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Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

Systematic review of mass media interventions designed to improve public recognition of stroke... Background: Mass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear. Methods: Systematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development. Results: Ten studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised. Conclusions: Campaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated. Background the general public, stroke patients and those at increased Given the evidence of effectiveness of thrombolysis for risk of stroke [6,7] have concluded that knowledge of acute stroke and of stroke units, stroke should be trea- stroke symptoms is generally poor and although most ted as a medical emergency in the same way as myocar- recognise the need for an emergency response this may dial infarction [1-3]. However, many patients are seen not translate into action. A recent study reported that too late to benefit from early treatment, often because an adequate knowledge of stroke symptoms (i.e. three of a lack of knowledge or awareness of stroke symp- correct signs) is not associated with the intention to call toms, or lack of emergency response to them, on the emergency services in response to stroke [8]. part of both the public and professionals [4]. Other fac- A number of different interventions to improve tors such as a belief that the symptoms will subside or knowledge of stroke symptoms and the appropriate that nothing can be done may also play a part in delay action have been tested, for example, community stroke to presentation at hospital [5]. Reviews of studies asses- screening events, patient education programmes and sing levels of stroke knowledge and awareness among mass media campaigns. A drawback of screening events and patient education programmes is they often target * Correspondence: [email protected] small numbers of people from a specific group such as Institute of Health and Society, Newcastle University, Newcastle upon Tyne, those who have suffered, or are at risk of, a stroke when UK it is argued there is a need to target wider demographic Full list of author information is available at the end of the article © 2010 Lecouturier et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lecouturier et al. BMC Public Health 2010, 10:784 Page 2 of 10 http://www.biomedcentral.com/1471-2458/10/784 groups [9] and those who may be a witness to a stroke and, more importantly, behaviour (calling an emergency [10]. Mass media interventions, although more costly, ambulance to ensure rapid access to treatment). have the potential to reach a much larger audience. In light of the recent national stroke awareness cam- Mass media interventions have been successful in paign in the UK and the continued use of mass media reducing the use of tobacco [11], in improving road campaigns in other countries it is timely to review the safety by reducing drink and driving [12], and increasing effectiveness and development of these interventions. the use of safety belts [13]. However, in other health Other reviews in the area of stroke education have focused related areas they have had a small to moderate impact on stroke prevention [21] or have included a combination on behaviour change [14]. Considering acute myocardial of different types of interventions [22]. We were unable to infarction - similar to stroke in that the event should be identify any reviews examining the effectiveness and regarded as an emergency - the success of mass media design of mass media interventions to improve knowledge campaigns in changing behaviour at the onset of symp- of stroke symptoms and awareness of the need for an toms was mixed. Two reviews concluded that mass emergency response. In terms of reviewing the develop- media interventions had little impact on reducing delay ment of the intervention, we believe mass media cam- to presentation at hospital and the findings are difficult paigns are complex interventions - where often the aim is to interpret as most studies were methodologically to change behaviour and improve knowledge - and should flawed [15,16]. Neither review commented on the qual- adhere to the structured development and evaluation as ity of, or theoretical base for, intervention development. suggested by the MRC Framework [23]. The evidence base for mass media campaigns more The aims of this study are to: widely is itself limited; a Cochrane systematic review included 15 studies evaluating mass media campaigns � conduct a systematic review to assess the effective- designed to increase health service utilisation, all inter- ness of mass media campaigns in changing knowl- rupted time series, and of variable methodological qual- edge (stroke symptoms/signs and need for ity [17]. The authors concluded that, despite limitations, emergency access), behaviour (access to emergency there was evidence that such campaigns may have “an services) or early treatment with thrombolysis. important role in influencing the use of health care � examine the methods and theoretical basis for interventions” but that “further research... is needed on development of the interventions using the MRC whether mass media coverage brings about appropriate Framework guidance. use of services in those patients who will benefit most”. It has been argued that adhering to the principles of Methods effective campaign design has led to an increase in the Search strategy success of mass media campaigns over the years [18]. The