1. Implementation and Evaluation of the Maine HeartSafe Communities Initiative APHA 139th Annual Meeting and Exposition Washington, DC Session 3451.0, Rural Health: Needs and Initiatives Monday, October 31, 2011: 4:30 PM Ruth Dufresne, MS; Center for Community and Public Health, University of New England, Portland, ME Danielle Louder, Public Health Division, Medical Care Development; Maine CDC CVH Program, Augusta, ME Patrick Madden, Market Decisions, Portland, ME Nisha Kini, M.B.B.S., M.P.H; Sara Huston, PhD ; and Robyn Reynolds, MPH, Department of Applied Medical Sciences, University of Southern Maine, Portland, ME Troy Fullmer, Diabetes Prevention & Control and Cardiovascular Health Programs, Division of Chronic Disease Maine CDC, DHHS, Augusta, ME

2. Acknowledgements Centers for Disease Control and Prevention Division of Heart Disease and Stroke Prevention: Jan Jernigan, Susan Ladd, Ron Todd Research Triangle Institute: Karen Isenberg, Deb Osber, James Hersey, Karen Bandel, Pam Williams- Piehota Maine CDC/DHHS Cardiovascular Health Program: Debra Wigand, Kathy Decker, Katie Meyer, Pat Hart Maine State and Regional Emergency Medical Services: Jay Bradshaw, Donnie Carroll, Steve Corbin, Joanne LeBrun and Rick Petrie APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives 2

3. Presenter Disclosure Ruth Dufresne No relationships to disclose APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives 3

4. Background 2006 – CDC Heart Disease and Stroke Prevention (HDSP) Promising Practices Project CDC solicited voluntary applications, 7 state programs selected for evaluation (including Maine HeartSafe Communities) 4APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

5. Background (cont.) Maine HeartSafe Communities Maine is a rural state, with many living in rural areas per U.S. Census Bureau Based on cardiovascular “Chain of Survival”; adapted and expanded from MA HeartSafe Community Program Developed by the Maine Center for Disease Control and Prevention’s Cardiovascular Health Program (MCVHP) and Maine Emergency Medical Services APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives5

6. Background (cont.) Requirements for Meeting Recognition Levels Recognition LevelProviders and/or their Community Partners Must... Basic Offer cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training to their community members. Offer cardiovascular-related education and/or awareness activities in their community, including symptoms of heart attack and stroke/call 911. Have at least one emergency response designated vehicle equipped with an AED. Have placement of at least one permanent AED with AED-trained personnel in public or private areas where many people are likely to congregate or be at higher risk for cardiac arrest (such as shopping malls, large employers, airports). Dispatch Advanced Cardiac Life Support (ALS) units or personnel to all priority medical emergencies either as primary responders or as ALS backup. ALS backup may occur on-scene, en-route, or at the hospital emergency department. Have an ongoing process to evaluate and improve the “chain of survival” in their community. Silver Pre-arrival instructions for Emergency Medical Dispatch (EMD) on heart attack and stroke calls. Gold 12-lead EKG capability and service permitted at paramedic level or interceptor agreement in place. Platinum Service licensed at paramedic level (paramedics are dispatched to 100% of calls). APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives6

7. Implementation (limited to education on heart attack and stroke symptom recognition) 2006: 7* HeartSafe Communities cover 20 communities & approx. 59,138 Maine residents 2007: 13* HeartSafe Communities cover 64 communities & 189,248 ME residents As of August, 2011 – 59 HeartSafe Communities cover 267+ communities & 829,500 ME residents (64% of the population) *There were more HSC initially, but this number remained at the time of analysis. Reapplication required every 2 years. APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives 7

8. Implementation (cont.) In FY 2008, CDC HDSP/RTI evaluation found HeartSafe Communities increased the number of community education events provided in their communities In FY 2010, HeartSafe Communities reported 182 community education activities APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives8

9. Implementation (cont.) As of FY 2011, 82% of local Healthy Maine Partnerships (local public health infrastructure) partnered with 482 worksites & their HeartSafe Community on education strategies APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives9

10. Other Statewide Educational Efforts: Heart Attack “In A Heartbeat” train-the-trainers have trained over 130 local EMS, nurses, health educators, etc. which have in turn provided heart attack education (symptom recognition/call 911) to more than 2,000 Maine residents in 50 different towns APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives10

