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Low thrombolysis rates for acute ischemic stroke is linked to delays in seeking immediate treatment due to low public stroke awareness. We aimed to assess whether “Child-Mediated Stroke Communication” (CMSC) could improve stroke literacy parents of children enrolled in a school-based stroke literacy program called Hip Hop Stroke (HHS).
Parents of children aged 9 to 12 years from two public schools in Harlem, NYC, were recruited to participate in stroke literacy questionnaires before and after their child’s participation in HHS, a novel CMSC intervention delivered in school auditoriums. Parental recall of stroke information communicated through their child was assessed 1-week following the intervention.
Fifth and Sixth grade students (n =182) were enrolled into HHS. 102 parents were approached in person to participate; 75 opted to participate and 71 completed both pretest and post-test (74% response rate and 95% retention rate). Parental stroke literacy improved after the program: before the program, 3 parents of 75 (3.9%) were able to identify the five cardinal stroke symptoms, distracting symptom (chest pains), and had an urgent action plan (calling 911), compared to 21 of 71 parents (29.6%) post-intervention (p<0.001). The FAST mnemonic was known by 2 (2.7%) of participants before the program vs. 29 (41%) after program completion (p<0.001).
Knowledge of stroke signs and symptoms remains low among residents of this high-risk population. The use of Child-Mediated Stroke Communication suggests that schoolchildren aged 9-12 may be effective conduits of critical stroke knowledge to their Parents.
Stroke affects 795,000 Americans each year and of these 610,000 are first attacks.1. National samples have consistently shown up to a three-fold greater stroke incidence in Black compared to non-Hispanic White Americans, especially among those aged 34-55 years, and a two-fold increase in mortality.2,3 Emergency treatment for ischemic stroke using intravenous tissue plasminogen activator (t-PA) can increase the odds of minimal to zero disability at three months by 31-50%.4,5 However, to be effective, t-PA must be administered within no more than 4.5 hours from symptom onset,4,5 although the best outcomes are seen when treatment begins within 90 minutes of stroke onset.6 Unfortunately, only 3-5% of ischemic stroke patients in the U.S. receive the treatment,7 mostly due to the latency between recognition of symptoms and arrival at the hospital.8,9 This latency has been linked to poor public knowledge concerning stroke symptoms and the appropriate urgent response to symptoms (calling 911) when they occur. Interventions designed to educate patients to seek treatment sooner when a stroke occurs may increase thrombolysis rates to 57%, if emergency medical system response times and in-hospital response times are optimized.8, 10
Data from 61,019 adults participating in the 2001 Behavioral Risk Factor Surveillance System (BRFSS) revealed that while most persons recognized one to three symptoms, only 9% for Blacks versus 19% for Whites were aware of the five cardinal symptoms of stroke (sudden confusion or trouble speaking, sudden numbness or weakness of face, arm, or leg, especially on one side of the body, sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, severe headache with no known cause) and would call 911 if they thought that someone was having a stroke.11 In a similar survey of 1023 residents in Central Harlem, a predominantly black high stroke-risk population, our group reported significant deficiencies in knowledge of stroke symptoms,12 consistent with the BRFSS survey, emphasizing the need for stroke awareness campaigns tailored to vulnerable populations.
Novel strategies for improving rapid recognition of stroke could include educating children about the time-urgent nature of stroke symptoms along with primary prevention.13 Stroke-educated children might rapidly activate the emergency medical system (EMS) if a family member suffers a stroke. Increases in the number of children living with grandparents and individuals delaying giving birth until after age 30 resulting in more children living with older parents14,15 support recommendations to expand health education for children to include stroke knowledge.
Hip Hop Stroke (HHS)16 is a school-based stroke communication intervention that uses what we have termed “Child-Mediated Stroke Communication (CMSC)”, a paradigm in which children may serve as a means of delivering an intervention to the target population (their parents and grandparents – whom we will now collectively call Parents - in their households). HHS uses a modular multi-media curriculum and Hip Hop music to teach children aged 9 to12 the five cardinal stroke symptoms, the correct course of action when they occur, and stroke prevention measures (collectively termed “stroke literacy”) in order to increase parental stroke literacy and the stroke literacy of the kids themselves.
