Interventions that promote stroke awareness: a literature review.

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Interventions That Promote Stroke Awareness: A Literature Review J. Danielle Martin

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Western Carolina University Published online: 14 Feb 2014.

To cite this article: J. Danielle Martin (2014) Interventions That Promote Stroke Awareness: A Literature Review, Journal of Community Health Nursing, 31:1, 20-33, DOI: 10.1080/07370016.2014.868732 To link to this article: http://dx.doi.org/10.1080/07370016.2014.868732

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Journal of Community Health Nursing, 31: 20–33, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.868732

Interventions That Promote Stroke Awareness: A Literature Review J. Danielle Martin

Downloaded by [Purdue University] at 11:45 01 September 2014

Western Carolina University

This review of literature explores various interventions that promote stroke awareness and knowledge of stroke warning signs in individuals. The review looks at the differences and similarities in several identified interventions, including mass media, printed materials, presentations, children’s programs, and stroke screenings. An assessment of these 5 interventions provides information on cost, personnel involved, number of persons reached, and knowledge retention from each program. Programs reviewed using the identified types of interventions demonstrate the benefits and challenges of each and enable program developers to coordinate programs based on these evaluations.

BACKGROUND Each year, close to 795,000 people experience a new or recurrent stroke (American Heart Association, 2013). Stroke is the fourth leading cause of death in the United States, behind heart disease, cancer, and chronic lower respiratory disease (National Heart Lung and Blood Institute, 2011). A harsh reality is that the burden of stroke continues after the initial injury. Strokes are a leading cause of serious, long-term disability in the United States, with less than half of Medicare patients being able to return home after hospital discharge. Of those who do not return home, 24% are discharged to inpatient rehabilitation and 31% are discharged to a skilled nursing facility (Buntin, Colla, Deb, Sood, & Escarce, 2010). Strokes impact patient and families because families often become caretakers or primary breadwinners of a household. Residual deficits are common after a stroke. These include weakness or paralysis on one side of the body, inability to communicate or understand speech and actions of others, and difficulty swallowing. The loss of function that can occur after a stroke challenges those individuals to adapt to a new life. Following a stroke, patients may have to use tube feedings, assistive ambulatory devices, or learn to communicate in different ways. Some strokes can leave people with partial paralysis on one side of the body, which may require help performing daily activities. Although many survivors learn to adapt to their disability, many of those who are at risk for stroke feel that certain effects from a stroke are worse than death (Solomon, Glick, Russo, Lee, & Schulman, 1994).

Address correspondence to J. Danielle Martin, MSN, RN, Western Carolina University, 43 Eola Avenue, Asheville, NC 28806. E-mail: [email protected]


INTERVENTIONS THAT PROMOTE STROKE AWARENESS

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Treatment for acute stroke, as well as the follow-up rehabilitation and care required for many patients, accounts for a significant number of healthcare dollars. The estimated lifetime cost of a mild stroke is $100,000 and the estimated cost of a severe stroke is $500,000 (Casper et al., 2003). In just the first year after inpatient rehab, Godwin, Wasserman, & Ostwald (2011) found that the average cost for outpatient stroke rehabilitation services and medications amounts to $11,145. The financial burden is confounded when patients are left disabled from their stroke and have difficulty returning to the workforce. In 1996, tissue plasminogen activator (tPA) changed how emergency medicine reacted to cerebrovacular attacks. The National Institute of Neurological Disorders and Stroke trial proved that patients experiencing ischemic strokes who received tPA within 3 hr of onset were 30% more likely to have minimal or no disability in 3 months (National Institute of Neurological Disorders and Stroke, 1995). Since this time, patients with ischemic strokes have been assessed for eligibility for thrombolytic treatment upon presentation to the emergency department. When patients do not present to a stroke treatment capable hospital within 3 hr from onset the risk for complications increase and patients may be excluded as candidates for tPA. Despite available treatment, delay in seeking medical attention after stroke onset is the most frequent reason for low rates of thrombolytic us (California Acute Stroke Registry, 2005). Studies suggest that those individuals who call EMS have shorter delay times but many still arrive by private vehicle (Fussman, Rafferty, Lyob-Callo, Morganstern, & Reeves, 2010; Morris et al., 2000; Schroeder, Rosamond, Morris, Evenson, & Hinn, 2000). Educating patients on the importance of activating EMS would provide patients with the opportunity to receive tPA for ischemic strokes by minimizing the delays to acute treatment facilities. Delays for seeking care can occur when patients are unable to recognize stroke warning signs. Multiple studies have demonstrated that a vast majority of the population lacks the ability to identify possible stroke warning signs and symptoms (Fussman et al., 2010, Schneider et al., 2003). There are two commonly used public messages for stroke identification. One message lists five warning signs and is generally referred to as the Suddens. This list includes: 1. 2. 3. 4. 5.

