Development of an education campaign to reduce delays in pre-hospital response to stroke

Caterina Caminiti, Peter Schulz, Barbara Marcomini, Elisa Iezzi, Silvia Riva, Umberto Scoditti, Andrea Zini, Giovanni Malferrari, Maria Luisa Zedde, Donata Guidetti, Enrico Montanari, Mario Baratti, Licia Denti, Educazione e Ritardo di Ospedalizzazione (E.R.O.I) study group, Paola Castellini, Carla Zanferrari, Annalisa Tanzi, Francesca Diodati, Silvia Olivato, Filippo Barbi, Guido Bigliardi, Maria Luisa Dell'Acqua, Laura Vandelli, Francesca Rosafio, Roberta Pentore, Livi Picchetto, Daniela Monaco, Eva Perticaroli, Ilaria Iafelice, Paolo Imovilli, Luca Vaghi, Angelica Guareschi, Caterina Caminiti, Peter Schulz, Barbara Marcomini, Elisa Iezzi, Silvia Riva, Umberto Scoditti, Andrea Zini, Giovanni Malferrari, Maria Luisa Zedde, Donata Guidetti, Enrico Montanari, Mario Baratti, Licia Denti, Educazione e Ritardo di Ospedalizzazione (E.R.O.I) study group, Paola Castellini, Carla Zanferrari, Annalisa Tanzi, Francesca Diodati, Silvia Olivato, Filippo Barbi, Guido Bigliardi, Maria Luisa Dell'Acqua, Laura Vandelli, Francesca Rosafio, Roberta Pentore, Livi Picchetto, Daniela Monaco, Eva Perticaroli, Ilaria Iafelice, Paolo Imovilli, Luca Vaghi, Angelica Guareschi

Abstract

Background: Systematic reviews call for well-designed trials with clearly described intervention components to support the effectiveness of educational campaigns to reduce patient delay in stroke presentation. We herein describe the systematic development process of a campaign aimed to increase stroke awareness and preparedness.

Methods: Campaign development followed Intervention Mapping (IM), a theory- and evidence-based tool, and was articulated in two phases: needs assessment and intervention development. In phase 1, two cross-sectional surveys were performed, one aiming to measure stroke awareness in the target population and the other to analyze the behavioral determinants of prehospital delay. In phase 2, a matrix of proximal program objectives was developed, theory-based intervention methods and practical strategies were selected and program components and materials produced.

Results: In phase 1, the survey on 202 citizens highlighted underestimation of symptom severity, as in only 44% of stroke situations respondents would choose to call the emergency service (EMS). In the survey on 393 consecutive patients, 55% presented over 2 hours after symptom onset; major determinants were deciding to call the general practitioner first and the reaction of the first person the patient called. In phase 2, adult individuals were identified as the target of the intervention, both as potential "patients" and witnesses of stroke. The low educational level found in the patient survey called for a narrative approach in cartoon form. The family setting was chosen for the message because 42% of patients who presented within 2 hours had been advised by a family member to call EMS. To act on people's tendency to view stroke as an untreatable disease, it was decided to avoid fear-arousal appeals and use a positive message providing instructions and hope. Focus groups were used to test educational products and identify the most suitable sites for message dissemination.

Conclusions: The IM approach allowed to develop a stroke campaign integrating theories, scientific evidence and information collected from the target population, and enabled to provide clear explanations for the reasons behind key decisions during the intervention development process.

Trial registration: NCT01881152 . Retrospectively registered June 7 2013.

Keywords: Cartoon; Intervention mapping; Media; Pre-hospital delay; Public campaign; Stroke.

Figures

Fig. 1
Fig. 1
Responses to STAT. STAT scenarios ordered by percentage of correct responses
Fig. 2
Fig. 2
Information sources. Local sources and channels of health information most commonly used by respondents
Fig. 3
Fig. 3
Flow diagram
Fig. 4
Fig. 4
Patient-reported barriers. Frequencies of barriers reported by patients who arrived at hospital after 3 hours, subdivided into patients who did and did not use EMS