Cochrane Stroke Group search terms for stroke The major principles of good design are as follows: gain [24] were used along with other terms developed, tested an understanding of the target audience in terms of the and then agreed by the study team and adapted for each problem behaviour, their preferred message and the database (Additional File 1). Searches were conducted in most effective means of delivering that message, through ten electronic databases (MEDLINE, EMBASE, exploratory research; use theory to identify the focus of CINAHL, Web of Knowledge, CSA Ilumina - ASSIA, the campaign message; to achieve maximum effective- Sociological Abstracts -, PsycInfo, ZETOC, AgeInfo and ness, segment the audience to create groups with similar FRANCIS) from 1980 to 2010, the Cochrane Library message preferences; design the message from the find- (1980-2010), EPPI-Centre database and National ings of the exploratory research and choose the channels Research Register. Manual searches through the refer- most widely viewed by the target group; evaluate and ence lists of papers were also carried out. monitor the process of campaign activities; use a rigor- ous design to evaluate the intervention such as time ser- Inclusion and exclusion criteria ies and controlled before and after designs [18]. Primary studies in English evaluating the effectiveness of In England, as part of the national stroke strategy [19], mass media interventions were included; where relevant, the Department of Health recently implemented a related papers were obtained to gather information on the national mass media campaign to promote public aware- methods of intervention development. Studies were ness of stroke symptoms and of the need for emergency selected according to the following criteria: (a) targeted response using the FAST (Face, Arm Speech, Time) test groups: the general public aged 18 or over; (b) outcomes: [20]. Implementation of this campaign begs an impor- knowledge of stroke symptoms and, awareness of the need tant question about the evidence base for the effective- for an emergency response, rates of acute stroke treat- ness of mass media campaigns in this specific area in ments, andtimeto presentationathospital; (c)design: changing knowledge of stroke (signs and symptoms) randomised controlled trials (RCTs), quasi-experimental Lecouturier et al. BMC Public Health 2010, 10:784 Page 3 of 10 http://www.biomedcentral.com/1471-2458/10/784 studies, controlled (CBA) and uncontrolled before and controlled before and after design [30,31]. Campaign after (BA) studies and interrupted time series (ITS). Inter- population coverage ranged from 80,000 to 5 million. ventions aimed solely at health professionals were The minimum duration of the intervention was two 10 excluded, but those that targeted both the general public week periods, the maximum 18 months. The longest and health professionals were included. period between the end of the campaign and outcome measurement was six months [27], the shortest one Data extraction month [26]. The majority collected post-intervention Titles and abstracts were screened to identify studies of data at only one point but one did so during and imme- likely relevance and full papers obtained. A structured diately following two campaigns and then six months form was used to determine study inclusion. Two later after the end of the second campaign [27]. One reviewers (JL, HR) extracted data from the final papers study [29] appears to have repeated their intervention in into structured tables. The results are presented as a nar- a different county in USA with the addition of the dis- rative synthesis as the interventions varied in their format tribution of written educational materials and a control and presentation, were evaluated using different methods group [31]. and outcomes, and included a range of study populations. Controlled before and after studies In Ontario, Canada, Silver et al. [30] evaluated an 18 Review of intervention development using the MRC month campaign of continuous high level TV advertis- Framework ing, intermittent TV advertising and newspaper adver- Intervention development for each study was classified tisements in each of three communities. A fourth using the five key phases suggested in the MRC Frame- community acted as a control and received only Heart work for evaluating complex interventions [25] as follows. and Stroke Foundation Public Service Announcements. Telephone interviews were conducted using random Preclinical phase to identify the evidence to support digit dialling; only residents aged 45 and over were the type of intervention: this could be from a sys- interviewed. Quota sampling was used to ensure equal tematic review or identifying or developing relevant numbers of males and females and that at least one theory third of participants were aged 65 and over. The Phase 1 Modelling the processes and outcomes of authors hoped to target men, older people and those the intervention in lower socioeconomic groups and hypothesised that Phase 2 Exploratory trial to test out the intervention television would be the most appropriate medium. The and outcome measures outcome of interest was knowledge of symptoms and Phase 3 Definitive RCT signs, but not emergency response. At three months Phase 4 Long term implementation post-intervention there were significant improvements in groups exposed to both high intensity and low level These phases were entered into a matrix. Each study television advertising but not to newspaper inserts. was examined, using the information