Sudden numbness or weakness of the face, arm, or leg on one side of the body; Sudden confusion or trouble understanding; Sudden trouble seeing in one or both eyes; Sudden trouble walking, dizziness, loss of balance or coordination; and Sudden severe headache with no known cause.

There is also the FAST acronym. FAST is easier to remember and reminds people of the correct action to take when they feel they or someone else may be experiencing a stroke. The FAST acronym stands for: Face: Arms: Speech: Time:

face numbness or weakness, especially on one side; arm numbness or weakness especially on one side; slurred speech or difficulty speaking or understanding; time to call 911.

Although FAST fails to include all possible agreed-upon warning signs of strokes, Kleindorfer et al. (2007) found that the FAST message caught 88.8% of all stroke cases and the Suddens caught 99.9%. The effectiveness of the FAST campaign was demonstrated in a study by Robinson, Reid, Haunton, Wilson, and Naylor (2012), which found 70% of the public they

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surveyed were familiar with FAST and had less trouble identifying those warning signs that were included in the FAST message. Despite an increase in the number of people that can identify one warning sign since 1995, Schneider et al. (2003) still found that only 70% of people surveyed could name just one stroke symptom.


PURPOSE This literature review aims to examine five educational interventions and strategies used in community settings to determine which interventions are most effective in teaching participants the warning signs of strokes, as well as the correct actions to take when a stroke occurs. Effectiveness will be based on cost feasibility of the intervention, number of people reached through the intervention, quality of instruction, the educators involved, and knowledge retention.

METHODOLOGY Research and peer-reviewed journal articles were searched through the Western Carolina University library’s search databases, including CINHAL and Academic Search Premier. The search included all full-text articles from 1995 until January 2013. Search words included stroke education, stroke warning signs, and stroke awareness. A more detailed search was conducted to look up specific authors and studies found in references from articles. Because many relevant articles were originally published in the Stroke journal, a search conducted on the journal’s search engine was completed using the same search words.

LITERATURE REVIEW A review of the literature has demonstrated five interventions frequently used for promoting awareness of stroke warning signs in the community. These interventions are similar in that they seek to offer education on stroke warning signs to community members. The differences lie in who conducts the education, the cost of the intervention, follow-up that is incorporated into their projects, and the number of people reached through the intervention. Reviewing each type of intervention, this review examines the strategies used for each category and assesses their effectiveness by looking at the cost, the personnel required, and the number of people reached. The five categories of interventions include the use of mass media, printed materials, presentations, children’s programs, and stroke screenings. Mass Media Mass media is a familiar advertising strategy to most people living in the United States. Mass media includes television advertisements and radio announcements. Through mass media, messages are distributed to a vast audience both in numbers and demographics. Depending on the gross rating points awarded to a particular segment on television, millions of viewers can be exposed to a message. Marx et al. (2010) exposed 400,000 viewers to their stroke awareness campaign. Similarly, Hodgson, Lindsay, and Rubini (2009) broadcasted, during one campaign,