References

    1. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376:1261–71. doi: 10.1016/S0140-6736(10)60809-4.
    1. Herlitz J, WireklintSundstrom B, Bang A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med. 2010;18:48. doi: 10.1186/1757-7241-18-48.
    1. Lecouturier J, Rodgers H, Murtagh MJ, White M, Ford GA, Thomson RG. Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment. BMC Public Health. 2010;10:784. doi: 10.1186/1471-2458-10-784.
    1. Mellon L, Doyle F, Rohde D, Williams D, Hickey A. Stroke warning campaigns: delivering better patient outcomes? A systematic review. Patient Relat Outcome Meas. 2015;6:61–73. doi: 10.2147/PROM.S54087.
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. doi: 10.1136/bmj.a1655.
    1. The EQUATOR Network | Enhancing the QUAlity and Transparency Of Health Research. . Accessed 12 July 2016
    1. Teuschl Y, Brainin M. Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. Int J Stroke. 2010;5:187–208. doi: 10.1111/j.1747-4949.2010.00428.x.
    1. Payne GH, Fang J, Fogle CC, Oser CS, Wigand DA, Theisen V, et al. Stroke awareness: surveillance, educational campaigns, and public health practice. J Public Health Manag Pract. 2010;16:345–58. doi: 10.1097/PHH.0b013e3181c8cb79.
    1. Boden-Albala B, Quarles LW. Education strategies for stroke prevention. Stroke. 2013;44(Suppl 1):48–51. doi: 10.1161/STROKEAHA.111.000396.
    1. Morgenstern LB, Staub L, Chan W, Wein TH, Bartholomew LK, King M, et al. Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project. Stroke. 2002;33:160–6. doi: 10.1161/hs0102.101990.
    1. Boden-Albala B, Edwards DF, St Clair S, Wing JJ, Fernandez S, Gibbons C, et al. Methodology for a Community Based Stroke PreparednessIntervention: The ASPIRE Study. Stroke. 2014;45:2047–52. doi: 10.1161/STROKEAHA.113.003502.
    1. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernández ME. Planning Health Promotion Programs: An Intervention Mapping Approach. 3rd edition. SanFrancisco, Jossey-Bass; 2011. Pretesting, revising and producing program components.
    1. Salute Emilia-Romagna - Servizio sanitario regionale. . Accessed 28 June 2016.
    1. A.L.I.Ce. Italia Onlus. . Accessed 28 June 2016.
    1. Kok G, Schaalma H, Ruiter RAC, Van Empelen P, Brug J. Intervention mapping: A protocol for applying health psychology theory to prevention programmes. J Health Psychol. 2004;9:85–98. doi: 10.1177/1359105304038379.
    1. Jauch EC, Saver JL, Adams HP, Jr, Bruno A, Connors JJ, Demaerschalk BM, American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947. doi: 10.1161/STR.0b013e318284056a.
    1. Billings-Gagliardi S, Mazor KM. Development and validation of the stroke action test. Stroke. 2005;36:1035–9. doi: 10.1161/.
    1. Denti L, Marcomini B, Riva S, Schulz PJ, Caminiti C, for EROI (Educazione e Ritardo di Ospedalizzazione per Ictus) study group Cross-cultural adaptation of the stroke action test for Italian-speaking people. BMC Neurol. 2015;15:76. doi: 10.1186/s12883-015-0335-z.
    1. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186–91. doi: 10.1097/00007632-200012150-00014.
    1. Mikulik R, Bunt L, Hrdlicka D, Dusek L, Vaclavik D, Kryza J. Calling 911 in response to stroke - A nationwide study assessing definitive individual behavior. Stroke. 2008;39:1844–9. doi: 10.1161/STROKEAHA.107.499806.
    1. Mikulik R, Goldemund D, Reif M, Brichta J, Neumann J, Jarkovsky J, et al. Calling 911 in Response to Stroke: No Change following a Four-Year Educational Campaign. Cerebrovasc Dis. 2011;32:342–8. doi: 10.1159/000330339.
    1. Hsia AW, Castle A, Wing JJ, Edwards DF, Brown NC, Higgins TM, et al. Understanding reasons for delay in seeking acute stroke care in an underserved urban population. Stroke. 2011;42:1697–701. doi: 10.1161/STROKEAHA.110.604736.
    1. Carroll C, Hobart J, Fox C, Teare L, Gibson J. Stroke in Devon: knowledge was good, but action was poor. J Neurol Neurosurg Psychiatry. 2004;75:567–71. doi: 10.1136/jnnp.2003.018382.
    1. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and Natural-History of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521–6. doi: 10.1016/0140-6736(91)93206-O.
    1. Chew LD, Bradley KA, Boyko EJ. Brief Questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.
