Preventive Medicine 86 (2016) 1–5
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Improving stroke knowledge through a ‘volunteer-led’ community education program in Australia Monique F. Kilkenny a,b,⁎, Tara Purvis a,b, Megan Werner c, Megan Reyneke a, Jude Czerenkowski c, Dominique A. Cadilhac a,b, On behalf of the National Stroke Foundation a b c
Stroke & Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC Australia Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC Australia National Stroke Foundation, Melbourne, VIC Australia
a r t i c l e
i n f o
Available online 26 January 2016 Keywords: Risk factors Education Stroke Australia Stroke signs Prevention Community
a b s t r a c t Background. Public awareness of stroke risks and warning signs remains poor. The National Stroke Foundation (NSF) in Australia has been undertaking a StrokeSafe Ambassador Education program to raise awareness of stroke. The format includes presentations by volunteers trained to be ‘ambassadors’ to spread standard information about stroke to the public. Our aim was to determine the change in knowledge of participants who attended presentations. Methods. Participants completed questionnaires before immediately after presentations, and at 3 months following the presentation. Information was collected on knowledge of risk factors and signs of stroke. McNemar's test was used to compare paired-responses over time. A p value of b 0.05 was considered significant. Results. Between March and April 2014, 591 participants attended 185 presentations and 591 (100%) completed them before and immediately after presentation questionnaires: 68% were female and 75% were aged 65 years or more. 258 consented for further follow-up with 192 completing follow-up. Comparing immediately after with before presentation showed significantly improved knowledge for all 10 stroke risk factors and all signs of stroke. Significantly improved knowledge for 7/10 risk factors and 1/3 signs of stroke was found when comparing follow-up and immediately after presentation results. Knowledge of 5/10 risk factors and 2/3 signs of stroke improved when comparing follow-up and before presentation. Conclusion. This study describes a novel approach to support the use of trained volunteers to provide a community-based, standardised education program for stroke. This program shows that community presentations can improve immediate and short-term knowledge of signs and risk factors for stroke. © 2016 Published by Elsevier Inc.
Introduction Similar to other countries, stroke is the second major cause of death and the leading cause of disability in Australian adults (Feigin et al., 2014). The burden of stroke can be reduced through improved prevention management and early medical intervention (Cadilhac et al., 2007). About 11.7 million (90%) adult Australians have at least one of the major modifiable risk factors (such as high blood pressure (BP), diabetes, high cholesterol, smoking, alcohol, poor diet, inadequate physical activity, obesity, atrial fibrillation, sleep disorders, and carotid stenosis) (Ebrahim and Harwood, 1999) for heart, stroke, and vascular disease (Senes and AIHW, 2006). There is poor knowledge and recognition of risk factors in countries worldwide (Stroebele et al., 2011). A systematic review of 22 studies found that between 18% and 86% of participants did ⁎ Corresponding author at: Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 1/43-51 Kanooka Grove, Clayton VIC, 3168 Australia. E-mail address: [email protected] (M.F. Kilkenny).
http://dx.doi.org/10.1016/j.ypmed.2016.01.015 0091-7435/© 2016 Published by Elsevier Inc.
not know any risk factors for stroke (Stroebele et al., 2011). Increasing knowledge of these risk factors for stroke may lead to improved prevention of stroke (Stroebele et al., 2011). In addition to prevention, facilitating timely access to effective medical interventions, such as thrombolytic therapy, can effectively reduce the burden of stroke by improving outcomes of those affected. Prehospital delays, particularly the time taken to seek medical help, remain a major challenge. Increased public awareness and knowledge of signs of stroke can reduce delays from stroke onset to hospital presentation and improve access to medical interventions (California Acute Stroke Pilot Registry, I., 2005). Stroke education programs have the potential to improve knowledge and health behaviours of people in the community (Rasura et al., 2014). To improve public awareness, many countries use marketing campaigns with multiple media modalities to convey simple messages to educate the community about the signs of stroke. In Australia, the National Stroke Foundation (NSF) utilises the health promotion message FAST which incorporates the signs of Facial weakness, Arm weakness, Speech difficulties, as well as emphasising that Time is critical. The
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public are informed that if any of these signs are evident, 000 is the Australian emergency telephone number that should be called to get an ambulance. Despite the Australian public's awareness of stroke signs improving after this national mass media campaign, almost 50% of the sampled population were unable to name the common stroke warning signs (Trobbiani et al., 2013). While these awareness campaigns have been found to increase stroke knowledge and thrombolysis rates, they tend to be quite costly due to the costs of advertising in the media (Trobbiani et al., 2013). Therefore, there is a need for additional complementary and lower-cost strategies to educate the public. The NSF in Australia has designed a volunteer-led StrokeSafe Ambassador Education Program to educate the general public about what stroke is, how to prevent stroke, how to recognise the early warning signs of stroke, and what to do if someone has a stroke. The program utilises a network of volunteer StrokeSafe Ambassadors (including stroke survivors, carers, health professionals, and general public) who have been interviewed, recruited, and trained by the NSF to deliver free standardised educational stroke presentations requested by community groups or organised by the NSF. The aims of this study were to 1) describe the participant profile of people who attended the community-based stroke education presentations and 2) determine the change in immediate and short-term stroke knowledge among participants. Methods Participant selection Overall, there were 5271 participants who attended 185 StrokeSafe presentations held between March and April 2014 in Australia. Forty-two StrokeSafe ambassadors volunteered to collect pre-post evaluation data during this period. A total of 591 participants who attended these 42 presentations were invited to and completed questionnaires. These presentations were held in English. Questionnaires (Appendix I) • Pre-presentation: Before the presentation, participants were asked to complete a questionnaire. The questionnaire covered information on participant demographics, baseline knowledge of risk factors, and signs of stroke. • Immediately post-presentation: Immediately after the presentation, participants were asked to complete a questionnaire on knowledge of risk factors for stroke and signs of stroke. Participants were asked to provide written consent to be followed-up in 3 months. • Follow-up: For participants who consented to be followed-up at 3 months, a questionnaire to assess short-term retention of knowledge was posted to them by staff from the NSF. Using the Dillman (Dillman, 1991) protocol, two attempts at contact were made by mail and then, if there was still no response, one attempt was made by telephone.
