COVID-19 Incidence and Mortality Among American Indian/Alaska Native and White Persons - Montana, March 13-November 30, 2020.

Geographic differences in infectious disease mortality rates have been observed among American Indian or Alaska Native (AI/AN) persons in the United States (1), and aggregate analyses of data from selected U.S. states indicate that COVID-19 incidence and mortality are higher among AI/AN persons than they are among White persons (2,3). State-level data could be used to identify disparities and guide local efforts to reduce COVID-19-associated incidence and mortality; however, such data are limited. Reports of laboratory-confirmed COVID-19 cases and COVID-19-associated deaths reported to the Montana Department of Public Health and Human Services (MDPHHS) were analyzed to describe COVID-19 incidence, mortality, and case-fatality rates among AI/AN persons compared with those among White persons. During March-November 2020 in Montana, the estimated cumulative COVID-19 incidence among AI/AN persons (9,064 cases per 100,000) was 2.2 times that among White persons (4,033 cases per 100,000).* During the same period, the cumulative COVID-19 mortality rate among AI/AN persons (267 deaths per 100,000) was 3.8 times that among White persons (71 deaths per 100,000). The AI/AN COVID-19 case-fatality rate (29.4 deaths per 1,000 COVID-19 cases) was 1.7 times the rate in White persons (17.0 deaths per 1,000). State-level surveillance findings can help in developing state and tribal COVID-19 vaccine allocation strategies and assist in local implementation of culturally appropriate public health measures that might help reduce COVID-19 incidence and mortality in AI/AN communities.

Does a History of Gestational Diabetes Mellitus Affect Key Outcomes in Women Participating in a Diabetes Prevention Program?

Objectives To evaluate lifestyle change outcomes among women with and without a history of gestational diabetes mellitus (GDM) enrolled in the Montana Diabetes Prevention Program (DPP). Methods Participation, self-monitoring behavior, weight loss, and cardiometabolic risk reduction were compared among 5091 women at high-risk for type 2 diabetes, with and without a history of GDM, enrolled in the Montana DPP between 2008 and 2015. Results Women with a history of GDM (6% of enrolled women, n = 283) were significantly younger than women without GDM. No significant differences in participation, self-monitoring fat intake, achievement of the physical activity goal, or weight loss were found among women with and without a history of GDM. Overall, women lost an average of 5.0 kg (± 6.5), and 45 and 29% of women achieved 5 and 7% weight loss, respectively. Both groups lost significant and comparable amounts of weight. After adjusting for age and other factors, no differences were found in achievement of ≥ 5% weight loss (AOR 0.84; 95% CI 0.61-1.16) or the ≥ 7% weight loss goal (AOR 1.04; 95% CI 0.73-1.47) among women with and without a history of GDM. Conclusions for Practice Our findings suggest that women with and without a history of GDM successfully participate in and achieve significant weight loss in the DPP. Health care providers should identify and refer women with risk factors for type 2 diabetes, including a history of GDM, to a DPP within their community.

Telehealth delivery of the diabetes prevention program to rural communities.

The Centers for Disease Control and Prevention, State and Local Health Departments, and other organizations in the USA are working to increase population access to the Diabetes Prevention Program (DPP) lifestyle intervention. Delivering the DPP through telehealth videoconference may increase access to this intervention, particularly in rural communities. The purpose of this study was to compare participation, monitoring of diet and physical activity, and weight loss in participants receiving the intervention on-site and those participating virtually through telehealth. Beginning in 2008, Holy Rosary Healthcare collaborated with the Montana Department of Public Health and Human Services to provide the DPP to participants on-site in one community and simultaneously through telehealth to participants in multiple other communities. From 2008 through 2015, 894 participants were enrolled in the program (29% at telehealth sites). The mean age of participants was 51.7 years and 84% were female. Overall, participants attended 14.4, 3.9, and 15.0 weekly core, post-core, and total sessions, respectively. There were no statistically significant differences in number of intervention sessions attended by the telehealth or on-site participants. There were no statistically significant differences in the mean weight loss or reduction in BMI between the telehealth and the on-site groups. There also were no statistically significant differences in the percentage of telehealth or on-site participants who achieved ≥5% weight loss (56 vs. 57%) or the 7% weight loss goal (38 vs. 41%). Our findings suggest that participants receiving the DPP through telehealth have similar rates of participation and achieve similar weight loss as participants attending the program on-site.