    1. Chew LD, Griffin JM, Partin MR, Noorbaloochi S, Gril JP, Snyder A, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23:561–6. doi: 10.1007/s11606-008-0520-5.
    1. Wallace LS, Cassada DC, Rogers ES, Freeman MB, Granadas OH, Stevens SL, et al. Can screening items identify surgery patients at risk of limited health literacy? J Surg Res. 2007;140:208–13. doi: 10.1016/j.jss.2007.01.029.
    1. World Health Organization. Health education: theoretical concepts, effective strategies and core competencies. 2012; . Accessed 22 March 2017
    1. Morgan DL. The focus group guidebook. Thousand Oaks: Sage; 1998.
    1. Morse JM. Principles of mixed methods and multimethod research design. In: Tashakkori A, Teddlie C, editors. Handbook of mixed methods in social and behavioral research. Thousand Oaks: Sage; 2003. pp. 189–208.
    1. Wilkinson S. Focus group research. In: Silverman D, editor. Qualitative research: Theory, method, and practice. Thousand Oaks: Sage; 2004. pp. 177–199.
    1. Emilia-Romagna Resident Year 2013. . Accessed 28 June 2016.
    1. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. New York: Wiley; 1982.
    1. Fleiss JL. Sttatistical methods for rates and proportions. 2. New York: Wiley; 1981.
    1. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. doi: 10.1186/1471-2288-3-21.
    1. Denti L, Artoni A, Scoditti U, Gatti E, Bussolati C, Ceda GP. Pre-hospital delay as determinant of ischemic stroke outcome in an Italian cohort of patients not receiving thrombolysis. J Stroke Cerebrovasc Dis. 2016;25:1458–66. doi: 10.1016/j.jstrokecerebrovasdis.2016.02.032.
    1. Safer MA, Tharps QJ, Jackson TC, Leventhal H. Determinants of three stages of delay in seeking care at a medical clinic. Med Care. 1979;17:11–29. doi: 10.1097/00005650-197901000-00002.
    1. Andersen BL, Cacioppo JT, Roberts DC. Delay in seeking a cancer diagnosis: delay stages and psychophysiological comparison processes. Br J Soc Psychol. 1995;34:33–52. doi: 10.1111/j.2044-8309.1995.tb01047.x.
    1. Leventhal HA, Brissette I, Leventhal EA. The common-sense model of self-regulation of health and illness. In: Cameron LD, Leventhal HA, editors. The self-regulation of health and illness behaviour. London: Routledge; 2003. pp. 42–65.
    1. NINDS Know Stroke Campaign. . Accessed 28 June 2016.
    1. Power to end stroke. . Accessed 7 July 2016
    1. Wall HK, Beagan BM, O'Neill J, Foell KM, Boddie-Willis CL. Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Prev chronic Dis. 2008;5:A49.
    1. Boden-Albala B, Stillman J, Perez T, Evensen L, Moats H, Wright C, et al. A stroke preparedness RCT in a multi-ethnic cohort: design and methods. Contemp Clin Trials. 2010;31:235–41. doi: 10.1016/j.cct.2010.02.003.
    1. Boden-Albala B, Carman H, Moran M, Doyle M, Paik MC. Perception of recurrent stroke risk among black, white and Hispanic ischemic stroke and transient ischemic attack survivors: the SWIFT study. Neuroepidemiology. 2011;37:83–87. doi: 10.1159/000329522.
    1. Addo J, Ayis S, Leon J, Rudd AG, McKevitt C, Wolfe CD. Delay in presentation after an acute stroke in a multiethnic population in South London: the South London stroke register. J Am Heart Assoc. 2012;1:e001685. doi: 10.1161/JAHA.112.001685.
    1. Dombrowski SU, Mackintosh JE, Sniehotta FF, Araujo-Soares V, Rodgers H, Thomson RG, et al. The impact of the UK 'Act FAST' stroke awareness campaign: content analysis of patients, witness and primary care clinicians' perceptions. BMC Public Health. 2013;13:915. doi: 10.1186/1471-2458-13-915.
    1. Kim YS, Park S-S, Bae H-J, Cho AH, Cho Y-J, Han M-K, et al. Stroke awareness decreases prehospital delay after acute ischemic stroke in korea. BMC Neurol. 2011;11:2. doi: 10.1186/1471-2377-11-2.
    1. Wolters FG, Paul NLM, Li L, Rothwell PM, on behalf of the Oxford Vascular Study Sustained impact of UK FAST-test public education on response to stroke: a population-based time-series study. Int J Stroke. 2015;10:1108–14. doi: 10.1111/ijs.12484.
    1. Kreuter MW, Green MC, Cappella JN, Slater MD, Wise ME, Storey D, et al. Narrative communication in cancer prevention and control: A framework to guide research and application. Ann Behav Med. 2007;33:221–35. doi: 10.1007/BF02879904.