Ambassadors with knowledge about stroke, as well as ensuring they would be confident public speakers. This included advice on effective presenting, managing questions, encouraging audience participation, and working with interpreters. The Ambassadors also received ongoing training in areas highlighted in an annual survey as areas of development, along with any updates on content of their presentations or the activities of the NSF. This included additional resources, e.g. brochures and contacts for more information, e.g. StrokeLine phone numbers and website links. StrokeLine is staffed by health professionals who can provide expert and individualised information and advice on stroke prevention, treatment and recovery. Presentation content StrokeSafe Ambassadors could choose from three different delivery methods for the presentation, determined by personal preference or availability of facilities: • StrokeSafe PowerPoint presentation – provided to the Ambassadors on a USB stick • StrokeSafe presentation visual aid – display easel with colour printed A3 size slides used as a flipchart • Speaking only – effective for ‘on the spot’ presentations with very limited time available (Fig. 1).
The presentations covered • What stroke is – What happens when someone is having a stroke and the different types of stroke. • How to recognise the signs of stroke – Learn the vital FAST signs which will help you recognise when someone is having a stroke. • What to do if someone is having a stroke – If you or someone else experiences the signs of stroke, no matter how long they last, call 000 immediately. • How to prevent stroke – Steps that can be taken to better understand and reduce the risk of having a stroke. • Where to get reliable further information?
Brochures Participants were given the following brochures at the end of the presentation: Stroke risk tick test (http://strokefoundation.com.au/site/media/NSF120_
Presentations StrokeSafe education presentations were requested by community groups such as sporting clubs, community centres, local councils, social groups, and health centres. The presentations took around 30 min plus question time. The presentations were directed at those aged over 55 years and built around adult learning principles and the impact of poor health literacy in the community was considered. This included the use of members of a local community as Ambassadors, storytelling and limiting the content covered to avoid confusion and overload. Information was also made relevant to people's daily lives and provided a clear ‘call to action’ about better health behaviours and acting FAST. A small number of Ambassadors were able to present in other languages. Ambassador recruitment Volunteer StrokeSafe Ambassadors were recruited and interviewed to be volunteer speakers for the StrokeSafe education program. Training of Ambassadors Comprehensive training including professional public speaking was provided for two consecutive days. The focus of this training was on equipping
Fig. 1. Overview of the StrokeSafe Education Program.
M.F. Kilkenny et al. / Preventive Medicine 86 (2016) 1–5
DLpads2011_final.pdf), Stroke Risk Information sheet (http://strokefoundation. com.au/site/media/StrokeFoundation_StrokeRiskInfo.pdf). and FAST wallet card. The Stroke Risk Information sheet was available in Mandarin, Vietnamese, Greek, Turkish, Macedonian, Arabic, and Italian. The Stroke risk tick test was only available in English. The participant may have been encouraged by the ambassadors at the presentation to read brochures and other information sheets provided. This would provide the opportunity to reinforce or expand on the 30-min educational presentation immediately following the presentation and before the 3-month follow-up, Analyses Immediate improvement and retention of knowledge of risk factors for stroke and the FAST signs of stroke was ascertained by comparing prepresentation and post-presentation responses from participants. For shortterm retention of knowledge, responses from participants were compared pre-presentation and at follow-up, as well as between immediately postpresentation and at follow-up. The analyses include only participants who completed both questionnaires (pre and post, or pre and immediately post, or pre and follow-up). McNemar's test was used to assess the significance of the difference of responses between the matched pairs of participants. Descriptive statistics were used including chi-square test and McNemar's test for paired analyses to estimate p values with level of significance b0.05. ‘Net change’ was calculated as difference in scores between pre-presentation and the relevant post-presentation comparison period. Stata (Version 12.1, StataCorp, College Station, TX, 2013) statistical software was used. Ethics approval for the evaluation was provided by the Monash University Human Research Ethics Committee (HREC No: CF12/1395–201,200,736).
Results Pre- and post-presentation questionnaires: From 42 presentations, there were 591 participants who agreed to complete the pre- and post-presentation questionnaires. Response rate of 100%. Participants were from the following states in Australia: 41% from New South Wales; 38% Queensland; 8% Victoria; 8% Tasmania; 5% South Australia. Three-quarters of participants were aged 65 years or more, 68% were female, 44% had a university qualification, 94% spoke English as their main language, and 1% identified as having an indigenous background. Three-month follow-up presentation questionnaires: There were 258/591 (44%) participants who consented to be followed-up in 3 months. Among these, 192/258 completed the follow-up questionnaire. Response rate of 74%. Age, gender, indigenous status, and English as main language were similar between those who were followed-up and all those who participated in an education presentation. However, participants with university education were more likely to complete the follow-up questionnaire (50% university-education vs 34% other education, p b 0.001). Immediate improvement in knowledge (pre- versus immediately postpresentation)
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Table 1 Immediate improvement in knowledge of risk factors and signs of stroke (pre-presentation versus immediately post). Knowledge
Pre Immediately post Net p value (N = 591)% (N = 591) % change
Risk factors for stroke High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate Signs of stroke Drooping face Slurred speech Not able to lift one or both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
89 58 36 62 66 27 28 62 58 22
94 81 64 76 69 64 60 78 77 58
5 23 28 14 3 37 32 16 19 36
b0.001 b0.001 b0.001 b0.001 0.034 b0.001 b0.001 b0.001 b0.001 b0.001
86 91 81 73 88 92
96 94 87 84 94 98
10 3 6 11 6 6
b0.001 0.016 0.001 b0.001 b0.001 b0.001
McNemar's test was used to estimate the p values; Pre: Pre-presentation. ⁎ Drooping face and slurred speech and not able to lift both arms. ⁎⁎ If observed drooping face.
correctly identify each sign of stroke between pre-presentation and follow-up questionnaires (Table 2); there was a significant increase for two of the signs of stroke (drooping face and not able to lift one/ both arms). The level of knowledge of all risk factors at follow-up remained higher than before the presentation (Table 2). At follow-up, an increased number of participants were able to identify multiple risk factors for stroke compared with pre-presentation (Fig. 2). Short-term improvement in knowledge (immediately post versus 3 month) Between the immediately post-presentation and follow-up questionnaires, there were no improvements in participants' knowledge for risk factors for stroke with significant decrease in knowledge for seven risk factors (Table 3). There was significant improvement in knowledge of signs of stroke for not able to lift one or both arms between the immediately post-presentation and follow-up questionnaires (net change 7%). Awareness of drooping face as a sign of stroke significantly improved between pre- (91%) and post-presentation (98%) but not from post-presentation to follow-up (97%). Interestingly, correct identification of all three signs of stroke increased from the postpresentation questionnaire (88%) to follow-up (93%). At follow-up, a decreased number of participants were able to identify multiple risk 100
Immediately following the education presentation, there were significant improvements in knowledge of all risk factors for stroke (Table 1) between the pre- and immediately post-presentation period (net change ranging from 3% to 37%). There were also significant improvements in the number of participants able to correctly identify each sign of stroke immediately after the presentations (Table 1, net change ranging from 3% to 10%). Immediately following the presentation, an increased number of participants were able to identify multiple risk factors for stroke compared with pre-presentation (Fig. 2).
