |
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Employer based | 614 (45.75) |
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Medicare or Medicaid | 251 (18.7) |
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Private insurance | 205 (15.28) |
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Self-insured | 44 (3.28) |
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Uninsured | 228 (16.99) |
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More than high school | 1053 (79.11) |
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High school or less | 278 (20.89) |
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No | 1187 (88.45) |
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Yes | 155 (11.55) |
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No | 1215 (90.74) |
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Yes | 124 (9.26) |
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No | 846 (63.18) |
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Yes | 493 (36.81) |
The median registrant age was 45 years; 69.54% (973/1390) were female and 55.68% (770/1383) were married. Overall, 32.05% (449/1401) of registrants self-identified as Hispanic, 25.62% (359/1401) self-identified as Black or African American, 23.63% (331/1401) self-identified as a non-Hispanic White person, and 13.63% (191/1401) self-identified as Asian.
A total of 63.5% (882/1389) of Stomp Out Stroke participants did not have children, 79.11% (1053/1331) had more than a high school education, and 45.75% (614/1342) had employer-based health insurance. Moreover, 155 Stomp Out Stroke participants were self-reported stroke survivors and 124 were caregivers. Nearly 36.81% (493/1339) of the registrants had a family history of stroke (
Hispanic participants were the least likely among the four ethnic groups to have education past high school (274/432, 63.4% vs 269/322, 83.5% non-Hispanic White; 291/338, 86.1% African American; and 164/176, 93.2% Asian participants), and African American participants were the least likely to be married (128/357, 35.9% vs 200/329, 60.8% non-Hispanic White; 274/443, 61.9% Hispanic; and 123/189, 65.1% Asian participants;
African American participants were the most likely to have Medicare or Medicaid insurance 24.6% (84/341), whereas Hispanic participants were the most likely to be uninsured 29.2% (127/435). In total, 19.9% (68/341) of African American registrants were stroke survivors; this group was the most likely to have a family history of stroke 46.5% (158/340) and more likely than non-Hispanic White or Hispanic people to have previously participated in Stomp Out Stroke (
Sociodemographic characteristics of Stomp Out Stroke participants by racial or ethnic group (N=1401).
Variable | Asian | Black or African American | Non-Hispanic White | Hispanic | |||
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<.001 | ||||||
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Participants, n | 187 | 353b | 330c | 443b,c |
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Value, median (IQR) | 45.0 (34.0-55.0) | 48.0 (38.0-58.0) | 49.0 (36.0-60.0) | 43.0 (34.0-55.0) |
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.01 | ||||||
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Participants | 188 (100)b | 358 (100)b,c | 330 (100)c | 446 (100) |
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Female | 124 (66) | 274 (76.5) | 216 (65.5) | 311 (69.7) |
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Male | 64 (34) | 84 (23.5) | 114 (34.5) | 135 (30.3) |
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<.001 | ||||||
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Participants | 176 (100)b,c | 338 (100)d | 322 (100)b,e | 432 (100)c,d,e |
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More than high school | 164 (93.2) | 291 (86.1) | 269 (83.5) | 274 (63.4) |
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High school or less | 12 (6.8) | 47 (13.9) | 53 (16.5) | 158 (36.6) |
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<.001 | ||||||
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Participants | 189 (100)b | 357 (100)b,c,d | 329 (100)c | 443 (100)d |
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Married | 123 (65.1) | 128 (35.9) | 200 (60.8) | 274 (61.9) |
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Not married | 66 (34.9) | 229 (64.1) | 129 (39.2) | 169 (38.1) |
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<.001 | ||||||
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Participants | 180 (100)b,c | 341 (100)b,d,e | 322 (100)d,f | 435 (100)c,e,f |
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Employer based | 107 (59.4) | 151 (44.3) | 182 (56.5) | 144 (33.1) |
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Medicare or Medicaid | 16 (8.9) | 84 (24.6) | 53 (16.5) | 87 (20) |
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Private insurance | 22 (12.2) | 50 (14.7) | 49 (15.2) | 70 (16.1) |
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Self-insured | 11 (6.1) | 11 (3.2) | 13 (4) | 7 (1.6) |
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Uninsured | 24 (13.3) | 45 (13.2) | 25 (7.8) | 127 (29.2) |
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.05 | ||||||
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Participants | 191 (100) | 355 (100) | 329 (100) | 448 (100) |
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No | 135 (70.7) | 225 (63.4) | 220 (66.9) | 270 (60.3) |
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Yes | 56 (29.3) | 130 (36.6) | 109 (33.1) | 178 (39.7) |
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<.001 | ||||||
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Participants | 180 (100)b,c | 341 (100)b,d,e | 321 (100)c,d | 438 (100)e |
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No | 173 (96.1) | 273 (80.1) | 284 (88.5) | 404 (92.2) |
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Yes | 7 (3.9) | 68 (19.9) | 37 (11.5) | 34 (7.8) |
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.03 | ||||||
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Participants | 178 (100)b | 339 (100) | 323 (100)b | 435 (100) |
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No | 152 (85.4) | 304 (89.7) | 301 (93.2) | 399 (91.7) |
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Yes | 26 (14.6) | 35 (10.3) | 22 (6.8) | 36 (8.3) |
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<.001 | ||||||
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Participants | 178 (100)b | 340 (100)b,c,d | 322 (100)c | 435 (100)d |
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No | 117 (65.7) | 182 (53.5) | 211 (65.5) | 292 (67.1) |
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Yes | 61 (34.3) | 158 (46.5) | 111 (34.5) | 143 (32.9) |
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<.001 | ||||||
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Participants | 181 (100) | 343 (100)b,c | 323 (100)b | 439 (100)c |
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No | 136 (75.1) | 221 (64.4) | 256 (79.3) | 353 (80.4) |
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Yes | 45 (24.9) | 122 (35.6) | 67 (20.7) | 86 (19.6) |
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aExcept for the
b-fIndicate significant differences in pairwise comparisons of either median scores or proportions in different ethnic groups. The presence of the same letter in the columns for two race or ethnic groups (ie, “a” in the Asian and “a” in the African-American race columns) indicate a significant difference between the median scores or proportions between those two respective ethnic groups.