    1. Hinyard LJ, Kreuter MW. Using narrative communication as a tool for health behavior change: a conceptual, theoretical, and empirical overview. Health Educ Behav. 2007;34:777–792. doi: 10.1177/1090198106291963.
    1. Leiner M, Handal G, Williams D. Patient communication: a multidisciplinary approach using animated cartoons. Vol. 19. Oxford Univ Press; 2004. p. 591–595.
    1. Calderón JL, Singer G, Heslin K, Baker RS. Animation as a venue for enhancing health literacy: implications for medical education. Ann Ann Behav Sci Med Educ. 2007;13(2):87–91.
    1. Mayer RE, Sims VK. For whom is a picture worth a thousand words? Extensions of a dual-coding theory of multimedia learning. J Educ Psychol. 1994;86:389–401. doi: 10.1037/0022-0663.86.3.389.
    1. Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns. 1998;35:83–8. doi: 10.1016/S0738-3991(98)00065-2.
    1. Müller-Nordhorn J, Wegscheider K, Nolte CH, Jungehülsing GJ, Rossnagel K, Reich A, et al. Population-based intervention to reduce prehospital delays in patients with cerebrovascular events. Arch Intern Med. 2009;169:1484–90. doi: 10.1001/archinternmed.2009.232.
    1. Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6:54. doi: 10.1186/1471-2288-6-54.
    1. Grant A, Treweek S, Dreischulte T, Foy R, Guthrie B. Process evaluations for cluster-randomised trials of complex interventions: a proposed framework for design and reporting. Trials. 2013;14:15. doi: 10.1186/1745-6215-14-15.
    1. Bray JE, Mosley I, Bailey M, Barger B, Bladin C. Stroke public awareness campaigns have increased ambulance dispatches for stroke in Melbourne, Australia. Stroke. 2011;42:2154–2157. doi: 10.1161/STROKEAHA.110.612036.
    1. Bray JE, O'Connell B, Gilligan A, Livingston PM, Bladin C. Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms? Int J Stroke. 2010;5:440–446. doi: 10.1111/j.1747-4949.2010.00484.x.
    1. Papapanagiotou P, Iacovidou N, Spengos K, Xanthos T, Zaganas I, Aggelina A, et al. Temporal trends and associated factors for pre-hospital and in-hospital delays of stroke patients over a 16-year period: The Athens Study. Cerebrovasc Dis. 2011;31:199–206. doi: 10.1159/000321737.
    1. Fogle CC, Oser CS, McNamara MJ, Helgerson SD, Gohdes D, Harwell TS. Impact of media on community awareness of stroke warning signs: a comparison study. J Stroke Cerebrovasc Dis. 2010;19:370–375. doi: 10.1016/j.jstrokecerebrovasdis.2009.06.007.
    1. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion campaigns: a campaign mapping approach. San Francisco: Jossey-Bass; 2006.
    1. Kok G, Bartholomew LK, Parcel GS, Gottlieb NH, Fernández ME. Finding theory-and evidence-based alternatives to fear appeals: intervention mapping. Int J Psychol. 2014;49:98–107. doi: 10.1002/ijop.12001.
    1. Flynn D, Ford GA, Rodgers H, Price C, Steen N, Thomson RG. A time series evaluation of the FAST National Stroke Awareness Campaign in England. PLoS One. 2014;9:e104289. doi: 10.1371/journal.pone.0104289.
    1. Mellon L, Hickey A, Doyle F, Dolan E, Williams D. Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign. Emerg Med J. 2014;31:536–40. doi: 10.1136/emermed-2012-202280.
    1. Mellon L, Doyle F, Williams D, Brewer L, Hall P, Hickey A. Patient behavior at the time of stroke onset: a cross-sectional survey of patient response to stroke symptoms. Emerg Med J. 2016;33:396–402. doi: 10.1136/emermed-2015-204806.
    1. Michie S, Wood CE, Johnston M, Abraham C, Francis JJ, Hardeman W. Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data) Health Technol Assess. 2015;19:1–188. doi: 10.3310/hta19990.
    1. Borek AJ, Abraham C, Smith JR, Greaves CJ, Tarrant M. A checklist to improve reporting of group-based behaviour-change interventions. BMC Public Health. 2015;15:963. doi: 10.1186/s12889-015-2300-6.
    1. Presseau J, Ivers NM, Newham JJ, Knittle K, Danko KJ, Grimshaw JM. Using a behaviour change techniques taxonomy to identify active ingredients within trials of implementation interventions for diabetes care. Implement Sci. 2015;10:55. doi: 10.1186/s13012-015-0248-7.
    1. Wood CE, Hardeman W, Johnston M, Francis J, Abraham C, Michie S. Reporting behaviour change interventions: do the behaviour change technique taxonomy v1, and training in its use, improve the quality of intervention descriptions? Implement Sci. 2016;11:84. doi: 10.1186/s13012-016-0448-9.

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