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to 26.5 million viewers. Air time is a powerful determinant in mass media campaigns and is evidenced by the increase in percentage of people who can name two or more warning signs in high-intensity television campaigns versus low-intensity television campaigns (Silver, Rubini, Black, & Hodgson, 2003). The exposure of mass media surpasses any other interventions reviewed, but has its costs. In large mass media campaigns for stroke awareness, the local government, or other invested business, assists with funding. Assistance with funding by larger corporations is apparent in the study by Hodgson et al. (2009) where the Heart and Stroke Foundation of Ontario funded the campaign, as well as in the study conducted by Marx et al. (2010) where funds came from the University of Mainz, the state government of Rhineland, and Boehringer Ingelheim Pharmaceuticals. Silver et al. (2003) reported in their research on the use of media campaigns, that the cost for a total of 7,200 rating points accrued to $107,704. Mass media reaches broad demographics. Multiple ways exist to include more diverse populations. For example, air time for an advertisement on television or radio can affect the broadcast channels, as well as the diversity of listeners or viewers. Hodgson et al. (2009) paid for advertisements that placed them with 1,990 gross rating points, which signifies the large target reach and number of exposures this campaign had. They included, in the second phase of their campaign, a translated version of the original black-and-white commercial into Cantonese, Mandarin, Hindi, Punjabi, Tamil, and Urdu languages. Even though media strategies reach a large proportion of a given population, it might not be as effective in spreading messages equally to all genders and age groups. In one study that used mass media and posters, women were more likely to state that they remembered the printed materials than the television ads. Men, on the other hand, were more likely to answer that they remembered the message from television ads (Marx et al., 2010). To further emphasize the disparities, Silver et al. (2003) found that television helped educate more men and those that had education at or below a high school level and did less to help educate older adults. The telephone surveys conducted by Marx et al. (2010) used random-digit dialing services. Some sought to capture a representative sample of the demographics of the listening areas (Marx et al., 2010); others performed call backs until the quota of completed surveys were filled (Hodgson et al., 2009). In the follow-up calls, questions assessing knowledge of stroke warning signs were asked along with additional demographic information. Results demonstrated a significant increase in recall of stroke warning signs after media campaigns in all the articles reviewed. An increase from 52.5% to 72.7% of responders were able to name two or more stroke warning signs in the study conducted by Hodgson et al. (2009). Silver et al. (2003) discovered an increase of 10.8% in the population that were able to name two or more warning signs in the low-level television campaign community and a 13.7% increase in the community with high-intensity advertising. The knowledge of stroke warning signs decreased significantly, however, after the disappearance of media campaigns. Hodgson et al. (2009) looked at two campaign phases, the first of which had more funding, which allowed longer advertising time, and the second (which had lost some funding) that had shorter advertisement times. The surveys taken after the first phase showed an increase in knowledge compared to the baseline. The surveys taken before the second phase of the campaign, having been exposed to the prior campaign, but after a 5-month blackout time, showed that knowledge had decreased significantly. The unintentional lack of funding for the second phase of the campaign led the researchers to conclude that longer, pulsating patterns of television advertisement equated to less of a decline in

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stroke knowledge than shorter advertisement campaigns. This same study showed that knowledge is quickly forgotten without consistent messaging. Mass media represents an effective means to reach a large audience, but it requires consistent funding and campaign efforts to produce ongoing public awareness. Funding must be acquired through larger agencies to support the cost of high-intensity paid television programming. Even with expansive exposure on main-stream networks, mass media does not touch all ages and genders equally. Campaigns should consider their target audience before committing to mass media campaigns.