from all relevant There was a significant decrease in the control group, published articles, to determine how the intervention an unexpected finding and one which the authors were was developed and evaluated; a summary of the process unable to explain. The television interventions had a was recorded into the matrix under the appropriate significant positive impact on younger (aged 45-64 phase. This enabled the team to examine across studies years) respondents (p = 0.0001) and those with less the extent to which the intervention development and than a secondary school education (p < 0.05), but did evaluation was in line with the guidance recommended not increase knowledge of stroke symptoms in those in the MRC Framework. aged 65 or over, the age group at greatest risk of stroke and most likely to witness a stroke. The low Results intensity television intervention was the most cost- Ten mass media intervention studies met the inclusion effective method of raising awareness (measured by the criteria and were included in the review (Figure 1). Six gross rating points per percentage point change in out- targeted the public [26-31] and four both public and come). This study was interesting in that, unlike the professionals [32-35]. Study characteristics for the ten other studies, the team were able to examine the effec- included studies are summarised in Additional File 2 tiveness of different media. One shortcoming was that and the results of evaluations in Additional File 3. the advertisements did not promote the need for an emergency response and numbers calling emergency Public only interventions services or attending hospital with suspected stroke Six mass media campaigns with patient reported out- were not measured. The study was underpowered and comes were reviewed [26-31]. Two studies used a this precluded examination of the effects of past Lecouturier et al. BMC Public Health 2010, 10:784 Page 4 of 10 http://www.biomedcentral.com/1471-2458/10/784 Records identified through Additional records identified database searching through other sources (n =4959) (n =3) Records after duplicates removed (n = 3940) Records screened Records excluded (n =3825) (n=3780) Full-text articles excluded, Full-text articles assessed as not mass media for eligibility interventions (n =45) (n =35) Studies included in qualitative synthesis (n =10) Studies included in quantitative synthesis (meta-analysis) (n =0) Figure 1 PRISMA flow diagram of search results. medical history or presence of stroke risk factors on weekly newsprint advertisements for the duration of the stroke knowledge. intervention. The television advertisements covered: Fogle et al. [31] compared awareness of stroke warn- stroke warnings signs and the need for an emergency ing signs and of the need for an emergency response response; a three step stroke test on identifying a stroke; between a group in Flathead County, exposed to 2 × 10 hospital staff reinforcing the need for an emergency week mass media campaigns, and a control group in a response to stroke; and brain cell death following a Gallatin County, Montana. There was a two-month gap stroke when treatment is delayed. The radio and news- between the end of the first and beginning of the second print advertisement ran along similar lines. Educational campaign. The target audience for the campaign was materials were posted to community doctors and phar- those aged 45 years and over. The campaign consisted macies, churches and care homes for older people; a of four television and three radio advertisements and stroke information brochure and magnet were posted to Eligibility Included Screening Identification Lecouturier et al. BMC Public Health 2010, 10:784 Page 5 of 10 http://www.biomedcentral.com/1471-2458/10/784 households with residents in the target age group. The witnessed a stroke, despite this being a major focus of control county received no campaign information. Tele- the campaign. Post-intervention outcomes were col- phone surveys were conducted with residents aged 45 lected at one month after the end of the campaign so years and older in both counties, using sequential ran- little can be said about the impact of the intervention in dom digit dialling, before and after the campaign. It was the longer term. In addition, although the message was not clear at what point pre- and post- campaign the tel- to promote an emergency response to stroke, only a ephone surveys were conducted. Following the campaign change in a person’s intention to act rather than an there was a statistically significant increase in those in actual change in behaviour could be measured. the intervention group (regardless of sex or age) who In Mainz, Germany Marx et al. [28] reported the could correctly identify twoormorestrokewarning impact of a mass media campaign of three months’ signs (p ≤ 0.05): this increase was significant for those duration. The intervention consisted of: billboard and who had two or more self reported risk factors for poster advertisements with short slogans; stroke interest stroke (p ≤ 0.05). There was no significant change in stories, slogans and interviews in local newspapers; stor- intention to call emergency services should they experi- ies, reports and interviews on television and radio; pub- ence or witness a stroke. A higher proportion post-cam- lic events; flyers sent to every household; and a stroke paign would call emergency services if they experienced guide distributed at the public events and through hos- or witnessed the symptom of numbness (p ≤ 0.05) or pital and family