Secondhand Smoke Exposure and Smoke-Free Policy Support Among Public Housing Authority Residents in Rural and Tribal Settings.

Previous research has shown that multi-unit housing (MUH) residents are at risk of secondhand smoke (SHS) exposure, which can transfer between units. The purpose of this study was to determine SHS exposure and examine attitudes towards smoking policies among public housing authority (PHA) residents in rural and tribal settings. A self-administered questionnaire was completed by 895 adult tenants (41 % response rate) living in PHA multiunit buildings in Montana in 2013. Our primary outcome was tenant support of smoke-free policies; our secondary outcome was exacerbation of child asthma symptoms due to SHS exposure. In 2014, we used multiple logistic regression models to test associations between independent variables and outcomes of interest. The majority (80.6 %) of respondents supported having a smoke-free policy in their building, with support being significantly higher among nonsmokers [adjusted odds ratio (aOR) 4.2, 95 % confidence interval (CI) 1.5-11.6] and among residents living with children (aOR 2.9, 95 % CI 1.3-6.2). Tribal residents were as likely to support smoke-free policies as non-tribal residents (aOR 1.4; 95 % CI 0.5-4.0). Over half (56.5 %) of respondents reported SHS exposure in their home; residents in a building with no smoke-free policy in place were significantly more likely to report exposure (aOR 3.5, 95 % CI 2.2-5.5). SHS exposure was not significantly associated with asthma symptoms. There is a significant reduction in exposure to SHS in facilities with smoke-free policies and there is strong support for such policies by both tribal and non-tribal MUH residents. Opportunities exist for smoke-free policy initiatives in rural and tribal settings.

Implementation of Strategies to Recognize and Control Hypertension in a Multispecialty Clinic, Montana, 2012-2013.

Benefis Medical Group, in Great Falls, Montana, improved identification and treatment of hypertension through multifaceted interventions. The interventions included adopting policies for collection of vital signs, enhancing system-level reporting capability, tracking patients for the registry, and conducting patient outreach activities. From baseline to follow-up (December 2012 through September 2013), the percentage of patients with a documented blood pressure increased from 67% to 80%, the percentage diagnosed with hypertension increased from 16% to 36%, and the percentage with blood pressure control increased from 41% to 64%. Benefis Medical Group plans to sustain the successful evidence-based strategies that were adopted.

Effectiveness of an Adapted Diabetes Prevention Program Lifestyle Intervention in Older and Younger Adults.

OBJECTIVES: To compare participation, self-monitoring behaviors, and weight loss outcomes in older and younger participants in an adapted Diabetes Prevention Program (DPP) lifestyle intervention. DESIGN: Pre- and postevaluation of outcomes in participants enrolled in the Montana Cardiovascular Disease (CVD) and DPP lifestyle intervention from 2008 through 2012. SETTING: Community. PARTICIPANTS: Adults at high risk for CVD and type 2 diabetes mellitus (N = 3,804). MEASUREMENTS: Number of core (16 weekly sessions) and postcore (6 monthly sessions) intervention sessions attended, weekly self-monitoring of fat intake and minutes of physical activity, weight loss outcomes and achievement of the weight loss goal, and improvements in CVD-related risk factors. RESULTS: Participants aged 65 and older were significantly more likely to attend more intervention sessions, self-monitor their fat intake, and achieve the physical activity and weight loss goals than those younger than 65. Older and younger participants experienced significant improvements in CVD-related risk factors. CONCLUSION: Older adults at high risk of CVD and diabetes mellitus participating in an adapted DPP lifestyle intervention had higher participation and self-monitoring rates than younger participants, were more likely to achieve physical activity and weight loss goals, and achieved similar CVD risk reduction.