11. Other Statewide Educational Efforts: Stroke Ongoing: State-wide partners provide stroke symptom recognition/call 911 awareness education in community, healthcare, school & worksite settings May - Stroke Awareness month: Stroke signs awareness media campaign in Southern ME with WGME News 13 (2007 & 2008) and statewide (2009) APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives11

12. Evaluation Evaluation Question (related to symptom recognition)Indicator Short-term Outcome: Is there an increase in the number of educational programs conducted by HeartSafe Communities on stroke and heart attack symptom recognition & 9-1-1 (CDC HDSP indicator 3.2.1) Reapplication/ HeartSafe database Intermediate outcome: Is there increased stroke and heart attack symptom recognition & 9-1-1 among people in HeartSafe Communities (3.4.1, 3.4.2) BRFSS module, HeartSafe database APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives12

13. Methods BRFSS data analyzed using SUDAAN & weighted to be representative of Maine’s adult population (age, gender, & race) Pulled out respondents from communities designated as HeartSafe in 2006 or 2007 (per evaluation/analysis plan to provide time for education programs and changes in knowledge) 13APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

14. Sample Size For various signs, decoy and call 911 - Heartsafe Community Since 2007: n=1,001 to 1,004 All other: n=2,731 to 2,744 14APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

15. Key Findings Heart Attack HeartSafe Communities designated in 2006 & 2007 had higher heart attack symptom recognition in 2009 than in 2005 (baseline) HeartSafe Communities (2006 & 2007) showed greater improvement between baseline and follow-up in heart attack symptom recognition compared to others (and this group also improved, as desired, given other statewide education efforts) 15APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

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17. Pain in the jaw, neck, or back Feeling weak, lightheaded, or faint Chest pain Pain in arms or shoulder Shortness of breath Sudden trouble seeing (decoy) Year200520092005200920052009200520092005200920052009 Heartsafe Community (2006 & 2007)49%62%61%66%90%96%86%91%82%89%46%39% Other52%62% 66%94%96%90%88%86%88%43%42% Symptom and Decoy Recognition: 2005-2009 Heart Attack 17APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

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19. Correctly Identified All Symptoms and Decoy 2005-2009: Heart Attack 20052009Change 2005-2009 Heartsafe Community (2006 & 2007)12.9%15.6%2.6% Other13.6%16.4%2.8% Difficult to correctly identify all symptoms & decoy An improvement, but still a long way to go 19APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

20. Correctly Identified All Symptoms, Decoy, and 911: 2005-2009 Heart Attack 20052009Change 2005-2009 Heartsafe Community (2006 & 2007)11.9%14.9%3.1% Other12.5%15.2%2.7% 20APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

21. Key Findings Stroke HeartSafe Communities designated in 2006 & 2007 had higher stroke symptom recognition in 2009 than in 2005 (baseline) HeartSafe Communities’ (2006 & 2007) improvement varied compared to others 21APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

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23. Symptom and Decoy Recognition: 2005-2009 Stroke Sudden confusion or trouble speaking Sudden numbness or weakness of face, arm, or leg… Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, or loss of balance Severe headache with no known cause Sudden chest pain or discomfort (decoy) Year200520092005200920052009200520092005200920052009 Heartsafe Community (2006 & 2007)86%93%92%97%66%75%81%88%52%63%37%39% Other89%93%94%96%69%76%86%89%56%58%38%42% 23APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

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25. Correctly Identified All Symptoms and Decoy: 2005-2009 Stroke 20052009Change 2005-2009 Heartsafe Community (2006 & 200718.6%24.0%5.3% Other19.9%22.9%3.0% Difficult to correctly identify all symptoms and decoy An improvement, but still a long way to go 25APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

26. Correctly Identified All Symptoms, Decoy, and 911: 2005-2009 Stroke 20052009Change 2005-2009 Heartsafe Community (2006 & 2007)16.9%21.1%4.2% Other18.1%20.6%2.5% 26APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives

27. Thank you Contact: Ruth Dufresne, MS Research Associate for Evaluation (CVH & Diabetes) Center for Community and Public Health University of New England Portland, ME 04103 Phone: 207.221.4571 Fax: 207.523.1914 Email: rdufresne@une.edurdufresne@une.edu http://www.une.edu/ccph/ 27APHA 2011, Session 3451.0, Rural Health: Needs & Initiatives