doctors. Telephone surveys were con- any of the three symptoms (speech difficulties, numb- ducted two months pre- and three months post- ness or paralysis) (p ≤ 0.05). There were no statistically intervention with German speaking residents, using ran- significant increases of awareness of stroke warning dom digit dialling. There was no change in spontaneous signs or need for an emergency response in the control recall of symptoms or signs but when presented with a county group between the first and second surveys. list (non-spontaneous recall) there was a significant There was a statistically significant increase in recall increase in the proportion who, could correctly identify across all stroke campaign media (television, radio and ‘paresis or weakness’ as astrokesymptom (p <0.01). newsprint) regarding stroke warning signs and the Therewas littlechangeinthose whowould respondto stroke test after the campaign but a smaller percentage a stroke as an emergency, albeit with a high baseline recalled the advertisement for stroke test (television (82%). This was the most comprehensive campaign 32%; radio 16%; newsprint 21%) than the one for warn- using a greater variety of media than the other studies, ing signs (television 71%; radio 32%; newsprint 43%). but it is not possible to determine which component Although this campaign promoted an emergency had the greatest impact. Respondents were asked which response to stroke, as with the previous controlled study information source they remembered but this may not they did not measure whether this had any impact on have been the medium that was effective in increasing behaviour when a stroke was suspected: in time to pre- awareness. A strength of this study was the use of both sentation to hospital or increased use of emergency ser- spontaneous and non-spontaneous recall, as it may be vices. Because of the design of the study the team are argued that the former may underestimate and the latter unable to demonstrate whether or not one particular may overestimate levels of knowledge; the authors could media is more successful at increasing awareness of compare the responses using both methods. stroke symptoms. In Ontario, Canada, Hodgson et al. [27] assessed the Uncontrolled before and after studies impact of two television advertising campaigns, of nine Becker et al. [26] assessed the impact of a five month and eight months’ duration, conducted by the Heart and campaign on Washington, USA, residents’ level of stroke Stroke Foundation. The campaigns were aimed at people knowledge and on proposed action on witnessing a age 45 years and older and illustrated five stroke warning stroke. The five month campaign targeted people aged signs (weakness, trouble speaking, vision, headache and 65 years and over and consisted of: public service dizziness) with an overlaying stamp reading “sudden”.A announcements and public interest stories on television; voiceover encouraged viewers to call 911 or their local advertisements and stroke interest stories in newspapers; emergency number if they experienced any of the symp- and public stroke screenings and flyers. Telephone inter- toms. Six telephone surveys were conducted with a sam- views were conducted with residents who could speak ple of Ontarians aged 45 and over using random digit English. Participants were selected using random digit dialling. These were carried out: two months prior to, dialling. One month after the end of a campaign, using during and immediately following the first campaign; and both television and newspapers, respondents were more during, immediately following and six months after the likely to know at least one symptom of stroke than one second campaign. The team also recorded emergency month before the campaign (p = 0.032). However, fewer department visits from three months pre- to six months (non-significant) would call emergency services if they post-intervention (31 months). There was an increase in Lecouturier et al. BMC Public Health 2010, 10:784 Page 6 of 10 http://www.biomedcentral.com/1471-2458/10/784 those who could name two or more symptoms (p < The community intervention consisted of billboard 0.001) and in the mean number of symptoms named (p < advertising, radio and television public service 0.001). However, six months after the end of the second announcements, news stories, brochures and posters. campaign, there was a decrease in those who could name Also, volunteers were trained in stroke recognition and two or more symptoms and in the mean number of appropriate action; these volunteers then trained others. symptoms named (p < 0.001). There was also a signifi- The intervention did not appear to target any specific cant increase in the mean number of emergency depart- group. A comparison control community was selected ment visits for stroke and TIA in campaign months with hospitals matched with the intervention commu- compared to non-campaign months (p < 0.01), but the nity and with similar demographic characteristics but in individual contribution of thecampaigntothisina a different media area. The health professional interven- regression model for stroke was small, explaining 9% of tion consisted of news stories and newsletters, highlight- the variance for total visits, 15% for visits within five ing successes and accomplishments in stroke treatment. hours, 5% for visits within 2.5 hours, although 30% for In addition hospital teams developed emergency depart- TIAs. Due to the decrease in awareness of symptoms in ment protocols, scheduled continuing medical education the five