The study population, Central Harlem, is a predominantly black (two-thirds of all residents), high-risk population with a high proportion of the population living under the federal poverty level and a high stroke death rate.17
The authors refined the content of our previously reported HHS intervention16 with input from members of the target community including school-aged children, and behavioral scientists. The intervention is based on two theories that have been demonstrated as important predictors of behavior change: (1) Reasoned Action Theory (RAT), which suggests that a series of related cognitive constructs operate to produce an intention to act, which is a precursor to engaging in the act or the desired outcome (i.e., making use of the stroke information as part of standard practice)18 and (2) Self Efficacy (SE) Theory, which posits that control over one’s outcomes produces a sense of mastery for those behaviors; and that increased self-efficacy predicts increased motivation to engage in the desired behaviors, as well as a demonstrated increase in the behavior itself.19 The refined HHS intervention is a 3-day 1 hour-per-day multi-media classroom intervention that uses Hip Hop songs written by a well-known artist, two 4-minute professionally produced cartoon music videos and a comic book to teach stroke literacy (Figure 1 and Supplemental Table 1: see http://stroke.ahajournals.org; see http://hiphoppublichealth.org for videos and comic book).. A stroke mnemonic “FAST” (“F” for “Face Droop”, “A” for “Arm Weakness”, “S” for Speech Affected/Slurred, and “T” for “Time to call 911”), derived from the Cincinnati pre-hospital stroke scale20 and other stroke symptoms not part of the “FAST” mnemonic were incorporated into the songs and overall curriculum. Five stroke symptoms were used to capture the major components of the BRFSS symptoms with some modifications. These included sudden slurred/confused speech sudden blurred vision (or loss of vision), sudden clumsiness/imbalance, sudden severe headache for no known reason, and sudden facial weakness/droop. This latter symptom – sudden facial weakness – was taught in the context of one-sided weakness of the face, arm, and leg, although separate variables for limb weakness and numbness were not measured. Other teaching methods included role-play to rehearse calling 911 in the event of a stroke, and “acting out” the cardinal stroke symptoms in skits. Parental engagement homework assignments in the form of “Hip Hop To-Go” kits (see Figure 1) were included to supplement the in-class materials and facilitate an increase in parental stroke knowledge through CMSC. Students were encouraged to view a DVD (containing the two 4-minute cartoons) with their Parents, review a comic book with their Parents, become “stroke reporters” by surveying their Parents on stroke knowledge with a “tear off” questionnaire located at the back of the comic book (evidence of parental engagement), and convince their Parents to place a HHS refrigerator magnet in a prominent place in their homes.
The current study assesses the potential public health impact of HHS beyond the classrooms by testing the following pre-specified hypothesis upon which our outcomes were based : (1) children enrolled in the HHS intervention will attempt to educate Parents about stroke, (2) Parents engaged by enrolled children will demonstrate increased stroke knowledge and the appropriate course of action in the event of a stroke using hypothetical real world scenarios 1 week after the completion of the HHS intervention. This second hypothesis – parental stroke knowledge - formed the basis of our primary outcome measure (Supplemental figure 2: see http://stroke.ahajournals.org), while proof of parental engagement captured by our first hypothesis was a secondary measure.
After obtaining approval from the Institutional Review Board at Columbia University, a sample of 5th- and 6th-grade students (N=182; ages 9-12) were recruited into the HHS intervention from two schools in Central Harlem. Two weeks prior to program initiation, Parents of students were contacted in person at three pre-specified in-school parent meetings arranged by school staff, and consented to complete a pretest stroke literacy questionnaire that included demographic information (Table 1). All participating Parents verified that they were the primary caregivers to the participating student and the individual at home with whom the child would be most likely to share information. Two trained lay-health facilitators delivered the intervention in English to the children in both schools. Parents did not participate in the school-based program. Returned student homework (“tear off” questionnaire from the comic book) assignments requiring parental participation were used as proof of parental engagement (“likelihood of discussing materials”). Small incentives, including program t-shirts, baseball caps, and wristbands were given to children who returned the homework assignment (“tear off” comic book questionnaire) completed by their Parent. Parental recall of stroke information communicated by their child was assessed by post-test questionnaires (Supplemental figure 2: see http://stroke.ahajournals.org) administered by telephone one week after the children had participated in the intervention.
