Preschool children deliver stroke knowledge to their families with the FAST 112 Heroes educational programme

Abstract

Background:

FAST (Face, Arm, Speech, Time) 112 Heroes is an educational programme that delivers information to children and their extended families helping them identify the principal signs of stroke and informing them how to respond appropriately in the event of a stroke.

Objectives:

To examine the baseline stroke literacy that extended families possess, as well as to assess whether children enrolled in FAST 112 Heroes programme effectively convey stroke knowledge to their extended family.

Design:

Field trial.

Setting:

Four schools in Northern Greece – two public and two private.

Methods:

Parents of preschool aged (5–7 years) children completed stroke knowledge questionnaires, before the programme began and one week after the completion of the FAST 112 Heroes programme. Findings were analysed.

Results:

In total, 240 parents of kindergarten children (146 women, 94 men; 20–59 years old; mean age: 38.81) completed the pre-programme questionnaire, whereas only 80 of them (33.33%) completed the post-programme questionnaire. Before the programme started, 30 out of 80 parents (37.5%) recognised the three rudimentary stroke symptoms, compared to 68 out of 80 (85%) after the completion of the programme (p = .00). Parental awareness of the emergency number 112 and of the FAST acronym before programme implementation was relatively poor.

Conclusions:

Improvement of stroke knowledge post-implementation was observed in the extended family of preschool children enrolled in the FAST 112 Heroes programme which suggests that the latter delivered stroke information to their families effectively.

Keywords

Extended family Fast 112 Heroes parents stroke stroke awareness

Introduction

The ability to act quickly and obtain the most appropriate treatment is crucial to a favourable outcome of stroke (Gonzalez-Aquines et al., 2018). Studies have noted that speedy action reduces emergency medical system response times and optimises in-hospital response times which may lead to an increase in thrombolysis rates to 57% (California Acute Stroke Pilot Registry [CASPR] Investigators, 2005). However, stroke patients are often unable to reach out for help due to cognitive and physical debilities (Tshiswaka et al., 2018) and lack of knowledge about the symptoms of stroke. Instead, they often rely on witnesses and bystanders to call emergency medical services (Mullen Conley et al., 2010).

It is well known that older adults are at greater risk of stroke than those in younger age groups (Gorelick, 2019; Teh et al., 2018; Tsivgoulis et al., 2018). In multigenerational families, older adults spend a substantial amount of time with their children or grandchildren, with grandparents often acting as secondary caregivers (Hill et al., 2017; Pulgaron et al., 2016). Women who do not give birth before the age of 30 are a typical example of older parents living in the family household. As a result, children may witness stroke in an older adult and play a crucial role in their transfer to the emergency department (Davis, 2008).

Mass media campaigns can be successful in raising stroke awareness in adults, especially when they present participants with clear and coherent messages (Hodgson et al., 2007). As part of these campaigns, various mnemonics have been used to target different age groups. The Stroke 112 study examined the impact of using the mnemonic STROKE as a way of targeting an adult community intervention (Zhao et al., 2018). Educational interventions targeting children, such as the Hip Hop Stroke (HHS) (Williams and Noble, 2008), have also achieved significant results. Research suggests that widespread promotion of FAST (Face, Arm, Speech, Time) campaigns has been effective in teaching the general public to recognise signs of stroke and seek treatment immediately after the occurrence of a stroke (Hickey et al., 2018). This helps minimise the deleterious effects that stroke may cause.

In the recent past, school-based educational programmes have successfully provided students with stroke-related knowledge (Hino et al., 2018; Li et al., 2020; Marto et al., 2017; Matsuzono et al., 2015; Williams and Noble, 2008). So far as we are aware, however, none of these programmes have targeted children of a younger age group (i.e. 5–7 years old). Educating children at a young age helps crystallise knowledge in long-term memory, aiding its recall during an emergency. The FAST 112 Heroes educational programme helps preschool children identify three cardinal signs of stroke and learn how to respond appropriately in the event of a stroke (Tsakpounidou et al., 2019, 2020). In the programme, a cartoon character, Timmy, responds quickly in a way that younger children aged 5–7 years can imitate.