90 80 70 60 % 50 40 30 20
Short-term improvement in knowledge (pre versus 3 month) Between the pre-presentation and follow-up questionnaires, there were improvements in participant's knowledge for all risk factors for stroke with significant improvements found for five risk factors (Table 2). There were improvements in the participant's ability to
10 0 Pre-education ≥ 1 Correct
Immediately post-education ≥ 5 Correct
Three-month follow-up
≥ 1 Incorrect
Fig. 2. Change in risk factor knowledge over time.
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Table 2 Short-term improvement in knowledge of risk factors and signs of stroke (pre-presentation versus 3 month follow). Knowledge
High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate
Pre (N = 192)
3 month follow (N = 192)
Pre versus 3 month follow
%
%
Net change
p value
93 70 47 74 80 43 36 72 71 28
5 13 10 8 7 16 6 9 7 7
0.15 0.002 0.005 0.06 0.05 b0.001 0.11 0.03 0.11 0.06
97 97 96 93 97 95
6 3 8 11 4 0
0.004 0.197 0.008 0.001 0.077 1.0
Risk factors for stroke 88 57 37 66 73 27 30 63 64 21
Signs of stroke 91 94 88 82 93 95
Drooping face Slurred speech Not able to lift one/both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
McNemar's test was used to estimate the p values; Pre: Pre-presentation; Follow: Followup. ⁎ Drooping face and slurred speech and not able to lift one or both arms. ⁎⁎ If observed drooping face.
factors for stroke compared with immediately post-presentation results (Fig. 2). Discussion This is the first study to present results on knowledge retention of people living in the general community who attended a stroke education presentation. We found that retention of knowledge immediately
Table 3 Short-term improvement of knowledge of risk factors and signs of stroke (immediately post presentation versus 3 month follow). Knowledge
Risk factors for stroke High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate Signs of stroke Drooping face Slurred speech Not able to lift one/both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
Immediately post (N = 192)
3 month follow (N = 192)
Immediately post versus 3 month follow
%
%
Net change
p value
94 82 69 81 74 70 67 82 83 61
93 70 47 74 80 43 36 72 71 28
−1 −12 −22 −7 6 −27 −31 −10 −8 −33
0.83 0.004 b0.001 0.07 0.14 b0.001 b0.001 0.02 0.003 b0.001
98 94 89 88 94 100
97 97 96 93 97 95
−1 3 7 5 3 −5
0.479 0.157 0.009 0.087 0.144 0.004
McNemar's test was used to estimate the p values; Post: post-presentation; Follow: Follow-up. ⁎ Drooping face and slurred speech and not able to lift one or both arms. ⁎⁎ If observed drooping face.
after the education presentation improved substantially for knowledge of risk factors for stroke and knowledge of FAST signs. In the short-term, the FAST signs of stroke continued to be recalled by participants. However, not unexpectedly, the participant's ability to recognise the risk factors for stroke had diminished at 3 months compared to immediately post-presentation. Importantly, at follow-up, the knowledge of risk factors was still greater than pre-presentation levels. The results immediately following the education presentation represent maximal knowledge gain by participants. The participants in our study had a vested interest in the area of stroke by the fact that they attended the presentation. For this reason, it is unsurprising that the proportion of participants who recognised each of the FAST signs of stroke were greater than that reported following general public awareness campaigns (Australia:England; face 47:86%, arm 36:74%, speech 27:66%) (Trobbiani et al., 2013). Knowledge of all risk factors for stroke improved significantly immediately post-presentation compared to pre-presentation. Hypertension was most commonly recalled from a pre-defined list by participants in the pre- and immediately postpresentation periods. As would be expected, these results using a predefined list are better than in other studies which asked participants to name risk factors for stroke by free recall (22%) (Slark et al., 2012). Similar to other studies, older participants aged 75 years or more were found to be less able to retain short-term knowledge (Stroebele et al., 2011; Bray et al., 2013). General cognitive decline and difficulties in word recall have been posed as possible explanations for this finding. As such, targeted content and the delivery mode of the presentation for older age groups should be considered (Stroebele et al., 2011). As with many education programs, the retention of immediate knowledge gained can diminish over time. Over the short-term, despite the decline in knowledge of risk factors when compared to immediately after the presentation, the level of knowledge at 3 months was still better than pre-education levels. This illustrates the effectiveness of the education program. In contrast, however, awareness of the FAST signs was maintained or actually improved short-term when compared to the immediately post-presentation results. These results are possibly due to the ongoing exposure to the NSF FAST message through the provision of material at the presentation or through media awareness campaigns throughout Australia. This may suggest that continuing exposure to information is important to support knowledge retention. Stroke education programs have been conducted with a range of populations varying in age and culture. There have been studies in ethnic groups, schools, or focussed high-risk community settings comparing knowledge of stroke before and after education presentations. A recent systematic review of stroke awareness in ethnic minorities (n = 15 studies) in the United States of America by Gardois et al. (2014) reported that 6 out of 8 studies using pre-post evaluation design provided evidence that the stroke education intervention was effective. A stroke education program in Japan using animated cartoons as teaching aids improved stroke knowledge in 493 students aged 12–13 years 3 months after the program (Shigehatake et al., 2014). In China, public lectures and instructive material were distributed to the community and its medical staff in China (Chen et al., 2013), improving awareness of signs of stroke. In America, 72 women were followed up 3 months after participating in the pilot of the Stroke Heroes Act FAST education message and more than 96% were able to recall the signs (Wall et al., 2008). Kleindorfer et al. (2008) used trained beauticians who delivered education on signs and risk factors for stroke during appointments to high-risk clientele (Kleindorfer et al., 2008). Similar to our results, improved knowledge of the signs of stroke was reported 6 weeks after the education, and this was also retained at 5 months post-education. In contrast to our results, they reported no difference in risk factor recall 5 months post-education compared to baseline, which may have related to their open-ended format of questions (Kleindorfer et al., 2008). While these studies show the efficacy of focussed education on targeted small populations, to our knowledge, this is the largest study conducted in the general community comparing knowledge of stroke before and