Printed Materials Printed materials (not including large direct mail campaigns) do not possess as expansive a reach as mass media does, but programs using printed materials allow for specific community needs to be addressed. Printed materials such as posters, brochures, and signs contribute to the interventions mentioned in this section. Many interventions using printed materials in the studies reviewed were specifically designed for a targeted population. This focus allowed creators of the interventions, and those that helped allocate them, to incorporate the needs and beliefs of the population. In one study, EMS personnel were asked to design their own advertising methods based on their familiarity of several West Virginia communities and its inhabitants (Tadros et al., 2009). This scenario yielded different advertising strategies than seen elsewhere in the literature including signs depicting the Suddens placed on school buses, educational packets being taken to businesses, and bookmarks that were placed in books purchased at a local bookstore. The results demonstrated that the interventions thought up by community EMS staff were effective in increasing stroke knowledge, most notably in remembering the warning signs of strokes. Another creative example of printed material meeting the needs of a community also involves West Virginians. In a study by Davis, Martinelli, Braxton, Kutrovac, and Crocco (2009), a poster using the parallel processing model was designed to promote awareness and a feeling of vulnerability to experiencing a stroke among a group of West Virginians. This article provides evidence that West Virginians have a high percentage of people with multiple risk factors for stroke, thus making it imperative that these people understand their risk for stroke and take action. Two posters were used in this project. One poster was developed as the intervention poster and included written messages that emphasized the likelihood that a stroke could happen to anyone. The other poster did not attempt to instill a sense of vulnerability in viewers, it merely offered basic information. The intervention targeted a population, which in this case needed to be informed of their risk, and developed an intervention specific to their needs. By testing an intervention that aimed to help more people feel vulnerable to stroke, researchers aided a population that needed to gain insight on the disease process and make behavior changes. Printed materials can be tailored to fit the beliefs of individuals. One example is the freeze the stroke project. In this project, nurses distributed printed materials on stroke warning signs for patient and family members to place on their freezers after discharge from the hospital. This project assumes that people will feel greater vulnerability when they witness someone close to them, or they themselves, experience a stroke. In this study, Cruz, Araújo, Alves, Magano, and Coutinho (2012) demonstrated that those who were witness to a stroke were, in fact, better able to recall stroke warning signs than those in the control group.



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There is versatility in the types of professionals that are used in programs that use printed materials. In the case of the EMS staff described in Tadros et al. (2009), trainers used PowerPoint presentations to standardize classes and then utilized all EMS staff in those classes to deliver stroke education to the public. Nurses assisted with the implementation of the freezer intervention. as did the family members themselves. The use of printed materials allowed the families to share information with neighbors and other family members. A variety of healthcare professionals and lay people can use printed materials to educate others. Printed materials are often less expensive when compared to other interventions. Tadros et al. (2009) reported spending $20,000 over 2 years for one county, and $20,000 split four ways between counties in phase two of their research study. For comparison, the study noted that these interventions still cost less than many mass media campaigns and the materials produced can be used in consecutive campaigns, reducing future costs. Educational pamphlets can be purchased through Web sites from The National Stroke Association, American Stroke Association, and others. Financial feasibility concerns all communities and greatly contributes to the sustainability of a stroke awareness campaign. Data gained from interventions that use printed materials suggest positive results regarding awareness of warning signs. Sullivan and Katajamaki (2009) described how, after having read over two stroke brochures for 10 min, participants demonstrated greater knowledge of stroke warning signs both immediately following the intervention and 1 week after. Similar results were recorded for the study conducted by Cruz et al. (2012), where the group that was given the information to take home from the hospital scored 54.2% higher than people that were not given information at discharge. The communities the EMS staff worked with also scored higher on survey questions, showing an increase from 73% to 85% recall to at least one warning sign on follow-up (Tadros et al., 2009). Davis et al. (2009) found that both posters used resulted in knowledge gain and the adapted version of the poster sustained more knowledge retention among its viewers than the other non-adapted poster. Age was a significant factor in knowledge retention. Adults older than 50 years old and who were classified as high risk in one study scored lower on the assessment than did younger adults who were considered low risk (Sullivan & Katajamaki, 2009). Davis et al. (2009) also found that younger adults learned more in the intervention that used posters. Other articles did not include an analysis of age differences and assessment scores. The differences found in these articles concerning age and knowledge acquisition could drive more educators to question written materials used with older adults. Participants in these studies were also prone to declining knowledge after time without intervention. The viewers of the stroke posters in the parallel process model designed by Davis et al. (2009) were less likely to remember stroke information, such as warning signs, 6 weeks after the intervention. EMS-designed educational material also did not have the long-term effect that one would hope to gain from a follow-up. Surveys conducted by telephone showed that the percentage of the participants capable of naming at least one warning sign dropped after each lull in advertisement (Tadros et al., 2009). Retention remained consistent in only one study for both young and older age groups, but follow-up was conducted at 1 week postintervention and might have been different if assessed after a longer waiting period (Sullivan et al., 2009). Printed materials provide greater flexibility in terms of cost, administrators of the material, and the focus one can have on a target population. These attributes make written materials an ideal part of any stroke education intervention. Printed materials offer the capability of reusing

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materials and saving money. Further research is needed to determine if written materials act as the only educational strategy that hinders older adults’ learning ability or if their learning is inherently lower than that of younger adults.