High mortality rate of unintentional poisoning due to prescription opioids in adults enrolled in Medicaid compared to those not enrolled in Medicaid in Montana.

BACKGROUND: Unintentional death due to prescription drug-related poisoning has been a growing problem nationally. Some sub-populations have been shown to be at higher risk than others. METHODS: In 2014, we matched death records to Medicaid eligibility files to determine enrollment status at the time of unintentional death from prescription opioid poisoning from 2003 to 2012 in Montana. Medicaid prescription claims for decedents were used to assess prescribing patterns and time between refills. RESULTS: The age-adjusted mortality rate per 100,000 from opioid poisoning for adults aged 18-64 years and enrolled in Medicaid at the time of death was eight times higher than the rate for non-Medicaid Montana adults (38.2 [95% CI (30.7-45.7)] vs. 4.7 [95% CI (4.1-5.3)]). Twenty-eight percent of unintentional poisoning deaths during this time frame were among Medicaid members. Only 33% of the Medicaid decedents had a claim for an opioid prescription during the month before their death. CONCLUSION: Our findings suggest that more needs to be done to address prescription opioid use in Montana. Adults enrolled in Medicaid continue to be at high risk for prescription opioid unintentional poisoning deaths. Data on prescribing practices suggest that there are opportunities to intervene and provide education on use of opioid medications for Medicaid members and prescribing providers.

Prevalence and reasons for initiating use of electronic cigarettes among adults in Montana, 2013.

We used data from the 2013 Montana Adult Tobacco Survey to estimate the prevalence of electronic cigarette (e-cigarette) use and reasons for initiation among Montana adults. More than 1 in 10 (11.2%, 95% confidence interval [CI], 9.1%-13.2%) adults reported ever using e-cigarettes, and 1.3% (95% CI, 0.7%-1.9%) reported current use. Most respondents reported "trying something new" (64%) or "trying to quit or reduce cigarette use" (56%) as a reason for initiating use. Ongoing surveillance of these addictive products is needed.

Intensive lifestyle intervention goals can be achieved as effectively with large groups as with small groups.

OBJECTIVE: The purpose of this study was to assess if group size is associated with weight loss outcomes among participants in an adapted diabetes prevention program. METHODS: Adults at high-risk (N=841) for CVD and diabetes were enrolled in the lifestyle intervention in 2011. Multiple logistic regression analyses were used to identify if group size (smaller group<16 participants; larger group ≥16 participants) was independently associated with weight loss outcomes among participants. RESULTS: In the bivariate analyses, participants in the smaller groups compared to those in the larger groups were significantly more likely to have a higher baseline body mass index, to attend fewer intervention sessions, and less likely to self-monitor their fat intake for ≥14 weeks, and to have lost less weight during the core intervention (5.1 kg [SD 4.7] versus 5.8 kg [4.5]). However, analysis adjusting for age, sex, baseline BMI, achievement of the physical activity goal, number of weeks self-monitoring fat intake, and group size, found only two factors to be independently associated with achievement of the 7% weight loss goal: frequency of self-monitoring of fat intake and achievement of the physical activity goal. CONCLUSIONS: Our findings indicate that intensive lifestyle intervention goals can be achieved as effectively with large or small groups.

Cooperative strategies to develop effective stroke and heart attack awareness messages in rural american Indian communities, 2009-2010.