The FAST 112 Heroes programme is based on the Child-Mediated Stroke Communication (CMSC) model in which children serve as conduits to disseminate knowledge to a wider population (e.g. their parents, grandparents and family friends, who we refer to as the extended family) (Williams et al., 2012). Adherence to school participatory activities, involvement in family activities and supplemental home activities are requisites for making the effects of an educational programme long-lasting (Ishigami et al., 2017). Importantly, a programme suited for the extended family is effective in promoting community health if it addresses both child and parental learning (Graybill et al., 2010; Ishigami et al., 2017; Kato et al., 2017; Morgenstern et al., 2007). Since previous studies have shown that intervention effects often cease when a health promotion programme is over (Morgenstern et al., 2007; Sakamoto et al., 2014), this programme aimed to deliver sustainable information by requiring children to disseminate stroke information to their extended family members, using posters, refrigerator magnets, stickers and other teaching aids (Hill et al., 2017). These aids act as positive reinforcers of programme participation and are integral to the programme’s effectiveness and sustainability.

Baseline and post-programme implementation knowledge of stroke preparedness among Greek families of children aged 5–7 years was evaluated using a comprehensive questionnaire that was created to measure all aspects of parental experiences and knowledge of stroke before and after participating in the programme. Programme adjustments to the curriculum and methodology focus, participant incentives and concept testing were made to the programme according to parental baseline knowledge and field-test results. Similar parental knowledge pre- and post-implementation questionnaires exist in the literature for other age groups (Hickey et al., 2018; Ishigami et al., 2017; Sug Yoon et al., 2001; Wall et al., 2008; Williams et al., 2012; Williams and Noble, 2008) but none for this parental age group. For this reason, a questionnaire was created to assess the knowledge of child caregivers who participated in the FAST 112 Heroes programme. A novel aspect of this study was patient engagement: and, two patient-researchers served on the educational team. They helped create the questionnaire as part of a patient engagement model in which collaboration engineered the environment so that priorities could be established and knowledge transfer could occur (Staniszewka, 2020). The medical histories for both patient-researchers included ischaemic stroke with no overt symptoms. Only one patient-researcher was involved in programme implementation, but both were involved in the development of the questionnaire.

There were two components to the present investigation. First, we assessed the baseline knowledge of the extended family. We expected that due to the scarcity of stroke educational campaigns in Greece, families’ general knowledge of stroke would be poor. Second, we studied the effects of the FAST 112 Heroes programme on the extended family. Children of age 9 years and higher are found to be effective conduits for delivering fundamental stroke knowledge to their families (Tshiswaka et al., 2018; Williams et al., 2012). Thus, we leveraged educated children of a younger age (i.e. 5–7 years, suggested by Davis, 2008) in order to examine whether they could convey stroke information to extended family members. We also explored the relationship between level of knowledge and participants’ personal experience (i.e. having a friend or relative who suffered a stroke), age and educational level.

Methods

The FAST 112 Heroes programme was implemented face to face in four kindergartens (two private and two public) in Thessaloniki Greece, where 247 preschool children (ages 4.8–7, mean age = 5.33, SD = 05.36) were recruited into the programme. Children’s extended families were informed about the programme via the schools’ administration. This was done either electronically or by using printed materials (briefing letters and leaflets taken home) to accommodate those without Internet access. The FAST 112 Heroes programme was not mandatory for students. No member of the extended families disallowed their child or themselves refused from participating in the programme. No incentives were provided for involvement in the study.

All participants noted that they were the primary caregivers of the enrolled child and that they were the person at home with whom the child would most likely disseminate the acquired knowledge. Only one member of the extended family, that is, parent or guardian was required to participate. This family member did not take part in the school-based implementation as the programme was delivered during school hours. The interested member of the extended family was asked to fill out the FAST 112 Heroes Stroke Preparedness Questionnaire pre-implementation (Online Supplemental Appendix A), before accessing any related information through their children and before the instructors together with classroom teachers began the programme implementation. During the 5-week implementation, the family member(s) received printed informative material at home (each preschool child was given this material by the FAST 112 Heroes team/classroom teacher), which was also used during the 1-hour weekly programme for the in-class presentation. This printed material was given as homework for preschool children to show to their extended family and review every week, for a total of 5 weeks. Families were also asked to register on the programme’s website (www.fastheroes.com) and watch the online educational videos. The videos included easily accessible information regarding stroke symptoms and information about the appropriate course of action in case one witnesses someone suffer a stroke. After the completion of 5 weeks, a FAST 112 Heroes Stroke Preparedness Questionnaire post-implementation questionnaire was sent home with the preschool children for their extended family to complete (Online Supplemental Appendix B).

