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for 15 months and found no significant decline in 4-out-of-5 cardinal stroke symptoms learned (except sudden headache - unpublished data).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.