Effects of stroke education using an animated cartoon and a manga on elementary school children

Analyzing prehospital delays in recurrent acute ischemic stroke: Insights from interpretable machine learning

OBJECTIVE

This study investigates prehospital delays in recurrent Acute Ischemic Stroke (AIS) patients, aiming to identify key factors contributing to these delays to inform effective interventions.

METHODS

A retrospective cohort analysis of 1419 AIS patients in Shenzhen from December 2021 to August 2023 was performed. The study applied the Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP) for identifying determinants of delay.

RESULTS

Living with others and lack of stroke knowledge emerged as significant risk factors for delayed hospital presentation in recurrent AIS patients. Key features impacting delay times included residential status, awareness of stroke symptoms, presence of conscious disturbance, diabetes mellitus awareness, physical weakness, mode of hospital presentation, type of stroke, and presence of coronary artery disease.

CONCLUSION

Prehospital delays are similarly prevalent among both recurrent and first-time AIS patients, highlighting a pronounced knowledge gap in the former group. This discovery underscores the urgent need for enhanced stroke education and management.

PRACTICE IMPLICATION

The similarity in prehospital delay patterns between recurrent and first-time AIS patients emphasizes the necessity for public health initiatives and tailored educational programs. These strategies aim to improve stroke response times and outcomes for all patients.

Healthcare-Seeking Delays in Acute Ischemic Stroke Patients: The Influence of Gender, Immigrant Status, and Educational Background

Purpose

Timely medical attention is crucial for patients with Acute Ischemic Stroke (AIS), as delays can significantly impact therapeutic outcomes. These delays are influenced by a combination of socio-cultural, educational, and clinical factors.

Patients and Methods

An in-depth analysis was conducted to assess the prevalence and median duration of healthcare-seeking delays in AIS patients. The study specifically investigated the independent impacts of sociocultural and clinical determinants on these delays, with a focus on immigrant status, gender disparities, and educational levels. Multivariate regression analysis was employed to identify these independent effects while controlling for potential confounding factors.

Results

Among 1419 AIS patients, 82.52% (n = 1171) experienced delays exceeding 2 hours from symptom onset of symptoms to hospital arrival. The median delay was 12.3 hours. Immigrant populations encountering longer delays compared to native groups. Younger males (<45 years) and elderly females were more prone to delay in healthcare-seeking. Identified independent risk factors for delay included male gender (OR = 1.65 [95% CI:1.14-2.48]), self-acknowledged diabetes (OR = 2.50 [95% CI:1.21-5.17]), small vessel (OR = 2.07 [95% CI:1.27-3.36]), and wake stroke (OR = 7.04 [95% CI:3.69-13.44]). Educational background (high school and above), GCS score with 3-8 points (OR = 0.52 [95% CI:0.09-0.69]), understanding stroke-related knowledge (OR = 0.26 [95% CI:0.09-0.44]), conscious disturbance (OR = 0.25 [95% CI:0.10-0.62]) and limb weakness (OR=0.21[95% CI:0.21-0.49]) are protective factors for timely treatment.

Conclusion

Immigrant populations experienced longer delays from symptom onset to hospital arrival. The crucial roles of education and knowledge about stroke underscore the need for enhanced health literacy campaigns and public awareness, with a targeted focus on younger males and elderly females.

Effectiveness of a digital application to improve stroke knowledge for kids

INTRODUCTION

Stroke is highly prevalent in Latin America and one of the leading causes of morbidity and mortality in the world. Educating children about stroke has been established as an effective method to detect symptoms early, reduce hospital visits, and raise awareness among adults.

OBJECTIVE

To analyze the effectiveness of a mobile application to improve knowledge and understanding of stroke among children.

METHOD

We conducted a focus group session including 12 children in order to analyze the behavior of 6 questions previously validated by expert neurologists. Subsequently, 105 primary school students between the ages of 7 and 12 completed a questionnaire on stroke symptoms and how to contact the emergency services before and after using an application on stroke symptoms. Qualitative analyses and the Student t test were used to verify the existence of differences between pre- and post-intervention test results.

RESULTS

After a single 40-min working session with the application, between 50% and 67% of the children were able to identify the signs of stroke, and 96.2% knew the national emergency services telephone number. Statistical analysis revealed statistically significant differences before and after the intervention with the digital application (t=19.54; p<0.001) and intragroup differences in the post-intervention test results (t=40.71; p<0.001).

CONCLUSION

Primary school children who used our digital application increased their knowledge, understanding, and learning of stroke symptoms.

A Student-Driven Community Engagement Model for School Nutrition Education Programs

BACKGROUND

Parental engagement in nutrition education programs often focuses on direct communication with parents. While this is an important component for the success of nutrition education, the role that students can play in connecting the program to their home is often overlooked.

METHODS

Feedback from students participating in a nutrition education program was used to develop an intervention that allowed students to take snacks they prepared in class home to their families. Change in parental awareness and family communication about the program was assessed in response to this intervention. A total of 257 third-grade students and 80 of their parents completed surveys to assess communication and interest in learning more about nutrition through the program.

RESULTS

A significant increase in family awareness and communication about the nutrition program was reported in response to the intervention that gave the students the ability to share food they made in class with their families.

CONCLUSIONS

Community engagement for school nutrition education programs is effective in stimulating family conversation about nutrition when methods are cognizant of students potential and motivation for driving these conversations. Our model for student-centered community engagement can be used by nutrition education programs to increase parental engagement.

The Effects of Cartoon Assisted Endoscopy Preparation Package on Children's Fear and Anxiety Levels and Parental Satisfaction in Turkey

PURPOSE

The study was conducted to determine the effect of the cartoon-assisted preparation package, developed for children undergoing an endoscopy procedure, on children's fear and anxiety levels and parental satisfaction.

DESIGN AND METHODS

The study was conducted in a randomized controlled experimental design between April 2018-July 2019. The study sample consisted of a total of 65 children and their parents (33 in the intervention group and 32 in the control group) who met the research inclusion criteria in this study population. The intervention group was prepared for an endoscopy procedure with the cartoon-assisted preparation package for endoscopy.

RESULTS

The mean fear scores of the children in the intervention group were 3.39 ± 0.56 before endoscopy, 1.67 ± 0.54 during endoscopy, and 0.52 ± 0.67 after endoscopy, with statistically significant difference between the mean fear scores. The mean fear scores in the control group were 3.00 ± 0.80 before endoscopy, 3.13 ± 0.79 during endoscopy, and 2.25 ± 1.16 after endoscopy, with statistically significant difference between the mean fear scores. The anxiety scores of the children were 33.79 ± 4.00 in the intervention group and 36.56 ± 3.52 in the control group before endoscopy, and the difference between anxiety scores was statistically significant (p < 0.05). The mean satisfaction scores of the parents in the experimental group after endoscopy (78.44 ± 10.01) was higher than that of the control group (73.52 ± 12.92), but the difference between the groups was not statistically significant (p > 0.05).

CONCLUSION

The cartoon-assisted preparation package for endoscopy was found to be effective in reducing fear and anxiety that may occur in children undergoing endoscopy, in the 7-12 age group.

Training intervention to improve hygiene practices in Islamic boarding school in Yogyakarta, Indonesia: A mixed-method study

Background

The primary objective of this study was to determine the effect of a training intervention in overall improvement in students’ (santris) knowledge, behavior, and outcome.

Methods

A mixed-methods exploratory sequential design was applied. First, qualitative data were collected from three focus group discussions with 20 supervisors and one in-depth interview with school principal to explore current hygiene practices. The information was then used to develop training intervention using either video, poster, and leaflet. To measure the effect, a stepped wedge cluster design with pre- and post-test analyses was conducted. A total of 452 junior high school santris in one Islamic boarding school were non-randomly allocated to either three intervention groups. Outcome measures were knowledge, personal behavior, and room hygiene. Codes and categories were produced in the qualitative analysis, while paired t-tests and Wilcoxon rank tests test were used in the quantitative analysis.

Results

The qualitative study identified poor practices on personal and room hygiene among the santris and proposed a training intervention. Overall, there was a significant increase in knowledge and personal behavior after the intervention (7.22 ± 1.34 pre-intervention to 7.70 ± 0.74 post-intervention and 9.75 ± 2.98 pre-intervention to 12.16 ± 2.12 post-intervention, respectively, p < 0.001). Room hygiene was significantly improved among boys and those who received leaflets.

Conclusion

Having developed a specific training materials, school-based hygiene training intervention improved knowledge and personal behavior. Its effect on room hygiene particularly for female santris needs further strengthening of the intervention in this Islamic boarding school setting.

Transferring Stroke Knowledge from Children to Parents: A Systematic Review and Meta-Analysis of Community Stroke Educational Programs

BACKGROUND

The purpose of this systematic review and meta-analysis on child-to-parent communication of stroke information (Child-Mediated Stroke Communication, CMSC) is to provide the highest levels of evidence supporting the role of this approach in community education.

METHODS

Databases such as PubMed, Google Scholar, PsycINFO, Web of Science, MEDLINE, and CINHAL were searched to gather information on CMSC followed by a meta-analysis. The eligibility criteria were as follows: (a) children aged 9-15years and parents, (b) randomized or nonrandomized trials, and (c) outcome variables that included the proportions of parents answering the pretest and post-test on stroke knowledge regarding risk factors, symptoms, and what to do in the event of stroke.

RESULTS

Of the 1668 retrieved studies, 9 articles were included. Meta-analytical findings yielded that the proportions of correct answers for stroke symptoms and its risk factors among parents were 0.686 (95% CI: 0.594-0.777) at baseline and increased to 0.847 (95% CI: 0.808-0.886) at immediate post-test and 0.845 (95% CI: 0.804-0.886) delayed post-test. The proportions of correct answers for behavioral intent to call 911 when witnessing stroke was 0.712 (95% CI: 0.578-0.846) at baseline, rising to 0.860 (95% CI: 0.767-0.953) at immediate post-test, and 0.846 (95% CI: 0.688-1.004) at delayed post-test.

CONCLUSIONS

CMSC is effective for educating families. More work is needed to increase the use of validated stroke literacy instruments and behavioral theory, and to reduce parental attrition in research studies.

Effects of a school-based stroke education program on stroke-related knowledge and behaviour modification-school class based intervention study for elementary school students and parental guardians in a Japanese rural area

OBJECTIVES

This study aimed to determine the effect of a stroke education programme on elementary school students and their parental guardians in a rural area in Japan that has high stroke mortality.

DESIGN

School class based intervention study.

SETTING

Eleven public elementary schools in Tochigi Prefecture, Japan.

PARTICIPANTS

268 students aged 11-12 years and 267 parental guardians.

INTERVENTIONS

Students received lessons about stroke featuring animated cartoons and were instructed to communicate their knowledge about stroke to their parental guardians using material (comic books) distributed in the lessons. Stroke knowledge (symptoms, risk factors and attitude towards stroke) and behavioural change for risk factors were assessed at baseline, immediately after the programme and at 3 months. We also evaluated behavioural change for risk factors among parental guardians.

RESULTS

The percentage of students with all correct answers for stroke symptoms, risk factors and the recommended response to stroke was significantly increased at 3 months P<0.001). We observed a significant increase in the percentage of guardians who chose all correct symptoms (P<0.001: 61.0% vs 85.4%) and risk factors (P<0.001: 41.2% vs 59.9%) at 3 months compared with baseline. The percentage of parental guardians with a high behavioural response to improving risk factors was significantly increased at 3 months compared with baseline (P<0.001).

CONCLUSIONS

In a rural population with high stroke mortality, stroke education can improve knowledge about stroke in elementary school students and their parental guardians.

ETHICS AND DISSEMINATION

We conducted the intervention as a part of compulsory education; this study was not a clinical trial. This study was approved by the Ethics Committee of the National Cerebral and Cardiovascular Center (M27-026).

Community Interventions to Increase Stroke Preparedness and Acute Stroke Treatment Rates

PURPOSE OF REVIEW

Acute stroke treatments reduce the risk of post-stroke disability. These treatments, tissue plasminogen activator (tPA) and intra-arterial treatment, are highly time-dependent; thus, one of the main barriers to treatment is pre-hospital delay. Stroke preparedness is defined as the ability to recognize stroke symptoms and the intent to activate emergency medical services (EMS). This review describes types of acute stroke treatment and preparedness interventions, including recent mass media interventions to increase acute stroke treatment rates, and adult and youth community interventions to increase stroke preparedness.

RECENT FINDINGS

The mass media campaigns show mixed results regarding acute stroke treatment rates, possibly attributed to the various media platforms utilized and resources available. The adult and youth community interventions reveal an overall increase in stroke symptom recognition and behavioral intent to call EMS. However, most of these community interventions were not grounded in health behavior theory, and they were tested in single group, pre-post test study designs that assessed behavioral rather than clinical outcomes. The delivery of stroke preparedness information by youth to adults, for example via home assignments, is a promising and innovative approach to stroke preparedness. Mass media and community interventions show promise to increase stroke preparedness and acute stroke treatment rates. The development of health behavior theory-based interventions that are tested via scientifically rigorous study designs are needed to prioritize which interventions should be disseminated to culturally and socially similar communities.

Cartoon versus traditional self-study handouts for medical students: CARTOON randomized controlled trial

OBJECTIVE

The objective of this study is to compare the effectiveness of a "cartoon-style" handout with a "traditional-style" handout in a self-study assignment for preclinical medical students.

METHODS

Third-year medical students (n = 93) at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, took a pre-learning assessment of their knowledge of intercostal chest drainage. They were then randomly allocated to receive either a "cartoon-style" or a "traditional-style" handout on the same topic. After studying these over a 2-week period, students completed a post-learning assessment and estimated their levels of reading completion.

RESULTS

Of the 79 participants completing the post-learning test, those in the cartoon-style group achieved a score 13.8% higher than the traditional-style group (p = 0.018). A higher proportion of students in the cartoon-style group reported reading ≥75% of the handout content (70.7% versus 42.1%). In post-hoc analyses, students whose cumulative grade point averages (GPA) from previous academic assessments were in the middle and lower range achieved higher scores with the cartoon-style handout than with the traditional one. In the lower-GPA group, the use of a cartoon-style handout was independently associated with a higher score.

CONCLUSIONS

Students given a cartoon-style handout reported reading more of the material and achieved higher post-learning test scores than students given a traditional handout.

Can Children Reduce Delayed Hospital Arrival for Ischemic Stroke?: A Systematic Review of School-Based Stroke Education

BACKGROUND

Delayed hospital arrival after onset of ischemic stroke reduces the number of patients eligible for tissue plasminogen activator, which must be given soon after stroke onset. There are conflicting results about the impact of mass media stroke education on timing of hospital arrival and tissue plasminogen activator administration rates. School-based programs are a new way to communicate stroke information.

METHODS

A search of MEDLINE, CINAHL, PsycINFO, and ERIC databases from 1995 to 2014 identified school-based stroke education interventions. Twelve studies involving 3,312 children and 612 parents met criteria for review.

RESULTS

School-based stroke education interventions were effective to improve knowledge of stroke symptoms among children in kindergarten through junior high. Improvement for stroke risk factors was less robust. Interventions were effective regardless of format, length, or who delivered the information. Despite low parental response rates in some studies, there was evidence that children transmitted stroke information to parents.

CONCLUSIONS

School-based stroke education programs appear effective to improve knowledge of stroke symptoms. Research is needed to determine if children who participate are able to recognize stroke and respond appropriately by calling 911 in the real world. More study is needed about transfer of stroke knowledge from child to parent. Strategies to improve parent participation are needed.

Delivering Knowledge of Stroke to Parents Through Their Children Using a Manga for Stroke Education in Elementary School

BACKGROUND

School-based intervention would be promising to spread stroke knowledge widely. This study aimed to clarify the effectiveness of our new educational aids that were developed for elementary school children to impart information about stroke to children and their parents in 2 different ways: with or without stroke lessons by a neurologist.

METHODS

We enrolled 562 children (aged 11 to 12 years) and their parents (n = 485). The students were divided into 2 groups: 323 received a lesson on stroke by a stroke neurologist without watching an animated cartoon (Group I), and 239 watched an animated cartoon without the lesson (Group II). All of the children took the manga home, and talked about stroke with their parents. Questionnaires on stroke knowledge were administered at baseline (BL), immediately after the lesson (IL), and 3 months (3M) after the lesson.

RESULTS

There were significant increases in the adjusted mean scores for risk factors as well as stroke symptoms at 3M in both groups compared with BL scores, although the children in Group I scored significantly better than those in Group II at IL and 3M (P < .05). In both children and parents, the correct answer rates of the FAST mnemonic at 3M were around 90%, with no significant differences between groups.

CONCLUSIONS

Stroke education for elementary school children using our educational aids provided knowledge of stroke symptoms to the children as well as their parents even without lessons on stroke, although a better understanding of stroke was obtained from lessons led by stroke neurologists.

Impact of stroke education on middle school students and their parents: A cluster randomized trial

Background School students are an attractive target for stroke education due to the potential impact on stroke prevention and recognition. Additionally, these students can drive behavioral changes in their families. Aim To evaluate the impact of stroke education on school students, in terms of students' and parents' acquired stroke knowledge. Methods A structured questionnaire on knowledge of stroke was filled out by eighth-grade students and one of their parents in seven public schools. In four of these schools, students attended a stroke lecture; educational flyers and magnetic posters were distributed and parent education was encouraged. Students and parents of the other three schools were included in a control group. Students and parents, of both intervention and control groups, were resubmitted to the initial structured questionnaire within one week of the stroke lecture and three months later. Results We included 764 students and 344 parents, 383 (50.1%) and 210 (61.0%) in the intervention group. Correct test scores for students before, within one week, and three months after the intervention were 54.49% versus 55.03% (p = 0.418), 98.69% versus 60.89% (p < 0.001), and 95.58% versus 75.7% (p < 0.001) in the intervention and control groups, respectively. Correct test scores for parents at the same time points were 68.78% versus 64.47% (p = 0.107), 96.89% versus 71.42% (p < 0.001), and 94.58% versus 76.54% (p < 0.001) in the intervention and control groups, respectively. Conclusions School-based interventions may improve stroke knowledge in middle school students and their parents.

Stroke preparedness in children: translating knowledge into behavioral intent: a systematic review and meta-analysis

BACKGROUND

If translated into behavioral intent, improving stroke knowledge may potentially impact on better outcomes. Children are an attractive target population since they can drive familial behavioral changes. However, the impact of interventions on stroke knowledge among children is unclear. We performed a systematic review and meta-analysis to investigate whether educational interventions targeting children improve stroke knowledge and lead to behavioral changes.

METHODS

We searched Ovid, PubMed, and Embase between January 2000 and December 2014. We included studies written in English reporting the number of children aged 6-15 years undergoing educational interventions on stroke and providing the results for baseline and early and late postintervention tests. We compared the proportion of correct answers between baseline, early, and late responses for two endpoints: knowledge and behavioral intent.

RESULTS

Of the initial 58 articles found, we included nine that met the inclusion criteria. Compared with baseline tests (51·7%, 95% confidence interval 40·9-62·4), there was improvement in stroke knowledge in early (74·0%, 95% confidence interval 64·4-82·5, P = 0·002) and late (67·3%, 95% confidence interval 55·4-78·2, P = 0·027) responses. There was improvement in the early (92·1%, 95% confidence interval 86·0-96·6, P < 0·001) and late (83·9%, 95% confidence interval 73·5-92·1, P = 0·001) responses for behavioral intent compared with the baseline assessment (63·8%, 95% confidence interval 53·5-73·4).

CONCLUSION

Children are a potentially attractive target population for improvement in stroke knowledge and behavioral intent, both in the short and long term. Our findings may support the implementation of large-scale stroke educational initiatives targeting children.

Factors Associated with Early Hospital Arrival in Patients with Acute Ischemic Stroke

Background and Purpose

Factors associated with early arrival may vary according to the characteristics of the hospital. We investigated the factors associated with early hospital arrival in two different stroke centers located in Korea and Japan.

Methods

Consecutive patients with ischemic stroke arrived hospital within 48 hours of onset between January 2011 and December 2012 were identified and the clinical and time variables were retrieved from the prospective stroke registries of Severance Hospital of Yonsei University Health System (YUHS; Seoul, Korea) and National Cerebral and Cardiovascular Center (NCVC; Osaka, Japan). Subjects were dichotomized into early (time from onset to arrival ≤4.5 hours) and late (>4.5 hours) arrival groups. Univariate and multivariate analyses were performed to evaluate factors associated with early hospital arrival.

Results

A total of 1,966 subjects (992 from YUHS; 974 from NCVC) were included in this study. The median time from onset to arrival was 6.1 hours [interquartile range, 1.7-17.8 hours]. In multivariate analysis, the factors associated with early arrival were atrial fibrillation (Odds ratio [OR], 1.505; 95% confidence interval [CI], [1.168-1.939]), higher initial National Institute of Health Stroke Scale scores (OR, 1.037; 95% CI [1.023-1.051]), onset during daytime (OR, 2.799; 95% CI [2.173-3.605]), and transport by an emergency medical service (OR, 2.127; 95% CI [1.700-2.661]). These factors were consistently associated with early arrival in both hospitals.

Conclusions

Despite differences between the hospitals, there were common factors related to early arrival. Efforts to identify and modify these factors may promote early hospital arrival and improve stroke outcome.