Table 1 Primary and secondary outcomes, moderators, and mediators

Primary Outcome

Systolic blood pressure control

(<130 mmHg)

Physical exam

Secondary Outcomes

Change in systolic blood pressure

Physical exam

Dyslipidemia: non-HDL cholesterol

CardioChek®

Glucose control: hemoglobin A1c

Dried blood spot

Inflammation: C-reactive protein

Dried blood spot

Adiposity: BMI, WC, WHR

Physical exam

Physical activity

Adapted from International Physical Activity Questionnaire [59]

Diet

California Health Interview Survey (CHIS) 2011–2012 [60]

Smoking

CHIS 2011–2012, Behavioral Risk Factor Surveillance System (BRFSS) 2013 [61]

Recurrent stroke or TIA

Questionnaire for Verifying Stroke-Free Status (QVSFS) [62]

Myocardial infarction

Medical history Common Data Element [45]

Cost

Sociodemographics: age, sex, race/ethnicity

NINDS Demographics Common Data Element [45]

Acculturation and Education: country of birth, primary language, education level

Adapted from NINDS Demographics CDE, subscale of Bidimensional Acculturation Scale for Hispanics [63]

Health-care system

Study site

Type of cerebrovascular event (TIA, ischemic stroke, intracerebral hemorrhage)

Medical record

Stroke severity

NIH Stroke Scale

Functional status

Modified Rankin Scale

Stroke Literacy

Stroke warning signs and risk factors for stroke [64]

Health Literacy

4-Item Brief Health Literacy Screening Tool (BRIEF) [65]

Medication adherence

Adapted from Simoni et al. [66] and Chesney et al. [67]

Self-management skills

Adapted from Self-Efficacy for Managing Chronic Disease 6-item scale [68]

Self-efficacy

General Self-Efficacy Scale [69]

Perceived risk of stroke

Adapted from Stroke Risk and Worry Survey [70]

Social isolation

8-Item Social Support Scale [71]

Depression

Center for Epidemiologic Studies Depression Scale (CES-D) [72]

Health related quality of life

SF-6D [73]

Perceptions of quality of care

Adapted from Patient Assessment of Chronic Illness Care (PACIC) [74] and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) [75]

Intervention Mediators

Coordination and communication with care team: number CHW home visits, CDSMP workshops attended, APC clinic visits, telephone visits; communication between APC and CHW

CommCare tracking technology