month period following the end of the interven- and mock ‘stroke codes’ for staff. Outcome measures tion the authors conclude that continuity of exposure to were rtPA treatment rates and time to presentation, and the campaign is important in maintaining and increasing data were collected at baseline and during the stroke awareness. interventions. Fogel et al. [29] conducted a study in Missoula The use of rtPA increased in all patients in the inter- County, USA of television, radio and newsprint adver- vention community (p = 0.01) with no change in the tisements targeting residents aged 45 and over. There control (p = 1.00). There was no change in time to hos- were four different television advertisements: warning pital presentation that could be ascribed to the interven- signs and the need for an emergency response; a three tion. Time to presentation to hospital decreased in both step test if a stroke is suspected; stroke risk factors; and communities, yet treatment rates increased only in the what happens to the brain when treatment is delayed. community receiving the intervention. This would sug- Radio and newsprint advertisements contained messages gest that the main impact may have been on profes- on stroke signs, the stroke test and the need for an sionals rather than on the public. However, it may be emergency response. The campaign ran for two 10 week that the community mass media campaign, which was periods, three months apart. Telephone surveys were inextricably linked to the professional campaign, also conducted before and after the campaign (times not contributed to the professional behaviour change, specified) using random digit dialling with residents though this is not possible to disentangle. A later study aged 45 and over. There was a significant increase in showed no significant increase in presentation within the mean number of correctly identified symptoms (p < two hours of onset, but did show increases in rtPA 0.05), and the ability to name two or more in both treatment rates that were sustained beyond the interven- women and men, and in those aged 45 and over (total tion, suggesting that the impact was on professional 84% after compared to 67% before). There was a signifi- awareness and service organisation rather than public or cant increase (p < 0.05) in those reporting that they patient awareness, despite a well developed public cam- would call emergency services if they experienced sud- paign[36] den speech problems (p < 0.05), numbness or loss of Uncontrolled before and after studies sensation (p < 0.05) or paralysis that did not go away (p In Durham, North Carolina, USA Alberts et al [32] eval- < 0.05) but not if they witnessed a stroke. uated the impact of interventions conducted to improve recruitment to a trial of t-PA (tissue-type plasminogen Interventions targeted at both the public and health activator). To target the community, features were professionals broadcast on television and radio where the use of t-PA Four papers evaluated studies where the public and was discussed, the need for early treatment was empha- health care professionals were both targeted [32-35]. sised and stroke symptoms were described. Newspaper Two studies were conducted as part of recruitment stra- articles were published covering the same points. For tegies in clinical trials of thrombolysis [32,33]. Only one health professionals, the intervention consisted of pre- study used a controlled before and after design [34], sentations about the t-PA study by specialists in local Controlled before and after studies and regional hospitals and at medical group meetings, In five East Texas counties, Morgenstern et al. [34,36] and letters (with the study protocol) sent to local and implemented two interventions of 15 months’ duration regional physicians. The interventions were of three to increase the proportion of patients treated with months’ duration. The outcomes of interest were time thrombolysis following licensing of rtPA in the USA. of presentation to hospital and data were collected from Lecouturier et al. BMC Public Health 2010, 10:784 Page 7 of 10 http://www.biomedcentral.com/1471-2458/10/784 14 months pre- to 12 months post-intervention. There significantly increased (from 42.2 to 45.8 minutes, p < was an increase in the number of patients with cerebral 0.01), as a result of increased time spent on scene and infarction who presented to hospital within 24 hours of time from scene to hospital, but overall the median symptom onset in the 12 months after the campaign (p increase was only 3.6 minutes. Impact on treatment < 0.00001). This study was conducted over 10 years ago rates was inconsistent across hospitals. Prior to the before the widespread availability of t-PA and they do intervention, two of the six study hospitals did not treat not report on presentation within the early hours fol- any strokes with rtPA; afterwards all hospitals did so lowing stroke. and treatment rates ranged from 6.8% to 17.2%. During Barsan et al’s [33] study, linked to the NIH Tissue the intervention four hospitals increased the number of Plasminogen Activator Pilot Study, evaluated a public rtPA treatments - in only one was this statistically sig- campaign and professional educational programme in nificant (p = 0.047) - and in two there was a reduction. three US states. The public campaign focused on stroke symptoms and the need for an emergency response, and Review of intervention development using the MRC entailed public service announcements and interviews Framework broadcast on television and radio and