Hypothesis 1: In the post-test instrument (Supplemental figure 2: see http://stroke.ahajournals.org) we collected Yes/No responses to the questions regarding communication by the child. We also collected homework assignments (“tear off” comic book questionnaire”) completed by the parent from the child.
Hypothesis 2 (primary outcome measure): Stroke symptom questions on our instrument (Supplemental figure 2: see http://stroke.ahajournals.org) were answered as either Yes/No whereas other questions were multiple choice (call 911 using case scenarios, stroke localization or knowledge that a stroke occurs in the brain, and identifying the term “brain attack”) or open response (naming components of the F.A.S.T. mnemonic). Knowledge of stroke prevention was also assessed using open responses. We compared pretest versus post-test performances by individual across the test sequence, using Wilcoxon paired signed ranks test (PASW Statistics v. 17.0 [SPSS, Inc, Chicago, Ill]). To improve comparability to BRFSS measures, we developed a composite of stroke symptoms, a distracter (chest pain), and an urgent action plan (call 911).
Stroke Literacy and Demographic Characteristics: We explored stroke knowledge responses relative to age, sex, race-ethnicity, and education, comparing pre-post performance within the strata. Simple odds ratios were determined using binary logistic regression.
A total of 102 Parents of children in our sample were contacted in person at 3 pre-specified in-school parent meetings during the 2-week lead-in period. This total number of parent contacts was limited by the short lead-in period and recruitment method selected by investigators. No child contributed more than 1 adult parent. Seventy-five Parents opted to participate (74%), and 71 (74%) completed both pretest and post-test. Parents’ ages ranged from 25-74 years, 72% non-Hispanic Black, and 24% Hispanic, 1% Asian Pacific Islander, 3% “Other”, 45% had a high school diploma or less, 27% had some college, and 28% were college graduates or had an advanced degree (Table 1). Of the original 75 participating Parents, most identified themselves as parents (61), followed by “relative” (3), grandparent (2), aunt/uncle (1), sibling or stepsibling (1), or not identified (7).
Hypothesis 1: All 71 Parents who completed both pretest and post-test indicated that their children communicated stroke information to them (100%), and of these, 54 (75%) were confirmed by returned homework assignments collected on the final day of the 3-day HHS intervention.
Hypothesis 2: Parental stroke literacy improved after the program (Tables 1, ,2,2, and and3).3). Parents were more likely to correctly report stroke localization after the program (51% correct at baseline vs. 85%, p<0.001)). In an open-response question, the F.A.S.T. stroke mnemonic was correctly known by 2 (2.7%) of participants before the program vs. 29 (41%) after the program had ended (p<0.001). Knowledge of stroke prevention measures significantly improved from a mean of 0.77 items named prior to the intervention compared with 1.08 afterward (p=0.001). Before the program, only 3 of the 75 Parents (3.9%) were able to correctly identify the five cardinal stroke symptoms (slurred speech/confusion, facial droop, blurred vision, clumsiness/imbalance, severe/unexplained headache), a non-stroke distracter (chest pains) and had an urgent action plan (calling 911), compared to 21 of the 71 Parents (29.6%) post-intervention (p<0.001). Fifty-two percent of Parents were able to correctly identify at least 4 out of 6 symptoms (including distracter) and this increased to 91.6% afterward (p<0.001, Supplemental figure 3: see http://stroke.ahajournals.org). Review of individual stroke symptom responses suggested improved likelihood of message retention for those included in the F.A.S.T. mnemonic (Supplemental figure 4: see http://stroke.ahajournals.org); facial paresis and slurred speech were identified in a high proportion of participants before the intervention (72.0% and 77.3%, respectively, p<0.01 [Pearson χ2] for both when compared with headache but not statistically significantly higher than blurry/loss of vision).