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after education presentations at both immediate and short-term time points. We acknowledge a number of limitations of our study. There was no control group for comparison, and possible selection bias, as those attending the education presentations were more likely to hold a university qualification and may be more knowledgeable than the general population as they have actively sought out information. This is reflected in the 44% of participants holding a university qualification compared with 25% of the population in Australia (Australian Bureau of Statistics, 1999). This may be represented in the high number of participants who were able to recognise at least one risk factor for stroke even pre-education. Indigenous Australians are poorly represented in the profile of participants, as this is a voluntary education program that is offered by community groups. We were unable to calculate a response rate for the completion of evaluation questionnaires in the education presentations, as we do not know the exact numbers who were invited to participate. There were only a small number of Ambassadors who were multilingual, and the presentation and the majority of the written materials were only in English, which meant there was an overall lack of ethnic diversity among the participants. This is reflected in the 94% of participants' main language at home being English compared with 85% of the population in Australia (Australian Bureau of Statistics, 1999). No information was collected on the profile of the Ambassadors or their presentation style in order to evaluate whether Ambassadors who agreed to collect evaluation data were representative of the overall ambassador cohort. A sample size of 42 (23%) of all ambassadors provides some reassurance that these ambassadors are likely to have had a variety of differing characteristics. However, we cannot rule out that our results may be overestimated if these ambassadors had particular traits that meant they were more engaging than those who did not contribute evaluation data which may have resulted in a stronger influence on retention of knowledge of their participants. Additionally, the presentations were directed at those over 55 years of age, so we are unsure of the effect of the education on younger adults and children. Self-report cannot be objectively verified. A further limitation is that we have no other information on the 5000 participants to show that the sample who completed the evaluation are representative. A minor limitation of using the FAST educational material for stroke signs is that the material is focused on signs of ischaemic stroke and excludes the signs of haemorrhagic stroke. Importantly, the strengths of the program were that the educational presentations provided by the StrokeSafe Ambassador used ‘nonmedical jargon’ and language tailored for the general population. The strengths of the study were that it had representation from all states in Australia, and that we had a large number of questionnaires completed and the response rate at follow-up was very good. Overall, the results provide evidence of the worth of volunteer-led community-based education concepts in improving immediate and short-term knowledge of the signs and risk factors of stroke which potentially can improve timely access to effective stroke treatments and help improve stroke prevention. Conclusion This important study describes a novel approach to support the use of trained volunteers to provide a community-based, standardised education program for stroke. Participants improved their knowledge of signs for stroke and stroke risk factors 3 months after the education presentation compared with pre-presentation. This program
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complements large-scale media awareness campaigns already undertaken in Australia and could easily be replicated in other countries. Conflict of interest The authors declare that there are no conflicts of interest. Transparency document The Transparency document associated with this article can be found, in online version. Acknowledgments We thank the research officers and program facilitators, as well as study participants for their contribution to this study. In particular we thank Erin Lalor (Chief Executive Officer) of the National Stroke Foundation for her assistance with the conception, development, and management of this program. Since August 2012, the program has received funding from the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. Dominique Cadilhac is supported by a co-funded National Health and Medical Research Council/ National Heart Foundation research fellowship (1063761). Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ypmed.2016.01.015. References Australian Bureau of Statistics, 1999. 4102.0 - Australian Social Trends: Australia. ABS, Canberra, p. 88. Bray, J.E., et al., 2013. Australian public's awareness of stroke warning signs improves after national multimedia campaigns. Stroke 44 (12), 3540–3543. Cadilhac, D., et al., 2007. Why invest in a national public health program for stroke? An example using Australian data to estimate the potential benefits and cost implications. Health Policy 83, 287–294. California Acute Stroke Pilot Registry, I., 2005. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology 64 (4), 654–659. Chen, S., et al., 2013. Effects of comprehensive education protocol in decreasing prehospital stroke delay among Chinese urban community population. Neurol. Res. 35 (5), 522–528. Dillman, D.A., 1991. The design and administration of mail surveys. Annu. Rev. Sociol. 17, 225–249. Ebrahim, S., Harwood, R., 1999. Stroke: Epidemiology, Evidence, and Clinical Practice. second ed. Oxford University Press, Oxford, p. 343 (ed. n. Ed.). Feigin, V.L., et al., 2014. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 383 (9913), 245–254. Gardois, P., et al., 2014. Health promotion interventions for increasing stroke awareness in ethnic minorities: a systematic review of the literature. BMC Public Health 14, 409. Kleindorfer, D., et al., 2008. The challenges of community-based research: the beauty shop stroke education project. Stroke 39 (8), 2331–2335. Rasura, M., et al., 2014. Effectiveness of public stroke educational interventions: a review. Eur. J. Neurol. 21 (1), 11–20. Senes, S., 2006. In: AIHW (Ed.), How We Manage Stroke in Australia. AIHW Cat no CVD 31. Australian Institute of Health and Welfare, Canberra, p. 60. Shigehatake, Y., et al., 2014. Stroke education using an animated cartoon and a manga for junior high school students. J. Stroke Cerebrovasc. Dis. 23 (6), 1623–1627. Slark, J., et al., 2012. Awareness of stroke symptomatology and cardiovascular risk factors amongst stroke survivors. J. Stroke Cerebrovasc. Dis. 21 (5), 358–362. Stroebele, N., et al., 2011. Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective. Int. J. Stroke 6 (1), 60–66. Trobbiani, K., et al., 2013. Comparison of stroke warning sign campaigns in Australia, England, and Canada. Int. J. Stroke 8 (Suppl. A100), 28–31. Wall, H.K., et al., 2008. Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Prev. Chronic Dis. 5 (2), A49.