in newsprint. In None of the studies reported that the intervention had relation to health professionals, each participating centre an identified theoretical base. For the majority there was developed an educational programme. These included no description of intervention development and no informational mailings, training programmes and educa- mention of any modelling and exploratory or pilot work tional lectures. The duration of the interventions were to test the processes [26-30,32,33,35]. A number not specified. Outcome data on time to presentation selected the design as they believed it had been effective and number of stroke related emergency calls were col- in earlier campaigns of stroke education [28,30] or fol- lected for 30 months from the time the intervention lowed on from previous work [27,31]. Only one study commenced. They found a significant decline in the had conducted any developmental work prior to the mean time of presentation to hospital during the inter- launch of the campaign [34]; in Phase 1 of the study, vention (p < 0.05), but no change in time to first medi- focus groups with stroke patients and carers and a tele- cal contact. The authors argue that use of emergency phone survey of the general population were conducted telephone call was the most likely explanation for this; to identify factors that might delay hospital presentation; although this varied across sites. Those travelling by these study authors also created a community advisory ambulance arrived earlier than those using other trans- board to support intervention development. port. A number of hospitals joined the project during the measurement period complicating analysis and Discussion interpretation. Again this study was conducted over This review has focused on evaluations of mass media 10 years ago before the widespread availability of rt-PA interventions designed to increase public recognition of but they are able to report on time to presentation from stroke symptoms, the emergency response to stroke and under one hour to 24 hours. early intervention. This is particularly pertinent when In Houston, Texas, Wojner-Alexandrov et al. [35] national mass media campaigns, such as the stroke assessed the impact of a 12 month community and awareness campaign (FAST) in England [20], are being health professional education intervention. In the com- funded and widely implemented. munity intervention television, radio and newsprint were used to convey information on the identification of Public only interventions stroke warning signs and the designation of stroke cen- Included studies evaluating public only interventions tres. In addition community stroke screening events used a range of methods within their mass media cam- were held. No target group within the community was paigns. Out of the six studies only two had a control specified. For professionals, monthly education sessions group [30,31]; therefore it is not possible to determine if were held for paramedic and hospital staff; also the Los any changes were due to the campaign in the uncon- Angeles Pre-Hospital Stroke Scale was implemented trolled studies. Only two employed a representative with paramedics for use in diagnosing stroke. For six population sampling strategy to evaluate impact [27,30]. months prior to and for the duration of the interven- Effectiveness was evaluated by telephone surveys, tion, paramedic diagnostic accuracy, time of presenta- thereby excluding members of the community without tion to hospital and thrombolysis rates were measured. access to, or unable to use, a telephone, possibly older There was an increase from 74 patients admitted per people and those with communication difficulties. Only month to 89 per month during the intervention phase one of the studies collected data on stroke admissions (p < 0.001). Paramedic diagnostic accuracy also and time to presentation [27]; the rest were not able to increased (statistics were not reported). Transport times demonstrate whether increased knowledge translated Lecouturier et al. BMC Public Health 2010, 10:784 Page 8 of 10 http://www.biomedcentral.com/1471-2458/10/784 into the appropriate action on witnessing or experien- Given the complexity of interventions and the dual cing a stroke. All used free recall of stroke symptoms nature (public and professional) of these four studies it which may underestimate the level of awareness; how- is very hard to disentangle any active components that ever one study also used assisted recall and found might explain any reported impact. This is a feature increased knowledge of only one specific symptom post- noted in the Cochrane systematic review evaluating intervention [28]. Some campaigns may have been con- mass media campaigns designed to increase health ser- taminated by other low level stroke education, such as vice utilisation, incorporating 15 interrupted time series public service announcements, making it difficult to studies [17]; nonetheless this concluded that “those attribute any changes to the intervention [26,28-30]. engaged in promoting better uptake of research infor- As stated earlier, only two studies used a more robust mation in clinical practice should consider mass media design and included a control arm. Unfortunately, one as one of the tools that may encourage the use of effec- was underpowered and did not target or measure aware- tive services and discourage those of unproven effective- ness of the need for an emergency response [30]. The ness”. As with our conclusions specific to stroke, the other controlled study