INTRODUCTION: National initiatives to improve the recognition of heart attack and stroke warning signs have encouraged symptomatic people to seek early treatment, but few have shown significant effects in rural American Indian (AI) communities. METHODS: During 2009 and 2010, the Montana Cardiovascular Health Program, in collaboration with 2 tribal health departments, developed and conducted culturally specific public awareness campaigns for signs and symptoms of heart attack and stroke via local media. Telephone surveys were conducted before and after each campaign to evaluate the effectiveness of the campaigns. RESULTS: Knowledge of 3 or more heart attack warning signs and symptoms increased significantly on 1 reservation from 35% at baseline to 47% postcampaign. On the second reservation, recognition of 2 or more stroke signs and symptoms increased from 62% at baseline to 75% postcampaign, and the level of awareness remained at 73% approximately 4 months after the high-intensity campaign advertisements ended. Intent to call 9-1-1 did not increase in the heart attack campaign but did improve in the stroke campaign for specific symptoms. Recall of media campaigns on both reservations increased significantly from baseline to postcampaign for both media outlets (ie, radio and newspaper). CONCLUSION: Carefully designed, culturally specific campaigns may help eliminate disparities in the recognition of heart attack and stroke warning signs in AI communities.

Prevalence of asthma among adults in metropolitan versus nonmetropolitan areas in Montana, 2008.

INTRODUCTION: Most US studies on asthma prevalence have been conducted in urban areas, and few have assessed the prevalence of asthma among residents of rural areas versus urban areas. The objective of this study was to compare the prevalence of asthma among adults living in metropolitan versus nonmetropolitan counties in Montana. METHODS: We analyzed data from 6,846 adult Montanans who completed the Behavioral Risk Factor Surveillance System survey in 2008. We used Rural-Urban Continuum Codes to categorize respondents' county of residence as metropolitan (Metro), nonmetropolitan and adjacent to a metropolitan county (NMA), and nonmetropolitan and nonadjacent to a metropolitan county (NMNA). We compared the prevalence of current self-reported asthma among respondents in the 3 areas, overall and by selected characteristics, and conducted multivariable logistic regression analyses to identify factors independently associated with current self-reported asthma. RESULTS: No differences in the prevalence of self-reported asthma were found between residents of Metro and NMA or NMNA counties, overall or by age, sex, race, years of education, health insurance status, annual household income, or body mass index. Respondents aged 65 years or older (adjusted odds ratio [AOR], 0.7; 95% confidence interval [CI], 0.5-0.9) and men (AOR, 0.6; 95% CI, 0.5-0.8) were less likely to report current asthma than younger respondents and women, respectively. Obese respondents were more likely (AOR, 1.9; 95% CI, 1.4-2.7) to report asthma than were respondents who were not obese. Metropolitan county of residence was not independently associated with self-reported current asthma. CONCLUSION: The prevalence of self-reported current asthma is similar in metropolitan and nonmetropolitan counties in Montana, but other sociodemographic differences exist. Our findings highlight the need to conduct regional and state surveillance of asthma to understand the demographic risk factors associated with it and to determine the potential geographic variation of asthma prevalence in the United States.

Implementation of diabetes prevention programs in rural areas: Montana and south-eastern Australia compared.

OBJECTIVE: To identify the key elements that enabled the Greater Green Triangle Diabetes Prevention Project (GGT DPP) and the Montana Cardiovascular Disease and Diabetes Prevention (CDDP) programs successful establishment and implementation in rural areas, as well as identifying specific challenges or barriers for implementation in rural communities. METHODS: Focus groups were held with the facilitators who delivered the GGT DPP in Australia and the Montana CDDP programs in the USA. Interview questions covered the facilitators' experiences with recruitment, establishing the program, the components and influence of rurality on the program, barriers and challenges to delivering the program, attributes of successful participants, and the influence of community resources and partnerships on the programs. RESULTS: Four main themes emerged from the focus groups: establishing and implementing the diabetes prevention program in the community; strategies for recruitment and retention of participants; what works in lifestyle intervention programs; and rural-centred issues. CONCLUSIONS: The results from this study have assisted in determining the factors that contribute to developing, establishing and implementing successful diabetes prevention programs in two rural areas. Recommendations to increase the likelihood of success of programs in rural communities include: securing funding early for the program; establishing support from community leaders and developing positive relationships with health care providers; creating a professional team with passion for the program; encouraging participants to celebrate their small and big successes; and developing procedures for providing post-intervention support to help participants maintain their success.