Presentations Presentations offer another method in which to teach stroke warning signs in the community. The programs that used presentations were found to incorporate audiovisuals, facilitated discussions, and train the trainer exercises. Adult learning strategies, experience sharing, and facilitated discussions were methods incorporated in several of the programs. Presentations were often conducted in public venues, often by knowledgeable and trained professionals, including medical students, nurses, and research coordinators. The number of presentations conducted by presenters in the literature ranges from one presentation to as many as 34. Participants involved in the trainings and groups ranged from 10 to 657. Some trainings offered opportunities for participants to later disseminate information to others resulting in expanded outreach. Studies that looked at knowledge gain and retention of warning signs demonstrated positive results. Nurses, medical students, and research coordinators conducted the studies using their knowledge and experienced backgrounds to help explain the programs’ messages. In a study conducted by Gutierrez-Jinmenez, Gongora-Rivera, Martinez, Escamilla-Garza, and Villarreal (2011), medical students offered a series of presentations that were provided to a housing community of 329 residents. Required training for the medical students, prior to conducting the presentations, was to attend a one month cerebrovascular course that met twice per week and reviewed general concepts of cerebrovascular disease, risk factors, signs and symptoms, treatment, and prevention. The training classes were taught by vascular neurologists, university professors, and hospital staff. These classes prepared the medical students to hold their own presentations which lasted one hour and fifteen minutes. A total of seven presentations were held at the housing community, three for each two housing units. The vascular neurologist attended the last and 7th presentation and assisted the medical students in a review of ischemic stroke. In another study, nurses facilitated sessions that reviewed topics such as personal experience with strokes, stroke warning signs and clinical manifestations, medications, diet, etc. These sessions were held eight different times for 2 hr each, once a week (Sit, Yip, Ko, Gun, & Lee, 2007). Other studies included the use of trained staff members and principle investigators to distribute and present information (Kleindorfer et al., 2008; Stern, Berman, Thomas, & Klassen, 1999). Knowledgeable staff members helped to engage participants and allowed for programs to adapt to participants’ specific concerns, as well as offered opportunities for participants to ask questions and demonstrate skills (Sit et al., 2007). These strategies offered more feedback to both trainers and participants compared to other interventions where direct communication is not possible. Professionals leading the presentations incorporated the use of several adult learning strategies to assist with acquisition of stroke knowledge. Participants in one study played games, shared experiences, and asked participants to reflect on their goals for the program (Sit et al., 2007). In this same study, participants were asked to list the issues they wanted to focus on, and these items were addressed one at a time by the nurses conducting the groups. Stern et al. (1999) compared a group of participants that were given an audio visual presentation to those that were given the same presentation with the addition of a facilitated group discussion that summarized