Both questionnaires included a section describing their purpose. Participants were asked to respond sequentially to a series of questions without the possibility of correcting previous answers. The pre-implementation questionnaire consisted of 10 questions: 3 questions recorded socio-demographic information on gender, age and educational level. All other questions were in alignment with previous questionnaires. One question was rated on a Likert-type scale, two were open-ended, requiring a one-word response while three were multiple choice. The first question was a self-assessment of stroke knowledge: ‘How would you rate your knowledge on the subject of stroke?’ (Hickey et al., 2018). The response was rated on a Likert-type scale ranging from 1 (= not at all) to 5 (= very much). The second question was, ‘Do you know which part of the body is affected by stroke?’ (Williams et al., 2012), which was a partially open question; it required a one-word response but in case the participant could not give a specific answer, a multiple-choice response (e.g. four choices were provided with only one correct) was provided. The third question explored any possible association between having had a personal experience with stroke and stroke-related knowledge: ‘Have you or do you know a close relative or family friend who has had a stroke (please specify)?’ (Wall et al., 2008). The three questions that followed were designed to investigate parents’ or guardians’ knowledge of stroke symptoms and the appropriate response to the occurrence of stroke: (1) ‘Do you know the initials in the acronym “FAST” are used to identify a stroke? If yes, what does “F”–“A”–“S”–“T” stand for?’ (Wall et al., 2008; Williams et al., 2012). Since FAST is an English acronym, we used ΧΟΠΑ as the Greek mnemonic, developed by the Hellenic Society of Cerebrovascular Diseases – Hellenic Stroke Society (https://www.cerebrovascular.gr/en/); (2) ‘What are the main symptoms of a stroke?’ (Sug Yoon et al., 2001); and (3) ‘If you see someone having a stroke, what should you do?’ (Ishigami et al., 2017). In addition, an original question was included that referred to the emergency number to call for a stroke emergency: ‘What is the most appropriate number used to call an ambulance in case of a stroke?’

After completion of the FAST 112 Heroes programme, the same questionnaire with two amendments was administered again. The first of these was the omission of the question regarding personal experience about having contact with someone having a stroke (Question 7). The second was the inclusion of the question ‘Has your child (or grandchild or other individual) told you about participating in the “FAST 112 Heroes” programme at school and discussed stroke information with you?’ This additional question measured the extent to which children disseminated the knowledge acquired at school to their extended family. All items and materials were translated and adapted in Greek. There was a standard forward-backward translation procedure from English to Greek by a team of two health care clinicians (members of the research team) who knew both languages; the translation was then checked by one of the co-authors, who is bilingual and comprehends and speaks both English and Greek. This was done in order to ensure the quality of the translation.

To assess validity, two stroke experts (neurologists) assessed questions, answers and the level of knowledge that the public should possess. In addition, five staff members from the Department of Educational and Social Policy, at the University of Macedonia (Thessaloniki, Greece) aged between 22 and 57 years (mean age: 43.4 years) proofread the questionnaire in Greek for clarity and language accuracy. To ensure patient-friendly content, the two stroke survivors (patient-researchers) were involved in proofreading and adjusting the questionnaire. Such engagement ensured a patient-friendly element in question development. Available data support the view that patient involvement guarantees overall important benefits, maximising the potential for democratic accountability (Staniszewka, 2020).

As can be seen in Figure 1, the sample of the pre-implementation questionnaire included 240 adults (146 women, 60.8%; 94 men, 39.2%). Of the participants, 4 (1.7%) had graduated from primary school, 99 (41.3%) had graduated from high school, 96 (40.0%) had completed a university degree, and 41 (17.1%) had completed post-graduate degree (master’s degree or doctorate). Only 80 individuals however answered and returned the post-implementation questionnaire. The number of participants from extended families was small due to the short lead-in period (1 week after the programme completion) and contact method (children had to return the family-completed questionnaire to the classroom) selected by investigators. All questionnaire items were presented in Greek. Written consent was obtained from adult participants both for themselves and for their children. The study was conducted in line with the ethical commitments enshrined in the Declaration of Helsinki. Study approval was also obtained from the Committee for Research Ethics of the University of Macedonia (Thessaloniki, Greece) (14/15.06.2020)

Figure 1.