Capacity of diabetes education programs to provide both diabetes self-management education and to implement diabetes prevention services.

OBJECTIVE: The purpose of this study was to assess the capacity of diabetes self-management education (DSME) programs in urban and rural counties to provide services to patients with diagnosed diabetes, lifestyle services to persons at high risk for developing diabetes, and to assess the potential barriers to providing diabetes prevention services. METHODS: In 2009, the Montana Department of Public Health and Human Services conducted an Internet-based survey of all DSME programs in Montana. RESULTS: Thirty of the 39 (77%) DSME programs completed the survey. Seventy-seven percent of the urban programs and 50% of the rural programs reported a capacity to provide DSME to additional patients with diagnosed diabetes. More than 70% of the urban and the rural programs currently provide lifestyle services to patients with abnormal glucose tolerance but without diabetes. Eighty-four percent of the urban programs and 60% of the rural programs reported a capacity to provide lifestyle services to additional persons at high risk for diabetes. Eighty-five percent of the urban programs and 58% of the rural programs have already implemented or intend to implement a lifestyle intervention service consistent with the Diabetes Prevention Program. Overall, the most frequently reported barriers to implementing a diabetes prevention services were lack of reimbursement (80%) and the lack of staff to provide the service (60%). CONCLUSION: Urban and rural DSME programs in Montana have the capacity to implement both DSME for patients with diagnosed diabetes and diabetes prevention lifestyle services to additional people at high risk for diabetes. Reimbursement for diabetes prevention services is critical to ensure program development and implementation.

Factors associated with achieving a weight loss goal among participants in an adapted Diabetes Prevention Program.

AIMS: To assess the factors associated with achieving the 7% weight loss goal among participants enrolled in an adapted Diabetes Prevention Program (DPP). METHODS: Adults at high-risk (N=989) for CVD and diabetes were enrolled in the lifestyle intervention. Multiple logistic regression analyses were used to identify factors associated with achieving the weight loss goal. RESULTS: Overall 37% of participants achieved the weight loss goal. Participants who were older, male, had a lower baseline BMI, self-monitored their fat and caloric intake more frequently, and who achieved higher levels of physical activity were more likely to achieve the weight loss goal compared to participants without these characteristics. In multivariate analyses more frequent self-monitoring of fat and caloric intake and higher levels of weekly physical activity were the only factors independently associated with participant achievement of the weight loss goal. CONCLUSIONS: In a real-world translation of the DPP lifestyle intervention participants who achieved the weight loss goal were more likely to have monitored their dietary intake frequently and increased their physical activity markedly both in a dose-response relationship. Our findings highlight the importance of supporting participants in lifestyle interventions to initiate and maintain dietary self-monitoring and increased levels of physical activity.

Factors associated with the maintenance or achievement of the weight loss goal at follow-up among participants completing an adapted diabetes prevention program.

AIMS: This study evaluated factors associated with achievement or maintenance of a 7% weight loss goal post intervention among adults at high-risk for cardiovascular disease (CVD) and diabetes who participated in an adapted Diabetes Prevention Program (DPP) intervention. MATERIALS AND METHODS: High-risk adults completed the intervention in 2008 or 2009 (N=466). In 2010, we conducted a follow-up survey of participants to assess characteristics, behaviors and barriers associated with the maintenance or achievement of the weight loss goal. RESULTS: Thirty-nine percent of respondents (73/188) maintained or achieved the goal post intervention. Participants who achieved the goal were more likely to have attended more intervention sessions, and to have lost more weight during the intervention compared to participants who did not achieve the goal. Participants who achieved or maintained the goal post intervention were more likely to engage in behaviors related to weight loss maintenance. DISCUSSION: Our findings suggest maintenance or achievement of a weight loss goal post intervention among participants in an adapted lifestyle intervention is consistent with the original DPP. Our findings also highlight the relationship between maintaining or achieving a weight loss goal post intervention and behaviors that can be reinforced and barriers that can be mitigated.