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the material and encouraged those involved to ask questions. Kleindorfer et al. (2008) had a stroke survivor share her experience during training to Black beauticians, in an effort to increase engagement and learning. Gutierrez et al. (2011) used medical students to provide a series of presentations which, if participants consistently attended, offers a higher likelihood that knowledge retention will take place due to repetition. Many of the presentations were held at local facilities and common areas in housing communities to attract targeted populations. Gutierrez-Jimenez et al. (2011) offered presentations in the common areas of a large housing community. They divided the community in half and conducted presentations in each half during the weeks the program was implemented to make it accessible and convenient to residents. Kleindorfer et al. (2008) also used community venues when training beauticians in both Atlanta and Cincinnati. Subjects involved in the study conducted by Stern et al. (1999) attended presentations at churches, community centers, local businesses, and service group venues. Because presentations require a common meeting venue, offering presentations at local and public venues makes it more convenient for community members to participate. Studies that looked at knowledge and retention of learned information demonstrated positive results in programs that implemented presentations. Wall, Beagan, O’Neill, Foell, and Boddie -Willis (2008) found that after showing a 3-min animation on stroke warning signs, participants’ knowledge increased. As an example, 98.6% of participants were able to recall immediately after the animation that facial droop was a warning sign of stroke compared to 91.7% before the audio slide show was used. Participants were better able to discriminate which symptoms were not related to stroke, such as chest pain and shortness of breath. However, at a 3-month followup, participants were less likely to discriminate these symptoms from their choices; only 55.4% were able to eliminate these incorrect choices, compared to 87.7% at baseline. Ability to identify the correct symptoms stayed almost consistent, with the first results immediately following the intervention. Sit et al. (2007) looked at control and intervention group results after the intervention group received a series of eight 2-hr sessions, each presenting on stroke topics and incorporating a wide range of learning strategies. Participants that attended the presentations demonstrated higher mean scores on questions that pertained to warning signs 1 week after the intervention and at 3 months. In another study, medical students’ presentations had positive results on their participants’ scores. After the 6-month program, 48.1% of the participants were able to name at least one warning sign and 18.9% were able to recall two or more, compared to 37.6% and 11.55%. Clients of the beauticians were surveyed both before and after education was provided to them by their beautician in the study by Kleindorfer et al. (2008). Six weeks following the intervention, more clients were able to name three warning signs demonstrating an increase from 40.7% at baseline to 50.8% at 6 weeks. This increase was apparent on the 5-month survey, as well with 50.6% identifying at least three warning signs. Stern et al. (1999) compared the effects of an audiovisual presentation and the same audiovisual presentation with the addition of a facilitated discussion. The study found that participants who engaged in the discussion led by the facilitator did not score significantly higher than those that only participated by watching the slide show, but both groups identified more warning signs compared to baseline. The literature has demonstrated increased knowledge of stroke warning signs, as well as longer retention of that knowledge. As previously mentioned, clients of the beauticians could recall almost just as many warning signs after 5 months as they could at 6 weeks postintervention (Kleindorfer et al., 2008). Similar results were shown in the study involving medical students. Their posttest results were surveys taken 6 months after the intervention. These results were


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significant even after the time that lapsed from intervention to assessment (Gutierrez-Jimenez et al., 2011). Another study collected results at 1 month and 3 months postintervention. In this study, retention of stroke knowledge showed only a slight decrease (Sit et al., 2007). These results raise the possibility that presentations led by trained or knowledgeable individuals may lead to longer retention of stroke knowledge. The number of participants that each presentation reached varied by study. Presentations that were designed to train the trainer, such as in the study that taught beauticians so that they could teach their clients, aimed to reach a larger participant group than the number in the original class. Kleindorfer et al. (2008) had a group size of 30 beauticians that participated in the initial training and then shared information with a group size that in total, accounted for 383 participants. Other studies measured only the effect that the presentation had on the individuals present in the initial program. Nurses in the one study worked to teach groups of 10–12 people, teaching 147 people in all (Sit et al., 2007). Medical students that held a series of presentations in a housing community collected 355 surveys from participants in phase three of their program that lasted for 6 months and incorporated seven conferences. Stern et al. (1999) collected 657 participants after coordinating and conducting 34 presentations in the community. The number of presentations and numbers of participants reached are important to note when analyzing the feasibility of such programs. Presentations offer a valuable way to share stroke information with a group. In some cases, that same information can be shared by participants to others. Having trained professionals facilitate the presentations allows for immediate assessment of participants’ knowledge by using various teaching strategies and allows participants to ask questions. Total time spent organizing the presentations and time spent presenting should be compared to the numbers of people that the program reaches. Knowledge retention is a sustainable aspect of presentation programs that may make these interventions worthy of replication.