Flowchart detailing extended family participation before programme implementation and attrition following programme implementation.

Statistical analysis was conducted using IBM^© SPSS^© Statistics 25 (IBM). In this study, the Cronbach’s alpha for both the pre-implementation questionnaire and post-implementation questionnaire was .67 and .73, respectively. Α Kolmogorov–Smirnov test was used to check the normality of all variables. The test indicated that the responses did not follow a normal distribution (p = .000), so nonparametric statistical analysis took place. We performed a χ² test of independence to examine the relationship between (1) age, gender, educational level, having a friend or loved one who suffered a stroke in the past and (2) self-evaluation of stroke awareness, knowledge of the FAST acronym, stroke symptom(s), correct emergency number and appropriate response in case of witnessing a stroke. Changes in parental stroke knowledge were assessed using the Wilcoxon signed-rank test (p < .05).

Results

A total of 240 parents answered the pre-implementation questionnaire. Of them, 143 rated their knowledge of stroke between 1 and 2 out of 5 (59.6%), whereas 97 rated their knowledge between 3 and 5 out of 5 (17.4%) (Question 1). The mean of participants’ self-evaluation of stroke awareness was 2.20 out of 5 (SD = 1.29). With regards to the body part affected by stroke in Question 2, 237 (98.8%) answered correctly in the pre-implementation questionnaire.

Regarding the FAST acronym, 227 (94.6%) participants responded that they did not know what the letters represented (Question 3). Nearly half of the 240 participants recognised all three stroke signs (n = 109; 45.4%). The most frequent response for a correct indicator of stroke was incoherent speech (n = 217; 90.4%) (Question 4). Fewer respondents (n = 124, 51.2%) reported arm weakness as a stroke sign. Participants’ knowledge of the actions required when witnessing a stroke were answered correctly by 213 participants (88.8%), who selected calling an ambulance (Question 5). Regarding which emergency number to call, only 34 participants (14.2%) responded correctly, whereas, 102 (85.8%) responded incorrectly using a different number (e.g. the local police) (Question 6).

The relationship between the demographic data and the other stroke-related variables was examined. The chi-square test showed statistical significance between educational level and knowing how to respond appropriately in case of a stroke, χ²(3, 240) = 10.099; p = .018. Table 1 illustrates participants’ responses in calling an ambulance in relation to their education level. Those with a master’s degree had the highest proportion of correct answers (40 correct out of the 41 in total). In addition, the association between having someone close who had suffered a stroke in the past and being able to identify stroke symptoms was statistically significant, χ²(3, 240) = 23.358; p = .000.

Table 1.

Responses by education level for appropriate course of action in witnessing stroke, Northern Greece.

Responses	Elementary school (n, %)	Junior high and high school (n, %)	Bachelor’s degree (n, %)	Master’s or doctorate degree (n, %)	Total (n, %)
Call an ambulance	4 (100%)	91 (91.9%)	78 (81.3%)	40 (97.6%)	213 (88.8%)
Other response	0 (0%)	8 (9.1%)	18 (18.7%)	1 (2.4%)	27 (11.2%)
Total	4 (100%)	99 (100%)	96 (100%)	41 (100%)	240 (100%)

Out of the 80 parents who returned the post-implementation questionnaire, 77 (96.3%) said that they were informed by their children about their participation in the FAST 112 Heroes programme and discussed stroke information with them (Question 1). Regarding knowledge on the subject of stroke, 6 rated their knowledge between 1 and 2 out of a total of 5 (7.5 %) and 74 rated their knowledge between 3 and 5 out of a total of 5 (92.5%) (Question 2). The mean of participants’ self-evaluation of stroke awareness was 4 out of 5 (SD = 1.03). Eighty parents (100%) answered correctly in the post-implementation questionnaire about the body part affected by a stroke (Question 3). Regarding the FAST acronym, only 5 individuals (6.2%) responded in the post-implementation questionnaire that they did not know what the letters represent (Question 4): that is, 68 participants recognised all three stroke signs (85%) (Question 5). All participants (n = 80, 100%) responded correctly with regard to the appropriate course of action that needs to be taken when witnessing a stroke: that is, they selected the option of calling an ambulance (Question 6) and used the emergency number 112 (Questions 7).