Stroke Literacy and Demographic Characteristics: We explored possible effects of sociodemographic factors on stroke knowledge learning (Tables 1, ,2,2, and and3).3). Greater educational attainment was associated in a dose-response manner with stroke knowledge on several questions on the pretests: stroke localization (p-test of trend=0.03), stroke symptoms: slurred speech (p=0.02), facial paresis (p=0.003), and clumsiness [p=0.004], as well as correctly identifying all stroke symptoms and chest pain as a distracter (p=0.01). However, education was more predictive of post-test performance: identifying stroke as a “brain attack” (p=0.01), and stroke symptom slurred speech (p=0.009). In the pretest period, higher education predicted better knowledge of stroke localization (college graduates v. less than high school: OR=4.33 (95% CI: 1.15-16.32) as well as stroke symptom recognition: slurred speech (high school graduate v. less than high school: OR=4.50, 95% CI: 1.13-17.88; college graduates v. less than high school: OR=6.00, 95% CI: 1.08-33.27), facial paresis (high school graduate v. less than high school: OR=5.20, 95% CI: 1.42-19.04; college graduates v. less than high school: OR=9.00, 95% CI: 1.64-49.45), and clumsiness (college v. less than high school: OR=7.43, 95% CI: 1.78-31.04). In the post-test, college graduates were 6.67 (OR 95% CI: 1.50-29.63) times more likely than those with less than high school education to correctly call a stroke a “brain attack.” In comparison to Hispanics, non-Hispanic Blacks were more likely to call 911 for a stroke during the pretest period (OR=3.2 [95% CI: 1.00-10.32]) but there was no significant difference on the post-test. We found no significant associations between age tertiles or sex on any test of stroke knowledge.
In a prior study, we tested HHS and found that children aged 9-11 years can rapidly learn stroke information, and retain the knowledge for at least three months.16 We also showed that incorporating Hip Hop music might improve retention of stroke knowledge among youth. We performed extended delayed post-tests on a group of students (n=85) tracked for 15 months and found no significant decline in 4-out-of-5 cardinal stroke symptoms learned (except sudden headache - unpublished data).
In this study, we found that children can serve as conduits for the delivery of stroke information into their homes. Before HHS, 4% of adults in this study were aware of the five cardinal symptoms of stroke, correctly identified chest pain as a non-stroke symptom, and would call 911; after our CMSC intervention this number increased substantially and significantly to 30%. In keeping with other reports,11 we found significant associations between education and stroke knowledge, including dose-response relationships with higher educational attainment being associated with greater stroke knowledge both before and after the program.
Pre-hospital delays continue to contribute the largest proportion of delay time to acute stroke care.9 Significant gaps exist between onset of stroke-like symptoms and the onset of recognition of the symptoms by the patient, family member, or witness, as urgent symptoms requiring immediate medical attention for which time dependent therapeutic benefit exists. Effectively addressing these knowledge gaps with evidence-based models are important steps, followed by trials evaluating their behavioral effect on reducing pre-hospital delays 8,10
Conventionally, most health education programs have assumed that communication of health information flows from parent to child and not the reverse. To our knowledge only two studies - one asthma study and one hypertension study - have successfully shown that young children are able to initiate health communications with parents and affect parental health behavior. Open Airways for Schools (OAS)21 showed that children with asthma were able to successfully teach their parents new patterns of asthma self-management at home. A school-based hypertension program showed that children might improve parents’ knowledge about hypertension and increase the likelihood the parents will consult their physician about their blood pressure.22 To date, four school-based stroke education programs for children have been published.16,23-25 Each has successfully demonstrated that young children are educable about stroke, and one program,16 Hip Hop Stroke, reported EMS activation by stroke-educated children. To date, no program has successfully demonstrated that stroke-educated children can effectively transfer stroke knowledge to adult family members either due to low parental participation, high attrition rates, or the absence of data. The Kids Identifying and Defeating Stroke (KIDS) study, a randomized controlled trial,23 found engagement of parents challenging, and were unable to report results on knowledge transfer to parents due to low parental response rates.