Children’s Programs Two studies have examined how stroke warning signs can be taught to school age children. Two studies were identified that measure the effectiveness of two different programs targeted for school age children. These programs implement unique strategies to target a younger audience. More than 500 students participated in both programs described in the two different studies. Williams and Noble (2008) included children and their adult family members. Both programs described in the literature demonstrate that educational interventions targeted to school age children can improve stroke knowledge on warning signs. Researchers described why they chose various educational strategies for their interventions. Conley et al. (2010) used role playing as part of their intervention to promote skill mastery. Students were able to act out what actions to take if they thought someone was experiencing a stroke. These researchers incorporated vicarious learning, also. The Web site developed for this program allowed kids to view other kids initiating the correct response to a stroke emergency. Vicarious learning promotes self-efficacy and encourages kids to feel empowered to act on knowledge they attain. In the Hip Hop stroke program, children were taught a professionally written hip hop song. The song included warning signs of stroke and helped teach these symptoms to the children.



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Because schools house a large number of students, participation was comparable to larger interventions. Programs were taught according to grades, either having different curriculum for each grade (Conley et al., 2010) or by teaching different grade levels at a time (Williams & Noble, 2008). The former study attempted to teach adult family members of the children, thus adding to the numbers of participants they aimed to educate. Issues did arise, however, with program completion from both children and adult family members. Conley et al. (2010) were unable to provide data on the effectiveness of homework that was assigned to students on stroke education that was designed to increase adult knowledge since so few parents returned surveys. Many students were lost to matriculation to other schools. Interim assessment scores evaluated after the intervention for 7th graders showed a positive correlation with one program. Students surveyed in this year, after having one intervention that included computer classes and role play, scored higher than those students who did not participate in the classes (Conley et al., 2010). Specifically, students in the intervention group showed an increase from 1.2 on the pretest to 2.1 after the intervention. The control group in this study only showed an increase from 0.9 to 1.2. Children also scored higher after participating in an educational program that introduced warning signs through a hip hop song (Williams & Noble, 2008). Students improved their scores on a quiz from 3.2 at baseline to 6.0 immediately after the song was taught, and maintained a score of 5.9 at a three month follow-up. Benefits discussed by Williams and Noble (2008) of educating young students on the warning signs of stroke include having them teach their parents who may be at higher risk for stroke as well as may have language barriers that prevent them from getting this information elsewhere. These researchers discussed the cultural characteristics of the Mexican American communities they targeted in their project. These communities rely on family and friends for much of their stroke education and knowledge, and children could assist in sharing this information. Retention measured in the study by Williams and Noble resulted in sustained increased awareness, but more studies could further conclude how much information is retained though these school-age activities. Even though children are at lower risk for stroke than older adults, they might be able to retain information regarding warning signs and risk factors into adulthood. Information on stroke warning signs plays a critical role regardless during childhood, since children can act on identifying warning symptoms in others.

Screenings One article from the search provided evidence on the effectiveness of stroke awareness through stroke screenings. DeLemos, Atkinson, Croopnick, Wentworth, and Akins (2003) followed up by telephone with 113 participants who were considered high risk after completing a community stroke screening. To measure the effectiveness of the screening on participants’ knowledge of stroke warning signs, participants took the same three-question quiz before, immediately following the screening, and 3 months later. The screening was conducted using the screening guidelines from the National Stroke Association. Blood pressures, glucose, cholesterol, bruit detection, and atrial fibrillation detections were offered, as well as counseling on risk factors and stroke knowledge. Participants who had more than one modifiable risk factor were considered high risk for stroke and were contacted for follow-up three months after the screening.