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Improving stroke knowledge through a ‘volunteer-led’ community education program in Australia Monique F. Kilkenny a,b,⁎, Tara Purvis a,b, Megan Werner c, Megan Reyneke a, Jude Czerenkowski c, Dominique A. Cadilhac a,b, On behalf of the National Stroke Foundation a b c
Stroke & Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC Australia Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC Australia National Stroke Foundation, Melbourne, VIC Australia
a r t i c l e
i n f o
Available online 26 January 2016 Keywords: Risk factors Education Stroke Australia Stroke signs Prevention Community
a b s t r a c t Background. Public awareness of stroke risks and warning signs remains poor. The National Stroke Foundation (NSF) in Australia has been undertaking a StrokeSafe Ambassador Education program to raise awareness of stroke. The format includes presentations by volunteers trained to be ‘ambassadors’ to spread standard information about stroke to the public. Our aim was to determine the change in knowledge of participants who attended presentations. Methods. Participants completed questionnaires before immediately after presentations, and at 3 months following the presentation. Information was collected on knowledge of risk factors and signs of stroke. McNemar's test was used to compare paired-responses over time. A p value of b 0.05 was considered significant. Results. Between March and April 2014, 591 participants attended 185 presentations and 591 (100%) completed them before and immediately after presentation questionnaires: 68% were female and 75% were aged 65 years or more. 258 consented for further follow-up with 192 completing follow-up. Comparing immediately after with before presentation showed significantly improved knowledge for all 10 stroke risk factors and all signs of stroke. Significantly improved knowledge for 7/10 risk factors and 1/3 signs of stroke was found when comparing follow-up and immediately after presentation results. Knowledge of 5/10 risk factors and 2/3 signs of stroke improved when comparing follow-up and before presentation. Conclusion. This study describes a novel approach to support the use of trained volunteers to provide a community-based, standardised education program for stroke. This program shows that community presentations can improve immediate and short-term knowledge of signs and risk factors for stroke. © 2016 Published by Elsevier Inc.
Introduction Similar to other countries, stroke is the second major cause of death and the leading cause of disability in Australian adults (Feigin et al., 2014). The burden of stroke can be reduced through improved prevention management and early medical intervention (Cadilhac et al., 2007). About 11.7 million (90%) adult Australians have at least one of the major modifiable risk factors (such as high blood pressure (BP), diabetes, high cholesterol, smoking, alcohol, poor diet, inadequate physical activity, obesity, atrial fibrillation, sleep disorders, and carotid stenosis) (Ebrahim and Harwood, 1999) for heart, stroke, and vascular disease (Senes and AIHW, 2006). There is poor knowledge and recognition of risk factors in countries worldwide (Stroebele et al., 2011). A systematic review of 22 studies found that between 18% and 86% of participants did ⁎ Corresponding author at: Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 1/43-51 Kanooka Grove, Clayton VIC, 3168 Australia. E-mail address: [email protected] (M.F. Kilkenny).
http://dx.doi.org/10.1016/j.ypmed.2016.01.015 0091-7435/© 2016 Published by Elsevier Inc.
not know any risk factors for stroke (Stroebele et al., 2011). Increasing knowledge of these risk factors for stroke may lead to improved prevention of stroke (Stroebele et al., 2011). In addition to prevention, facilitating timely access to effective medical interventions, such as thrombolytic therapy, can effectively reduce the burden of stroke by improving outcomes of those affected. Prehospital delays, particularly the time taken to seek medical help, remain a major challenge. Increased public awareness and knowledge of signs of stroke can reduce delays from stroke onset to hospital presentation and improve access to medical interventions (California Acute Stroke Pilot Registry, I., 2005). Stroke education programs have the potential to improve knowledge and health behaviours of people in the community (Rasura et al., 2014). To improve public awareness, many countries use marketing campaigns with multiple media modalities to convey simple messages to educate the community about the signs of stroke. In Australia, the National Stroke Foundation (NSF) utilises the health promotion message FAST which incorporates the signs of Facial weakness, Arm weakness, Speech difficulties, as well as emphasising that Time is critical. The
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public are informed that if any of these signs are evident, 000 is the Australian emergency telephone number that should be called to get an ambulance. Despite the Australian public's awareness of stroke signs improving after this national mass media campaign, almost 50% of the sampled population were unable to name the common stroke warning signs (Trobbiani et al., 2013). While these awareness campaigns have been found to increase stroke knowledge and thrombolysis rates, they tend to be quite costly due to the costs of advertising in the media (Trobbiani et al., 2013). Therefore, there is a need for additional complementary and lower-cost strategies to educate the public. The NSF in Australia has designed a volunteer-led StrokeSafe Ambassador Education Program to educate the general public about what stroke is, how to prevent stroke, how to recognise the early warning signs of stroke, and what to do if someone has a stroke. The program utilises a network of volunteer StrokeSafe Ambassadors (including stroke survivors, carers, health professionals, and general public) who have been interviewed, recruited, and trained by the NSF to deliver free standardised educational stroke presentations requested by community groups or organised by the NSF. The aims of this study were to 1) describe the participant profile of people who attended the community-based stroke education presentations and 2) determine the change in immediate and short-term stroke knowledge among participants. Methods Participant selection Overall, there were 5271 participants who attended 185 StrokeSafe presentations held between March and April 2014 in Australia. Forty-two StrokeSafe ambassadors volunteered to collect pre-post evaluation data during this period. A total of 591 participants who attended these 42 presentations were invited to and completed questionnaires. These presentations were held in English. Questionnaires (Appendix I) • Pre-presentation: Before the presentation, participants were asked to complete a questionnaire. The questionnaire covered information on participant demographics, baseline knowledge of risk factors, and signs of stroke. • Immediately post-presentation: Immediately after the presentation, participants were asked to complete a questionnaire on knowledge of risk factors for stroke and signs of stroke. Participants were asked to provide written consent to be followed-up in 3 months. • Follow-up: For participants who consented to be followed-up at 3 months, a questionnaire to assess short-term retention of knowledge was posted to them by staff from the NSF. Using the Dillman (Dillman, 1991) protocol, two attempts at contact were made by mail and then, if there was still no response, one attempt was made by telephone.