Participant interest in attending Stomp Out Stroke by racial or ethnic group (n=1330).
Variable | Asian | Black or African American | Non-Hispanic White | Hispanic | ||||||||
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.01 | |||||||||||
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Participants | 191 (100)b | 359 (100)b | 331 (100) | 449 (100) |
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No | 125 (65.4) | 186 (51.8) | 188 (56.8) | 270 (60.1) |
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Yes | 66 (34.6) | 173 (48.2) | 143 (43.2) | 179 (39.9) |
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.03 | |||||||||||
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Participants | 191 (100) | 359 (100) | 331 (100)b | 449 (100)b |
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No | 82 (42.9) | 137 (38.2) | 156 (47.1) | 167 (37.2) |
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Yes | 109 (57.1) | 222 (61.8) | 175 (52.9) | 282 (62.8) |
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<.001 | |||||||||||
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Participants | 191 (100)b,c | 359 (100)d,e | 331 (100)b,d | 449 (100)c,e |
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No | 86 (45) | 158 (44) | 193 (58.3) | 256 (57) |
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Yes | 105 (55) | 201 (56) | 138 (41.7) | 193 (43) |
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.002 | |||||||||||
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Participants | 191 (100) | 359 (100)b | 331 (100)b | 449 (100) |
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No | 107 (56) | 193 (53.8) | 223 (67.4) | 278 (61.9) |
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Yes | 84 (44) | 166 (46.2) | 108 (32.6) | 171 (38.1) |
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<.001 | |||||||||||
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Participants | 191 (100)b | 359 (100)c | 331 (100)b,c | 449 (100) |
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No | 137 (71.7) | 268 (74.7) | 283 (85.5) | 353 (78.6) |
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Yes | 54 (28.3) | 91 (25.3) | 48 (14.5) | 96 (21.4) |
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aExcept for the
b-eIndicate significant differences in pairwise comparisons of either median scores or proportions in different ethnic groups. The presence of the same letter in the columns for two race or ethnic groups (ie, “a” in the Asian and “a” in the African-American race columns) indicate a significant difference between the median scores or proportions between those two respective ethnic groups.
During the 2018 and 2019 events, 2774 health screenings were completed within a period of 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A1c (102/2774, 3.67%).
Before the 2018 event, 27 Facebook posts were displayed between December 21, 2017, and April 23, 2018, reaching 17,975 people, with 782 likes, comments, and shares; 648 post clicks; 339 page likes; and 340 page followers. The hashtag
This study provides novel insights regarding the implementation of Stomp Out Stroke, using multimedia engagement, followed by in-person stroke education and health screening initiative, among a large minority population disproportionately affected by large-scale flooding events and cerebrovascular disease. Stomp Out Stroke registrants were representative of Houston racial or ethnic demographics, including Hispanic or Latino (449/1401, 32.05%), African American (359/1401, 25.62%), and Asian (191/1401, 13.63%). Our population was young (median age 45 years), largely female, and had received more than a high school education. Overall, 16.99% (228/1342) of Stomp Out Stroke participants were uninsured, and 18.70% (251/1342) of the participants were insured through Medicare or Medicaid.
The low adoption rates of electronic consultations for cerebrovascular risk factors, such as hypertension and diabetes, leave questions about overall use and generalizability [
The American Heart Association has recently focused on the use of internet-based recovery strategies for stroke survivors [
An analysis by the City of Houston estimated that 208,353 of 848,340 households were affected by Hurricane Harvey, with a disproportionate number consisting of racial or ethnic minorities and those of lower socioeconomic status [
Community engagement paradigms focused on stroke literacy help improve the awareness of signs and symptoms [
This study has some limitations. First, the organization and planning of Stomp Out Stroke is led by the Director of Stroke Community Outreach and Education, a full-time faculty member at the McGovern Medical School at UTHealth trained in Vascular Neurology. Her position is supported by endowment funds; sustaining Stomp Out Stroke requires collaborative efforts from multiple faculty members and neurology departmental support staff. Second, Stomp Out Stroke is funded through sponsorships, educational grants, philanthropy, and in-kind donations. Cost mitigation occurred by leveraging free educational resources at the local, state, and national levels. Third, a formalized emergency medical services and safety plan (
Stomp Out Stroke combined multimedia engagement with in-person health screenings to improve environmental justice for underserved populations at increased risk of urban flooding and cerebrovascular disease. The next step will focus on the use of mHealth technology to assess behavioral changes among repeat attendees, recurrent stroke among stroke survivors, and objective measures of stroke knowledge and preparedness.
Stomp Out Stroke program content.
Modified Framingham stroke risk profile—males and females.
Stomp Out Stroke multimedia report.
Stomp Out Stroke emergency medical services and safety plan.
mobile health
University of Texas Health Science Center at Houston
None declared.