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After 3 months, a healthcare professional made the call to participants who were at high risk and who provided their telephone numbers. The same quiz that was given before and immediately after the screening was given again, over the phone. Participants’ scores improved immediately following the screening, from 59% average score to 94% on the quiz. At 3 months, however, the average score decreased to 77%. This decline in retention compares similarly to other interventions in this review. Researchers of this program discussed several challenges involving advertised screenings. First, many of the participants that registered for the event were older adults and categorized by the researchers as “worried well” and not in the highest risk category. The challenge involves attracting those individuals with greater stroke risks that may benefit greatly from the education. Another challenge discussed was the apparent lack of knowledge retention on follow-up. Researchers argued that the older age of the participants at the screening may have had an effect on the ability to remember. A study by Anderson, Camacho, Iaconi, Tegeler, and Balkrishnan (2011) looked not at the knowledge of participants after screenings, but at their behavior changes in regards to stroke risk. This study found that participants who were given a follow-up telephone call using motivational interviewing skills, modeled after the Health Belief Model, had higher recall on stroke risk factors. Even though this study does not specifically look at participants’ knowledge on stroke warning signs, further studies could assess whether these phone calls could influence knowledge retention. Another important factor regarding screenings concerns the cost of the screening itself. The screening guidelines used in the screenings that Anderson et al. (2011) looked at resemble those from the screening in the study by DeLemos et al. (2003) in that they both provided cholesterol and glucose levels to participants. Other services aside, these results cost money to the organizers of the screenings and, unless community members are asked to pay, financial obligation must be promised by committed parties in order for screenings to occur. More newspaper advertisements than research papers resulted from a search on screenings, which provides some evidence on the popularity of community stroke screenings. Challenges and issues persist, however, in how to reach those at highest risk and how to make screenings financially sustainable and effective.

CONCLUSION Programs examined in this review illustrate the unique attributes of each intervention. The differences are seen in numbers of persons taught, the type of educators involved, and the amount of knowledge that is retained, providing future planners of stroke awareness programs with more information on which intervention meets their goals and available resources. Although one intervention cannot be labeled as the superior intervention for all programs, the description of methods and outcomes for each will help planners match which intervention to replicate. Each intervention influenced a different number of people. Mass media reached the largest proportion of people through paid programming on television and radio. The numbers were not without cost; interventions involving mass media relied on funding from established organizations including government agencies. Presentations, on the other hand, offered training that not only taught the direct participant but, sometimes, was given indirectly to people who were taught by the participants in the program. When participants were trained to teach others, the numbers



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influenced by the project increased. However, many of the projects that used presentations as their intervention demanded a significant amount of time from staff and participants. Interventions using printed materials reached a smaller population than mass media, but provided adaptability of the designed message to fit the beliefs of the persons assumed to view it. Being able to reuse many of the printed materials, such as signs and posters, assumes a financially feasible and sustainable campaign. Most studies showed that the longer an intervention is withheld, the broader the gap in knowledge scores will be. The adult learning strategies featured in the presentations, as well as the in-person opportunities to discuss topics and ask questions, typically resulted in longer retention of knowledge (Gutierrez-Jimenez et al., 2011; Kleindorfer et al., 2008; Sit et al., 2007; Wall et al., 2008), in comparison to other interventions. These programs still showed a decline in knowledge, but it was less than that of other studies. The hip hop program designed for-school age children resulted in positive retention scores as well and, although grouped in a separate category based on the program’s unique approach to target the learning needs of children, can still be defined as a presentation. Not all programs have access to knowledgeable staff to coordinate and educate the community in the same ways. In this review, EMS staff, nurses, research coordinators, and neurologists were included in the beginning of each intervention to train either additional staff or participants directly. The time dedicated by each professional varied within interventions, suggesting that some interventions, such as presentations, used more of a professional’s time; where, as others like mass media, used it much less. A professional’s time is a resource to consider when program planning.

IMPLICATIONS Developers of future stroke awareness programs may find the review of literature on the topic helpful as they weigh the benefits and barriers of each intervention and take into account the resources they have available to conduct a stroke awareness program. In addition, this review may offer ideas on what tools may be used to measure knowledge retention and what interventions are most appropriate for a specific population. By encouraging stroke awareness programs, the community will benefit through knowledge gained, and more so, by the treatment they will receive if they do experience a stroke, identify the symptoms, and call 911 immediately. I hope that this review of literature might be used in future studies measuring the effectiveness of various interventions. More data concerning the effectiveness of stroke screenings on community stroke awareness is being collected using a four-question stroke quiz. The quiz will measure knowledge retention at baseline and after screenings are implemented to different groups in the western North Carolina region. The quiz will provide data on participant’s knowledge on stroke recognition, risk factors, and the correct response to take in the event of a stroke. The quiz will be given before an event, to provide baseline information, and then again at one and three months to measure retention. Designing effective stroke education programs makes it possible to impact the burden of stroke in our communities.

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MARTIN


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