Ambassadors with knowledge about stroke, as well as ensuring they would be confident public speakers. This included advice on effective presenting, managing questions, encouraging audience participation, and working with interpreters. The Ambassadors also received ongoing training in areas highlighted in an annual survey as areas of development, along with any updates on content of their presentations or the activities of the NSF. This included additional resources, e.g. brochures and contacts for more information, e.g. StrokeLine phone numbers and website links. StrokeLine is staffed by health professionals who can provide expert and individualised information and advice on stroke prevention, treatment and recovery. Presentation content StrokeSafe Ambassadors could choose from three different delivery methods for the presentation, determined by personal preference or availability of facilities: • StrokeSafe PowerPoint presentation – provided to the Ambassadors on a USB stick • StrokeSafe presentation visual aid – display easel with colour printed A3 size slides used as a flipchart • Speaking only – effective for ‘on the spot’ presentations with very limited time available (Fig. 1).
The presentations covered • What stroke is – What happens when someone is having a stroke and the different types of stroke. • How to recognise the signs of stroke – Learn the vital FAST signs which will help you recognise when someone is having a stroke. • What to do if someone is having a stroke – If you or someone else experiences the signs of stroke, no matter how long they last, call 000 immediately. • How to prevent stroke – Steps that can be taken to better understand and reduce the risk of having a stroke. • Where to get reliable further information?
Brochures Participants were given the following brochures at the end of the presentation: Stroke risk tick test (http://strokefoundation.com.au/site/media/NSF120_
Presentations StrokeSafe education presentations were requested by community groups such as sporting clubs, community centres, local councils, social groups, and health centres. The presentations took around 30 min plus question time. The presentations were directed at those aged over 55 years and built around adult learning principles and the impact of poor health literacy in the community was considered. This included the use of members of a local community as Ambassadors, storytelling and limiting the content covered to avoid confusion and overload. Information was also made relevant to people's daily lives and provided a clear ‘call to action’ about better health behaviours and acting FAST. A small number of Ambassadors were able to present in other languages. Ambassador recruitment Volunteer StrokeSafe Ambassadors were recruited and interviewed to be volunteer speakers for the StrokeSafe education program. Training of Ambassadors Comprehensive training including professional public speaking was provided for two consecutive days. The focus of this training was on equipping
Fig. 1. Overview of the StrokeSafe Education Program.
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DLpads2011_final.pdf), Stroke Risk Information sheet (http://strokefoundation. com.au/site/media/StrokeFoundation_StrokeRiskInfo.pdf). and FAST wallet card. The Stroke Risk Information sheet was available in Mandarin, Vietnamese, Greek, Turkish, Macedonian, Arabic, and Italian. The Stroke risk tick test was only available in English. The participant may have been encouraged by the ambassadors at the presentation to read brochures and other information sheets provided. This would provide the opportunity to reinforce or expand on the 30-min educational presentation immediately following the presentation and before the 3-month follow-up, Analyses Immediate improvement and retention of knowledge of risk factors for stroke and the FAST signs of stroke was ascertained by comparing prepresentation and post-presentation responses from participants. For shortterm retention of knowledge, responses from participants were compared pre-presentation and at follow-up, as well as between immediately postpresentation and at follow-up. The analyses include only participants who completed both questionnaires (pre and post, or pre and immediately post, or pre and follow-up). McNemar's test was used to assess the significance of the difference of responses between the matched pairs of participants. Descriptive statistics were used including chi-square test and McNemar's test for paired analyses to estimate p values with level of significance b0.05. ‘Net change’ was calculated as difference in scores between pre-presentation and the relevant post-presentation comparison period. Stata (Version 12.1, StataCorp, College Station, TX, 2013) statistical software was used. Ethics approval for the evaluation was provided by the Monash University Human Research Ethics Committee (HREC No: CF12/1395–201,200,736).
Results Pre- and post-presentation questionnaires: From 42 presentations, there were 591 participants who agreed to complete the pre- and post-presentation questionnaires. Response rate of 100%. Participants were from the following states in Australia: 41% from New South Wales; 38% Queensland; 8% Victoria; 8% Tasmania; 5% South Australia. Three-quarters of participants were aged 65 years or more, 68% were female, 44% had a university qualification, 94% spoke English as their main language, and 1% identified as having an indigenous background. Three-month follow-up presentation questionnaires: There were 258/591 (44%) participants who consented to be followed-up in 3 months. Among these, 192/258 completed the follow-up questionnaire. Response rate of 74%. Age, gender, indigenous status, and English as main language were similar between those who were followed-up and all those who participated in an education presentation. However, participants with university education were more likely to complete the follow-up questionnaire (50% university-education vs 34% other education, p b 0.001). Immediate improvement in knowledge (pre- versus immediately postpresentation)
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Table 1 Immediate improvement in knowledge of risk factors and signs of stroke (pre-presentation versus immediately post). Knowledge
Pre Immediately post Net p value (N = 591)% (N = 591) % change
Risk factors for stroke High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate Signs of stroke Drooping face Slurred speech Not able to lift one or both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
89 58 36 62 66 27 28 62 58 22
94 81 64 76 69 64 60 78 77 58
5 23 28 14 3 37 32 16 19 36
b0.001 b0.001 b0.001 b0.001 0.034 b0.001 b0.001 b0.001 b0.001 b0.001
86 91 81 73 88 92
96 94 87 84 94 98
10 3 6 11 6 6
b0.001 0.016 0.001 b0.001 b0.001 b0.001
McNemar's test was used to estimate the p values; Pre: Pre-presentation. ⁎ Drooping face and slurred speech and not able to lift both arms. ⁎⁎ If observed drooping face.
correctly identify each sign of stroke between pre-presentation and follow-up questionnaires (Table 2); there was a significant increase for two of the signs of stroke (drooping face and not able to lift one/ both arms). The level of knowledge of all risk factors at follow-up remained higher than before the presentation (Table 2). At follow-up, an increased number of participants were able to identify multiple risk factors for stroke compared with pre-presentation (Fig. 2). Short-term improvement in knowledge (immediately post versus 3 month) Between the immediately post-presentation and follow-up questionnaires, there were no improvements in participants' knowledge for risk factors for stroke with significant decrease in knowledge for seven risk factors (Table 3). There was significant improvement in knowledge of signs of stroke for not able to lift one or both arms between the immediately post-presentation and follow-up questionnaires (net change 7%). Awareness of drooping face as a sign of stroke significantly improved between pre- (91%) and post-presentation (98%) but not from post-presentation to follow-up (97%). Interestingly, correct identification of all three signs of stroke increased from the postpresentation questionnaire (88%) to follow-up (93%). At follow-up, a decreased number of participants were able to identify multiple risk 100
Immediately following the education presentation, there were significant improvements in knowledge of all risk factors for stroke (Table 1) between the pre- and immediately post-presentation period (net change ranging from 3% to 37%). There were also significant improvements in the number of participants able to correctly identify each sign of stroke immediately after the presentations (Table 1, net change ranging from 3% to 10%). Immediately following the presentation, an increased number of participants were able to identify multiple risk factors for stroke compared with pre-presentation (Fig. 2).
90 80 70 60 % 50 40 30 20
Short-term improvement in knowledge (pre versus 3 month) Between the pre-presentation and follow-up questionnaires, there were improvements in participant's knowledge for all risk factors for stroke with significant improvements found for five risk factors (Table 2). There were improvements in the participant's ability to
10 0 Pre-education ≥ 1 Correct
Immediately post-education ≥ 5 Correct
Three-month follow-up
≥ 1 Incorrect
Fig. 2. Change in risk factor knowledge over time.
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Table 2 Short-term improvement in knowledge of risk factors and signs of stroke (pre-presentation versus 3 month follow). Knowledge
High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate
Pre (N = 192)
3 month follow (N = 192)
Pre versus 3 month follow
%
%
Net change
p value
93 70 47 74 80 43 36 72 71 28
5 13 10 8 7 16 6 9 7 7
0.15 0.002 0.005 0.06 0.05 b0.001 0.11 0.03 0.11 0.06
97 97 96 93 97 95
6 3 8 11 4 0
0.004 0.197 0.008 0.001 0.077 1.0
Risk factors for stroke 88 57 37 66 73 27 30 63 64 21
Signs of stroke 91 94 88 82 93 95
Drooping face Slurred speech Not able to lift one/both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
McNemar's test was used to estimate the p values; Pre: Pre-presentation; Follow: Followup. ⁎ Drooping face and slurred speech and not able to lift one or both arms. ⁎⁎ If observed drooping face.
factors for stroke compared with immediately post-presentation results (Fig. 2). Discussion This is the first study to present results on knowledge retention of people living in the general community who attended a stroke education presentation. We found that retention of knowledge immediately
Table 3 Short-term improvement of knowledge of risk factors and signs of stroke (immediately post presentation versus 3 month follow). Knowledge
Risk factors for stroke High blood pressure High level of cholesterol Diabetes Smoking Family history Excessive intake of alcohol Poor diet Being overweight Lack of exercise/fitness Irregular heart rate Signs of stroke Drooping face Slurred speech Not able to lift one/both arms All signs of stroke identified⁎ 2 signs of stroke identified Call 000⁎⁎
Immediately post (N = 192)
3 month follow (N = 192)
Immediately post versus 3 month follow
%
%
Net change
p value
94 82 69 81 74 70 67 82 83 61
93 70 47 74 80 43 36 72 71 28
−1 −12 −22 −7 6 −27 −31 −10 −8 −33
0.83 0.004 b0.001 0.07 0.14 b0.001 b0.001 0.02 0.003 b0.001
98 94 89 88 94 100
97 97 96 93 97 95
−1 3 7 5 3 −5
0.479 0.157 0.009 0.087 0.144 0.004
McNemar's test was used to estimate the p values; Post: post-presentation; Follow: Follow-up. ⁎ Drooping face and slurred speech and not able to lift one or both arms. ⁎⁎ If observed drooping face.
after the education presentation improved substantially for knowledge of risk factors for stroke and knowledge of FAST signs. In the short-term, the FAST signs of stroke continued to be recalled by participants. However, not unexpectedly, the participant's ability to recognise the risk factors for stroke had diminished at 3 months compared to immediately post-presentation. Importantly, at follow-up, the knowledge of risk factors was still greater than pre-presentation levels. The results immediately following the education presentation represent maximal knowledge gain by participants. The participants in our study had a vested interest in the area of stroke by the fact that they attended the presentation. For this reason, it is unsurprising that the proportion of participants who recognised each of the FAST signs of stroke were greater than that reported following general public awareness campaigns (Australia:England; face 47:86%, arm 36:74%, speech 27:66%) (Trobbiani et al., 2013). Knowledge of all risk factors for stroke improved significantly immediately post-presentation compared to pre-presentation. Hypertension was most commonly recalled from a pre-defined list by participants in the pre- and immediately postpresentation periods. As would be expected, these results using a predefined list are better than in other studies which asked participants to name risk factors for stroke by free recall (22%) (Slark et al., 2012). Similar to other studies, older participants aged 75 years or more were found to be less able to retain short-term knowledge (Stroebele et al., 2011; Bray et al., 2013). General cognitive decline and difficulties in word recall have been posed as possible explanations for this finding. As such, targeted content and the delivery mode of the presentation for older age groups should be considered (Stroebele et al., 2011). As with many education programs, the retention of immediate knowledge gained can diminish over time. Over the short-term, despite the decline in knowledge of risk factors when compared to immediately after the presentation, the level of knowledge at 3 months was still better than pre-education levels. This illustrates the effectiveness of the education program. In contrast, however, awareness of the FAST signs was maintained or actually improved short-term when compared to the immediately post-presentation results. These results are possibly due to the ongoing exposure to the NSF FAST message through the provision of material at the presentation or through media awareness campaigns throughout Australia. This may suggest that continuing exposure to information is important to support knowledge retention. Stroke education programs have been conducted with a range of populations varying in age and culture. There have been studies in ethnic groups, schools, or focussed high-risk community settings comparing knowledge of stroke before and after education presentations. A recent systematic review of stroke awareness in ethnic minorities (n = 15 studies) in the United States of America by Gardois et al. (2014) reported that 6 out of 8 studies using pre-post evaluation design provided evidence that the stroke education intervention was effective. A stroke education program in Japan using animated cartoons as teaching aids improved stroke knowledge in 493 students aged 12–13 years 3 months after the program (Shigehatake et al., 2014). In China, public lectures and instructive material were distributed to the community and its medical staff in China (Chen et al., 2013), improving awareness of signs of stroke. In America, 72 women were followed up 3 months after participating in the pilot of the Stroke Heroes Act FAST education message and more than 96% were able to recall the signs (Wall et al., 2008). Kleindorfer et al. (2008) used trained beauticians who delivered education on signs and risk factors for stroke during appointments to high-risk clientele (Kleindorfer et al., 2008). Similar to our results, improved knowledge of the signs of stroke was reported 6 weeks after the education, and this was also retained at 5 months post-education. In contrast to our results, they reported no difference in risk factor recall 5 months post-education compared to baseline, which may have related to their open-ended format of questions (Kleindorfer et al., 2008). While these studies show the efficacy of focussed education on targeted small populations, to our knowledge, this is the largest study conducted in the general community comparing knowledge of stroke before and
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after education presentations at both immediate and short-term time points. We acknowledge a number of limitations of our study. There was no control group for comparison, and possible selection bias, as those attending the education presentations were more likely to hold a university qualification and may be more knowledgeable than the general population as they have actively sought out information. This is reflected in the 44% of participants holding a university qualification compared with 25% of the population in Australia (Australian Bureau of Statistics, 1999). This may be represented in the high number of participants who were able to recognise at least one risk factor for stroke even pre-education. Indigenous Australians are poorly represented in the profile of participants, as this is a voluntary education program that is offered by community groups. We were unable to calculate a response rate for the completion of evaluation questionnaires in the education presentations, as we do not know the exact numbers who were invited to participate. There were only a small number of Ambassadors who were multilingual, and the presentation and the majority of the written materials were only in English, which meant there was an overall lack of ethnic diversity among the participants. This is reflected in the 94% of participants' main language at home being English compared with 85% of the population in Australia (Australian Bureau of Statistics, 1999). No information was collected on the profile of the Ambassadors or their presentation style in order to evaluate whether Ambassadors who agreed to collect evaluation data were representative of the overall ambassador cohort. A sample size of 42 (23%) of all ambassadors provides some reassurance that these ambassadors are likely to have had a variety of differing characteristics. However, we cannot rule out that our results may be overestimated if these ambassadors had particular traits that meant they were more engaging than those who did not contribute evaluation data which may have resulted in a stronger influence on retention of knowledge of their participants. Additionally, the presentations were directed at those over 55 years of age, so we are unsure of the effect of the education on younger adults and children. Self-report cannot be objectively verified. A further limitation is that we have no other information on the 5000 participants to show that the sample who completed the evaluation are representative. A minor limitation of using the FAST educational material for stroke signs is that the material is focused on signs of ischaemic stroke and excludes the signs of haemorrhagic stroke. Importantly, the strengths of the program were that the educational presentations provided by the StrokeSafe Ambassador used ‘nonmedical jargon’ and language tailored for the general population. The strengths of the study were that it had representation from all states in Australia, and that we had a large number of questionnaires completed and the response rate at follow-up was very good. Overall, the results provide evidence of the worth of volunteer-led community-based education concepts in improving immediate and short-term knowledge of the signs and risk factors of stroke which potentially can improve timely access to effective stroke treatments and help improve stroke prevention. Conclusion This important study describes a novel approach to support the use of trained volunteers to provide a community-based, standardised education program for stroke. Participants improved their knowledge of signs for stroke and stroke risk factors 3 months after the education presentation compared with pre-presentation. This program
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complements large-scale media awareness campaigns already undertaken in Australia and could easily be replicated in other countries. Conflict of interest The authors declare that there are no conflicts of interest. Transparency document The Transparency document associated with this article can be found, in online version. Acknowledgments We thank the research officers and program facilitators, as well as study participants for their contribution to this study. In particular we thank Erin Lalor (Chief Executive Officer) of the National Stroke Foundation for her assistance with the conception, development, and management of this program. Since August 2012, the program has received funding from the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. Dominique Cadilhac is supported by a co-funded National Health and Medical Research Council/ National Heart Foundation research fellowship (1063761). Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ypmed.2016.01.015. References Australian Bureau of Statistics, 1999. 4102.0 - Australian Social Trends: Australia. ABS, Canberra, p. 88. Bray, J.E., et al., 2013. Australian public's awareness of stroke warning signs improves after national multimedia campaigns. Stroke 44 (12), 3540–3543. Cadilhac, D., et al., 2007. Why invest in a national public health program for stroke? An example using Australian data to estimate the potential benefits and cost implications. Health Policy 83, 287–294. California Acute Stroke Pilot Registry, I., 2005. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology 64 (4), 654–659. Chen, S., et al., 2013. Effects of comprehensive education protocol in decreasing prehospital stroke delay among Chinese urban community population. Neurol. Res. 35 (5), 522–528. Dillman, D.A., 1991. The design and administration of mail surveys. Annu. Rev. Sociol. 17, 225–249. Ebrahim, S., Harwood, R., 1999. Stroke: Epidemiology, Evidence, and Clinical Practice. second ed. Oxford University Press, Oxford, p. 343 (ed. n. Ed.). Feigin, V.L., et al., 2014. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 383 (9913), 245–254. Gardois, P., et al., 2014. Health promotion interventions for increasing stroke awareness in ethnic minorities: a systematic review of the literature. BMC Public Health 14, 409. Kleindorfer, D., et al., 2008. The challenges of community-based research: the beauty shop stroke education project. Stroke 39 (8), 2331–2335. Rasura, M., et al., 2014. Effectiveness of public stroke educational interventions: a review. Eur. J. Neurol. 21 (1), 11–20. Senes, S., 2006. In: AIHW (Ed.), How We Manage Stroke in Australia. AIHW Cat no CVD 31. Australian Institute of Health and Welfare, Canberra, p. 60. Shigehatake, Y., et al., 2014. Stroke education using an animated cartoon and a manga for junior high school students. J. Stroke Cerebrovasc. Dis. 23 (6), 1623–1627. Slark, J., et al., 2012. Awareness of stroke symptomatology and cardiovascular risk factors amongst stroke survivors. J. Stroke Cerebrovasc. Dis. 21 (5), 358–362. Stroebele, N., et al., 2011. Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective. Int. J. Stroke 6 (1), 60–66. Trobbiani, K., et al., 2013. Comparison of stroke warning sign campaigns in Australia, England, and Canada. Int. J. Stroke 8 (Suppl. A100), 28–31. Wall, H.K., et al., 2008. Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Prev. Chronic Dis. 5 (2), A49.