Statewide efforts to narrow the rural-urban gap in acute stroke care.

BACKGROUND: Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure. PURPOSE: The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative. METHODS: In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009. RESULTS: There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs. CONCLUSIONS: A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities.

Implementing a state-based cardiovascular disease and diabetes prevention program.

OBJECTIVE: To evaluate weight loss and cardiometabolic risk reduction achieved through an adapted Diabetes Prevention Program intervention among adults at high risk for cardiovascular disease (CVD) and diabetes. RESEARCH DESIGN AND METHODS: Eight health care facilities implemented a group-based lifestyle intervention beginning in 2008. Participants attended 16 weekly core sessions followed by 6 monthly after core sessions. RESULTS: A total of 1,003 participants were enrolled, 816 (81%) completed the core and 578 (58%) completed the after core. Of participants completing the core and after core, 45 and 49% achieved the 7% weight loss goal, respectively. There were significant improvements in blood pressure, fasting glucose, and LDL cholesterol among participants completing the intervention. CONCLUSIONS: Our findings indicate it is feasible for state-coordinated CVD and diabetes prevention programs to achieve significant weight loss and improve cardiometabolic risk.

Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community.

PURPOSE: To evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in a rural community. METHODS: In 2008, the Montana Diabetes Control Program worked collaboratively with Holy Rosary Healthcare to implement an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (N = 101). Participants set targets to reduce fat intake and increase physical activity (> or = 150 mins/week) in order to achieve a 7% weight loss goal. FINDINGS: Eighty-three percent (n = 84) of participants completed the 16-session core program and 65 (64%) participated in 1 or more after-core sessions. Of those completing the core program, the mean participation was 14.4 +/- 1.6 and 3.9 +/- 1.6 sessions during the core and after core, respectively. Sixty-five percent of participants met the 150-min-per-week physical activity goal during the core program. Sixty-two percent achieved the 7% weight loss goal and 78% achieved at least a 5% weight loss during the core program. The average weight loss per participant was 7.5 kg (range, 0 to 19.7 kg), which was 7.5% of initial body weight. At the last recorded weight in the after core, 52% of participants had met the 7% weight loss goal and 66% had achieved at least a 5% weight loss. CONCLUSION: Our findings suggest that it is feasible to implement a group-based DPP in a rural community and achieve weight loss and physical goals that are comparable to those achieved in the DPP.

Adapted diabetes prevention program lifestyle intervention can be effectively delivered through telehealth.

PURPOSE: The purpose of this study was to assess the feasibility of delivering an adapted group-based version of the Diabetes Prevention Program's (DPP) lifestyle intervention through telehealth video conferencing. METHODS: In 2009, the Montana Department of Public Health and Human Services in collaboration with Holy Rosary Heathcare implemented the DPP lifestyle intervention, which was provided to an on-site group in 1 community and simultaneously through telehealth to a second group in a remote frontier community. Participants obtained medical clearance from their primary care physician and were eligible if they were overweight and had 1 or more of the following risk factors: prediabetes, impaired glucose tolerance/impaired fasting glucose (IGT/IFG), a history of gestational diabetes (GDM) or the delivery of an infant >9 pounds, hypertension, or dyslipidemia. RESULTS: A total of 13 and 16 eligible adults enrolled in the on-site and the telehealth program, and 13 (100%) and 14 (88%) participants completed the 16-week program, respectively. Both the on-site and telehealth groups achieved high levels of weekly physical activity and there were no significant differences between groups. Over 45% of on-site and telehealth participants achieved the 7% weight loss goal with the average weight loss per participant greater than 6.4 kg in both groups. CONCLUSIONS: Our findings suggest that it is feasible to deliver an adapted group-based DPP lifestyle intervention through telehealth resulting in weight loss outcomes similar to the original DPP.

Impact of media on community awareness of stroke warning signs: a comparison study.

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms.