Long-term learning of stroke knowledge among children in a high-risk community

Impact of a theory-informed and user-centered stroke information campaign on the public's behaviors, attitudes, and knowledge when facing acute stroke: a controlled before-and-after study

Background

Public awareness of stroke symptoms is a key factor to ensure access to reperfusion strategies in due time. We designed and launched a regional theory-informed and user-centered information campaign and assessed its impact on emergency medical services (EMS) calls for stroke suspicion, time-to-call, and public attitudes and awareness concerning stroke.

Methods

A controlled before-and-after study was conducted during 3 sequential time-periods in 2 separate counties. Key messages of the campaign were underpinned by stroke representations and the theory of planned behavior, and focused on recognition of stroke warning signs and the need to call EMS urgently. The campaign included posters, leaflets, adverts and films displayed in bus and subway stations, internet, social networks, and local radio. Outcome measures on behavior, attitudes, and knowledge were assessed before the launch of the campaign, at 3 months, and 12 months.

Results

The number of EMS calls for stroke suspicion increased by 21% at 12 months in the intervention county and this change was significantly different to that observed in the control county (p = 0.02). No significant changes were observed regarding self-reported attitudes in case of stroke. An 8% significant increase in recognizing at least 2 stroke warning signs was observed in the intervention county (p = 0.04) at 3 months, while it did not change significantly in the control county (p = 0.6). However, there was no significant difference in warning sign recognition between both counties (p = 0.16).

Conclusion

The campaign significantly improved public’s behavior of calling EMS, although stroke knowledge was not improved as much as expected. Repeating these campaigns over time might further help improve timeliness and access to reperfusion strategies.

Trial registration

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02846363.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09795-y.

Educational technologies for health education on stroke: an integrative review

OBJECTIVE

to identify in the scientific literature the educational technologies used in the health education process related to stroke.

METHOD

integrative review, whose eligibility criteria of the articles were: match the keywords "health education" and "stroke"; be a research paper; be in Portuguese, English and Spanish; be available electronically in the databases LILACS, PubMed/Medline, Scopus and CINAHL; year of publication between 2000 and 2016.

RESULTS

24 publications were found. The analysis was carried out by means of analytical and interpretive readings. There were many educational technologies used in the health education process for stroke.

FINAL CONSIDERATIONS

the printed material for general public stood out, aiming to the recognition of alert signs of the disease and the emergency decision-making before suspicious cases of the disease.

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.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

A Review of Hip Hop-Based Interventions for Health Literacy, Health Behaviors, and Mental Health

OBJECTIVE

African-American children and adolescents experience an undue burden of disease for many health outcomes compared to their White peers. More research needs to be completed for this priority population to improve their health outcomes and ameliorate health disparities. Integrating hip hop music or hip hop dance into interventions may help engage African-American youth in health interventions and improve their health outcomes. We conducted a review of the literature to characterize hip hop interventions and determine their potential to improve health.

METHODS

We searched Web of Science, Scopus, PsycINFO, and EMBASE to identify studies that assessed hip hop interventions. To be included, studies had to (1) be focused on a psychosocial or physical health intervention that included hip hop and (2) present quantitative data assessing intervention outcomes. Twenty-three articles were identified as meeting all inclusion criteria and were coded by two reviewers. Articles were assessed with regards to sample characteristics, study design, analysis, intervention components, and results.

RESULTS

Hip hop interventions have been developed to improve health literacy, health behavior, and mental health. The interventions were primarily targeted to African-American and Latino children and adolescents. Many of the health literacy and mental health studies used non-experimental study designs. Among the 12 (of 14) health behavior studies that used experimental designs, the association between hip hop interventions and positive health outcomes was inconsistent.

CONCLUSIONS

The number of experimental hip hop intervention studies is limited. Future research is required to determine if hip hop interventions can promote health.

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.

Community-Level Measures of Stroke Knowledge among Children: Findings from Hip Hop Stroke

BACKGROUND

Community-level determinants of stroke knowledge among children are unknown but could meaningfully impact public stroke education campaigns. We explored for associations between community- and school-level quality measures relative to baseline stroke knowledge among children participating in the Hip Hop Stroke program.

METHODS

Baseline stroke knowledge assessments were performed in 2839 fourth-, fifth-, and sixth-grade students (ages 9-11 years) from November 2005 to April 2014. Knowledge was assessed relative to school performance grade (SPG, graded A-F; a school-level measure determined by the New York City [NYC] Department of Education) and economic need index (ENI, range: 0-2; a community-level, within-school measure of subsidized housing and meals with higher scores indicating more socioeconomic distress).

RESULTS

Schools studied included those with SPG = B (n = 196), SPG = C (n = 1590), and SPG = D (n = 1053) and mean ENI = .85 (standard deviation: .23). A composite assessment of knowledge, including 4 stroke symptoms (blurred vision, facial droop, sudden headache, and slurred speech), was conducted consistently since 2006. Overall, students correctly identified a mean of 1.74 stroke symptoms (95% confidence interval: 1.70-1.79; possible range: 0-4, expected value of chance response alone or no knowledge = 2). For quartiles of ENI, mean knowledge scores are as follows: ENI_Q1 = 2.00, ENI_Q2 = 2.09, ENI_Q3 = 1.46, and ENI_Q4 = 1.56 (ENI_Q3 and ENI_Q4 versus ENI_Q1, P < .001). For SPG, SPG = B schools: 2.09, SPG = C: 1.83, and SPG = D: 1.56 (SPG = C and SPG = D versus SPG = B schools, P ≤ .05).

CONCLUSIONS

Children's stroke knowledge was lowest in NYC communities with greater economic need and lower school performance. These findings could guide stroke education campaign implementation strategies.

Parental Care-Seeking Behavior and Prehospital Timelines of Care in Childhood Arterial Ischemic Stroke

BACKGROUND AND PURPOSE

Taking appropriate action in the prehospital setting is important for rapid stroke diagnosis in adults. Data are lacking for children. We aimed to describe parental care-seeking behavior and prehospital timelines of care in childhood arterial ischemic stroke.

METHODS

A structured questionnaire was developed, using value-focused event-driven conceptual modeling techniques, to interview parents of children presenting to the emergency department with arterial ischemic stroke from 2008 to 2014.

RESULTS

Twenty-five parents (median age 41 years, interquartile range 36-45) were interviewed. Twenty-four children were awake, and 1 child was asleep at stroke onset; 23 had sudden onset symptoms. Location at stroke onset included home (72%), school (8%), or other setting (20%). Carergivers present included parent (76%), another child (8%), teacher (4%), or alone (8%). Eighty-four percent of parents thought symptoms were serious, and 83% thought immediate action was required, but only 48% considered the possibility of stroke. Initial actions included calling an ambulance (36%), wait and see (24%), calling a general practitioner (16%) or family member (8%), and driving to the emergency department or family physician (both 8%). Median time from onset to emergency department arrival was 76 minutes (interquartile range 53-187), being shorter for ambulance-transported patients.

CONCLUSIONS

Stroke recognition and care-seeking behavior are suboptimal, with less than half the parents considering stroke or calling an ambulance. Initiatives are required to educate parents about appropriate actions to facilitate time-critical interventions.

Promotion, prevention and protection: interventions at the population- and community-levels for mental, neurological and substance use disorders in low- and middle-income countries

BACKGROUND

In addition to services within the health system, interventions at the population and community levels are also important for the promotion of mental health, primary prevention of mental, neurological and substance use (MNS) disorders, identification and case detection of MNS disorders; and to a lesser degree treatment, care and rehabilitation. This study aims to identify "best practice" and "good practice" interventions that can feasibly be delivered at these population- and community-levels in low- and middle-income countries (LMICs), to aid the identification of resource efficiencies and allocation in LMICs.

METHODS

A narrative review was conducted given the wide range of relevant interventions. Expert consensus was used to identify "best practice" at the population-level on the basis of existing quasi-experimental natural experiments and cost effectiveness, with small scale emerging and promising evidence comprising "good practice". At the community-level, using expert consensus, the ACE (Assessing Cost-Effectiveness in Prevention Project) grading system was used to differentiate "best practice" interventions with sufficient evidence from "good practice" interventions with limited but promising evidence.

RESULTS

At the population-level, laws and regulations to control alcohol demand and restrict access to lethal means of suicide were considered "best practice". Child protection laws, improved control of neurocysticercosis and mass awareness campaigns were identified as "good practice". At the community level, socio-emotional learning programmes in schools and parenting programmes during infancy were identified as "best practice". The following were all identified as "good practice": Integrating mental health promotion strategies into workplace occupational health and safety policies; mental health information and awareness programmes as well as detection of MNS disorders in schools; early child enrichment/preschool educational programs and parenting programs for children aged 2-14 years; gender equity and/or economic empowerment programs for vulnerable groups; training of gatekeepers to identify people with MNS disorders in the community; and training non-specialist community members at a neighbourhood level to assist with community-based support and rehabilitation of people with mental disorders.

CONCLUSION

Interventions provided at the population- and community-levels have an important role to play in promoting mental health, preventing the onset, and protecting those with MNS disorders. The importance of inter-sectoral engagement and the need for further research on interventions at these levels in LMICs is highlighted.

Hip Hop Stroke: Study Protocol for a Randomized Controlled Trial to Address Stroke Literacy

Objective

Stroke is the fifth leading cause of death and the leading cause of serious long-term adult disability in the US. Acute stroke treatments with intravenous thrombolysis and endovascular therapy are proven to reduce disability, however a critical limitation on their effectiveness is the narrow time window for administration, which is 4.5 hours and 6 hours respectively from the onset of symptoms. Our overarching goal is to reduce pre-hospital delays to acute stroke treatments in economically disadvantaged minority communities where the greatest delays exist, using Hip Hop Stroke.

Methods

Hip Hop Stroke (HHS) is a school-based, child-mediated, culturally-tailored stroke communication multimedia intervention developed using validated models of behavior change and designed to improve stroke literacy (knowledge of stroke symptoms, the urgent need to call 911, and prevention measures) of 4^th, 5^th and 6^th grade students and their parents residing in poor urban communities. Children in the intervention arm will receive the HHS intervention, while those in the attentional control arm will receive standardized nutrition education based on the USDA's MyPyramid program. Children will be trained and motivated to share stroke information with their parents or other adult caregiver. Both children and parents will complete a stroke knowledge assessment at baseline, immediately following the program, and at 3-months post-program. The primary outcome is the effect of the child mediation on parental stroke literacy.

Conclusion

Stroke literate children, a captive audience in school systems, may represent a viable channel for spreading stroke information into households of poor urban communities where mass media stroke campaigns have shown the lowest penetration. These children may also call 911 when witnessing a stroke in their homes or communities. The HHS program may highlight the potential role of children in the chain of stroke recovery as a strategy for reducing prehospital delays to acute stroke treatment.

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.

Hip Hop HEALS: Pilot Study of a Culturally Targeted Calorie Label Intervention to Improve Food Purchases of Children

OBJECTIVES

We explored the effect of a culturally targeted calorie label intervention on food purchasing behavior of elementary school students.

METHOD

We used a quasi-experimental design with two intervention schools and one control school to assess food purchases of third through fifth graders at standardized school food sales before and after the intervention (immediate and delayed) in schools. The intervention comprised three 1-hour assembly-style hip-hop-themed multimedia classes.

RESULTS

A mean total of 225 children participated in two baseline preintervention sales with and without calorie labels; 149 children participated in immediate postintervention food sales, while 133 children participated in the delayed sales. No significant change in purchased calories was observed in response to labels alone before the intervention. However, a mean decline in purchased calories of 20% (p < .01) and unhealthy foods (p < .01) was seen in immediately following the intervention compared to baseline purchases, and this persisted without significant decay after 7 days and 12 days.

CONCLUSION

A 3-hour culturally targeted calorie label intervention may improve food-purchasing behavior of children.

Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial

Background

Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 − 4½ h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City.

Design and Methods

In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films – one in English and one in Spanish – on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up.

Discussion

This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities.

Trial registration

NCT01909271; July 22, 2013

Educational campaigns at point of purchase in rural supermarkets improve stroke knowledge

BACKGROUND

The number of elderly people is dramatically increasing, and this trend is especially pronounced in rural populations. The aim of the present study was to verify the effectiveness of stroke education in a rural area.

METHODS

The stroke educational flyers were distributed for 3 weeks at the point of purchase within supermarkets. Questionnaires were used to determine knowledge about stroke and appropriate emergent action on identifying stroke.

RESULTS

A total of 882 people responded to the questionnaires before (n = 409) and 3 months after (n = 473) the campaign. Of these, 686 (77.8%) were aged 65 years or older. The percentages of correct answers for hemiplegia and one-sided numbness (P < .05 for both) and calling emergency medical services (EMS) on identifying stroke occurrence (P < .001) were higher after the campaign compared with those before the campaign. Of the respondents aged 65 years or older, the percentages of correct answers for numbness on one side and calling for EMS on identifying stroke were higher after the campaign (P < .05 and P < .001, respectively).

CONCLUSIONS

A simple point-of-purchase stroke campaign using educational flyers could meaningfully affect stroke knowledge among elderly persons in a rural community.

Improving Dementia Health Literacy Using the FLOW Mnemonic

Background. Dementia health literacy is low among the public and likely poses a significant barrier to Alzheimer’s disease (AD) symptom recognition and treatment, particularly among minority populations already facing higher AD burden. We evaluated the pilot phase of a novel AD health education program, Old SCHOOL (Seniors Can Have Optimal Aging and Ongoing Longevity) Hip-Hop (OSHH), which is designed to enable children to be AD health educational conduits in the home (“child-mediated health communication”). Method. OSHH applied our stroke-validated model of engaging, dynamic, and age- and culturally appropriate curriculum delivered to elementary school-age children (fourth/fifth grades, ages 9-11 years). We assessed AD knowledge among the children at baseline, immediately following the intervention (1-hour program delivered daily over 3 consecutive days), and 3 months later. For key AD symptoms, we developed the FLOW mnemonic ( forget, lose, overlook, write/wander); students were additionally taught action plans for recognized symptoms. Results. Seventy-five students completed baseline assessments, and 68 completed posttesting. AD symptoms in FLOW were not well known at baseline (individually ranging from 16% to 71% correct) but were highly learned after 3 days (89% to 98% correct) and retained well after 3 months (80% to 95% correct, p ≤ .01 for all comparisons vs. baseline). AD localization, including its effect on memory and the hippocampus, was also highly learned and retained ( p < .001). Eighteen students (24%) reported having a close friend/family member with AD. Conclusions. This study suggests our hip-hop health education model may be an effective method to improve AD health literacy.

Stroke knowledge among diabetics: a cross-sectional study on the influence of age, gender, education, and migration status

Background

Stroke campaigns are educating about the need to immediately contact the emergency medical system if symptoms occur. Despite higher stroke rates among patients with diabetics and some migrant populations, there are few data about stroke knowledge in these groups.

Methods

We performed a cross-sectional questionnaire survey among 250 diabetes patients from Germany and Turkey in a primary care and diabetes practice center. The two-page questionnaire asked for stroke knowledge and socio-demographic data. Also, medical and communication data were obtained. Stroke knowledge was defined as good if a participant knew (1) at least two stroke symptoms (good symptom knowledge) and (2) that immediate hospital admission or an emergency call is necessary in case of stroke symptoms (good action knowledge).

Results

A total of 231 of 250 patients took part in the survey (participation rate 92.4%) with 134 natives (53.6%), 84 migrants from Turkey (33.6%) and 13 migrants (5.2%) from other countries. Comparing natives and migrants from Turkey good symptom knowledge was documented in 52.8% of the participants, good action knowledge in 67.9%, and good stroke knowledge in nearly forty percent (39.4%) of patients (n = 218). A logistic regression analysis showed better stroke knowledge if patients were younger than 61 years, had good language abilities and were living in an one-generation household (p < 0.05), while gender, years since migration and diabetes control did not play a role.

Conclusions

We documented stroke knowledge deficits among patients with diabetes, both natives and migrants. Additional information strategies for these high risk populations are needed.