A Wilcoxon Signed-Rank Test indicated that participants scored significantly higher in the post-implementation questionnaire than the pre-implementation questionnaire (p = .000) with respect to median scores in the extended family’s answers. This was consistent for most questions regarding stroke symptoms knowledge and awareness; the only exception was the one referring to the appropriate response in case of witnessing a stroke (Z = 0.00; p = 1.00) (Table 2).

Table 2.

Changes in extended family’s responses before and after participating in the educational programme.

Questions	BEI, %(n = 80)	AEI, %(n = 80)	p value
Self-evaluation rating regarding stroke • 1 • 2 • 3 • 4 • 5	3.8 32.5 35.0 25.0 3.7	3.8 3.7 15.0 47.5 30.0	.00
Knowledge of F.A.S.T. acronym 0 letters • 1 letter • 2 letters • 3 letters • 4 letters	80.0 5.0 7.5 3.8 3.8	6.3 – – 5.0 88.8	.00
Stroke symptoms • 0 symptom • 1 symptom • 2 symptoms • 3 symptoms	3.8 15.0 43.8 37.5	– – 15.0 85.0	.00
Adequate action when stroke onset • Call an ambulance	88.8	100	1.00
Emergency number preference • 112	40	100	.00

BEI: before educational implementation; AEI: after educational implementation.

Discussion

In earlier work, we showed that children 5–7 years of age recalled stroke information immediately after programme implementation and remembered it approximately one month later (Tsakpounidou et al., 2020). In this study, we found that kindergarteners can also serve as conduits of stroke information to their extended families. Family members self-evaluated their stroke knowledge using a 5-point Likert-type scale, rating their knowledge between 2 and 3 in the pre-implementation questionnaire. Previous literature has reported that the general public is poorly informed about stroke symptoms and the appropriate response in the event of a stroke (Hatzitolios et al., 2014). In keeping with other reports, the self-evaluation rates for stroke knowledge in this study were relatively low. In addition, the FAST acronym was correctly identified by 2.7% participants (Bäckström and Sundin, 2007; Williams et al., 2012; Williams and Noble, 2008). This aligns with our results, as quite a few participants were aware of the acronym’s meaning before implementation. After the implementation of the FAST 112 Heroes programme, nearly all participants reported high self-evaluation rates.

Almost half the participants (45.4%) in the current study identified the three most common stroke symptoms in the pre-implementation questionnaire. The most recognisable symptoms were speech disturbance, weakness on one side of the body and facial palsy, which corresponded well with other Greek results (Ntaios et al., 2015) and international studies (Amano et al., 2014; Ishigami et al., 2017; Lundelin et al., 2012; Williams and Noble, 2008; Yang et al., 2014). Regarding the correct response in case of witnessing a stroke, 9 of 10 participants (88.8%) in this study answered correctly by choosing the option of calling an ambulance. Results of previous literature indicate a correct response rate of between 50% and 90% (Hickey et al., 2018; Ishigami et al., 2017; Sakamoto et al., 2014; Sug Yoon et al., 2001). In a study conducted in Greece, 20 (68.7%) adult participants responded that they would call the ambulance in case of a stroke emergency (Ntaios et al., 2015). In the present study, children transferred stroke knowledge to their family and respondents’ knowledge of choosing the correct course of action – calling an ambulance – increased further: that is, by 20.1% more, compared to the earlier study conducted by Ntaios et al. (2015). This finding suggests that knowledge gains for the appropriate course of action in case of a stroke showed a significant upward in which trend in contrast to other studies’ primary normative data. Our results for pre-programme implementation awareness of the 112 European emergency number align with those in a European Commission Report at least 8 of 10 respondents said they would call a national emergency number in Greece (TNS Political & Social, 2013). Of the respondents, 40% noted that they would call 112, before participating in the programme, while the rest of the participants would call the National Emergency Centre number (Kotsiou et al., 2018). This suggests that the European emergency number for stroke is not common knowledge (TNS Political & Social, 2018 number). Thus, as expected, a low of participants chose the number 112, before implementation of the programme. Participants’ education level and knowing someone with a history of stroke are predictors of a high level of stroke awareness (Farrag et al., 2018; Giorli et al., 2019; Hosseininezhad et al., 2017 key). This is in agreement with the overall results of our questionnaire which suggest that education level plays a role in the ability to reach out for the requisite medical help (Rossnagel et al., 2004).