Based on the success of HHS, child-mediated health communication may serve as the basis for intervention in any number of content areas such as medication adherence, and healthy eating. This model may represent an innovative vehicle for public health education because of its potential to: (1) provide public health officials with a “captive” audience in the schools, (2) improve child health literacy and risk-related behaviors, (3) utilize children’s access to their parents to influence parental health literacy and risk-related behaviors, and (4) provide a cost-effective alternative to expensive mass media campaigns. Thus, the significance of our study is not limited to the public health problem under study—stroke symptom identification and urgent response – but also to the potential development and refinement of a more general model of intervention.
Despite the large effect sizes found, several limitations of our study should be mentioned. Our report is a non-randomized single arm pretest post-test design, whose limitations may include the threat of instrument reactivity. However, the instrument, which encompasses only the knowledge domain (either the child did or did not report; either the parent can or cannot recall specific items), reduces the likelihood that parental knowledge is subject to reactive bias. Another limitation is the inability to control for contamination from other local public health stroke education programs; however, low baseline knowledge and short follow up duration reduce the likelihood of this. A low number of Parents, 56% (102/182) were approached, and of these our response rate was 74%. However, the total number of recruited Parents represented 41% (75/182) of the potential sample. This low percentage could have introduced bias into our findings, although even if those not responding to the survey had learning nothing, the results in this report still would indicate significant gains in stroke knowledge in a population with very low baseline stroke awareness. The short follow-up period precludes assessment of long-term retention by Parents. We did not assess Parental occupation, which could better inform patterns of stroke awareness confounded by education and race-ethnicity. We acknowledge that our study of potentially explanatory sociodemographic factors for stroke knowledge are exploratory and associated findings may be an artifact of multiple comparisons. Moreover, given the small sample size, we were unable to simultaneously control for various socioeconomic confounders, which often covary, precluding definitive conclusion. However, considering that analyses of educational attainment suggested both a dose response and greater differences in pretest performance associated with higher educational attainment, we plan to explore this further in future study. In addition, our study did not assess which elements of HHS were most responsible for improving parental knowledge; these could include stand-alone assessments of the related songs, cartoons, and comic book, or informal conversation related to learning from the program.
In summary, we have shown data that supports the viability of a CMSC model for stroke awareness and consideration of child-mediated health communication when developing other public health programs. Randomized controlled studies are needed to confirm these findings and assess behaviors related to improved community stroke literacy.
The authors would like to thank Dr. John Brust, Dr. Mitchell Elkind, and Dr. Elizabeth Cohn for critically reviewing the manuscript and making helpful comments. The authors would also like to thank and acknowledge Electric Black Experience, Inc. for the production of multimedia materials.
Sources of Funding. The authors are supported by a grant from the NIH/NINDS 1 R01 NS067443-01A1 (Dr. Olajide Williams. PI). Dr. Williams receives additional research support from NIH/NHLBI 1R01HL092860-01A1 (Dr. Olugbenga Ogedegbe. PI). Dr. Gerin receives additional research support from the NIH/ NHLBI 5R01HL089402-02 (Dr. William Gerin PI). Dr. Noble receives additional research support from the Alzheimer’s Association. Production of “Stroke Ain’t No Joke” cartoon was supported by grants from GE Healthcare, National Stroke Association, and New York City Council Member Inez Dickens.
Conflicts of Interest/Disclosures: None of the authors have a potential conflict of interest to disclose.
Access to Data: Dr. Williams, Dr. Noble, and Ms. DeSorbo had full access to all study data and take responsibility for data integrity and accuracy of data analysis.
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