The most consistent result of our study was the unequivocal communication of stroke information from children to their parents. We documented an increase in the ability of parents to correctly recognise stroke symptoms as well as in the ability to respond quickly by choosing the appropriate emergency number in case of witnessing a stroke. Family communication of the kind encouraged by this study is a novel channel for public health education providing children with opportunities to enhance health literacy of their extended family (Williams et al., 2012). Such a strategy may offer a cost-effective alternative to big-budget mass media campaigns, whose effects are often short-lived. Further research is needed however to ascertain whether community settings such as schools constitute sustainable means of delivering stroke knowledge to specific subgroups (Rasura et al., 2014) and whether they are cost-effective.

Children in this study produced significant improvements in parental FAST mnemonic knowledge. According to Sopekan et al. (2020), the learning process is enhanced when children watch cartoons, because they can imitate what they learn and this influences how they relate to the world. In this study, cartoon superheroes were used to target young children (5–7 years old). Similar to the ‘Stroke 112’ campaign (Zhao et al., 2018), we maintained the European emergency number 112 in our programme’s methodology and matched each digit to one of the three basic stroke symptoms.¹ By combining the two elements, cartoon superheroes and an easily memorable acronym, stroke knowledge could be transferred by children to their extended family.

To the best of our knowledge, this is the first attempt to assess efficacy in stroke education among Greek adults (extended family). This study narrows the gap between successful informative campaigns like FAST and the stroke preparedness information. In the future, such knowledge could be expanded to mass educational programmes. Educational campaigns such as FAST 112 Heroes could be used to build a movement for change in health education policy in schools. We believe that this is of great societal importance, rather than using campaigns which explicitly target groups at high risk of suffering stroke(s) (Wolters et al., 2015).

Limitations

The present study has certain limitations. First, the effects of non-random attrition at the post-implementation questionnaire stage cannot be ruled out. Second, long-term knowledge retention must remain an open issue, as we examined only immediate post-programme knowledge. Third, the high number of participants who correctly selected the ‘brain’ as the body part which suffers during a stroke may be attributed to linguistic factors. The Greek word for brain is εγκέφαλος (/eŋgefalos/) and the Greek term for stroke is literally translated as ‘brain event’ or ‘brain episode’ (εγκεφαλικό επεισόδιο, /eŋgefaliko episoðio/). In other studies where the linguistic root for stroke does not match its localisation, less than half the answers were given correctly (Williams et al., 2012; Williams and Noble, 2008).

Conclusion

Findings from this study reveal how educating children can enhance family stroke knowledge. Learning about the symptoms of stroke as well as the importance of an immediate and correct response is beneficial in decreasing stroke-related disabilities. The success of this educational programme has implications for the future bringing together of teacher-led stroke training and family education. Enhancing stroke knowledge nationwide could lead to a future reduction in onset-to-hospital-door time.

Supplemental Material

sj-pdf-1-hej-10.1177_0017896921990406 – Supplemental material for Preschool children deliver stroke knowledge to their families with the FAST 112 Heroes educational programme

Supplemental material, sj-pdf-1-hej-10.1177_0017896921990406 for Preschool children deliver stroke knowledge to their families with the FAST 112 Heroes educational programme by Kalliopi Tsakpounidou and Hariklia Proios in Health Education Journal

Footnotes

Acknowledgements

We thank the Super Grand League Team as well as the two young volunteer individuals with a history of stroke for their interest in patient engagement and research to support stroke awareness and education. We also like to thank the parents/guardians of the children who enrolled in the FAST 112 Heroes, for participating in the programme. Finally, we thank Editage () for English language editing.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article. This work was supported by the Boehringer Ingelheim and Angels Initiative (Grant Number 395479, 2019).

ORCID iD

Hariklia Proios

Supplemental material

Supplemental material for this article is available online.

Notes

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