was a repeat of an earlier cam- authors stated that it was “difficult to determine extent paign [29] in a different county but with the addition of [of change] attributable to changes in health care provi- distributed written educational materials and a control ders or consumers” given that many targeted both pub- county [31]. The second controlled campaign revealed a lic and professionals. lower percentage point increase in awareness of stroke symptoms and intention to call emergency services if Intervention design they experienced or witnessed specific stroke symptoms Despite the importance of a theoretical base and early than in the first uncontrolled study (Additional File 3). stage research in the design of the intervention [18] As there were no significant changes in the control only one study described conducting exploratory work community it can be concluded that any increases to identify factors that may have influenced people from demonstrated, albeit modest, were more likely to be as a seeking emergency medical care at the onset of stroke result of the intervention. symptoms [34]. Nevertheless the findings from that Data on the longer term retention of stroke knowledge study indicate that any increase in thrombolysis rates of symptoms and signs was poor in most of the studies. were most probably due to the component of the inter- Only one study collected outcomes six months after the vention targeting health professionals rather than those end of the campaign to assess longer term impact and in the community. Had the team carried out an explora- found that knowledge declined post- intervention [27]. tory trial to test the intervention in the community they It is impossible to assess the longer term impact, or to may havebeen abletorefineit accordinglyand influ- know whether or when an intervention should be ence time to presentation at hospital. repeated, unless evaluations measure impact at a range A few conducted their community campaigns based of time points following intervention. on the results of earlier ones [28,30] even when the Overall, the impact of these interventions was incon- impact on the community was not determined [34] and sistent. Nonetheless, all showed some significant any improvement in awareness of stroke symptoms was increase in awareness of symptoms but little impact on not measured beyond one month post-intervention [26]. the awareness of the need for, or intention to call, an emergency response, although baseline levels were high. Limitations In view of the fact that these campaigns have failed to There are limitations to this review as a result of the increase awareness of the need for an emergency range of methods and study designs employed in the response to stroke [26,28,29,31] or prompt those experi- included studies. Only three studies used a controlled encing a stroke to present at hospital immediately [27] before and after design [30,31,34], limiting the conclu- further research is warranted to explore people’svalues sions that can be drawn. Of the ten studies only the lat- and beliefs in relation to stroke. ter three would be accepted as valid for inclusion in a systematic review by the Cochrane Effective Practice Public and professional interventions and Organisation of Care Group [37]. Therefore it is The public and professional campaigns largely focused not possible to state with any degree of confidence on outcomes of time to hospital and thrombolysis rates whether any changes identified were attributable to the [32-35]. Measures of time to arrival varied across stu- intervention or to other factors. Few studies had pre- dies. Two of the studies were over 10 years old and specified primary outcome measures and several used were part of a drive to increase recruitment into trials multiple analyses. None of the studies used qualitative of r-PA and most of the professional intervention methods (such as interviews with participants) to help appeared to be aimed at raising awareness of the trial. understand their findings [38]. There was very little Lecouturier et al. BMC Public Health 2010, 10:784 Page 9 of 10 http://www.biomedcentral.com/1471-2458/10/784 reporting of the theoretical or empirical basis of inter- Unlike other interventions, such as stroke patient educa- ventions, or of their development methods, as recom- tion and community stroke screening programmes, mass mended by the MRC Framework for development and media campaigns have the potential to improve knowl- evaluation of complex interventions; it appears that few edge and awareness and change the behaviours of a studies have built upon earlier, potentially promising, large number of people. We would urge future develo- interventions. pers of mass media campaigns to consider a more struc- One published study not included in this review tured approach, such as that recommended in the MRC reported the development and piloting of an educational Framework for the Development and Evaluation of kit (Stroke Heroes Act FAST animation, brochure and Complex Interventions [23]. poster) designed to improve knowledge of the symptoms of stroke and the need for emergency action using the Additional material FAST acronym [39]. The materials from this educational kit have been used in 28 countries. In Massachusetts Additional File 1: Search Terms for Medline. they have been used in mass media campaigns and eval- Additional File 2: Characteristics of Included Studies. uated through telephone surveys [40] and claim to have Additional File 3: Results of Evaluations. significantly improved knowledge of symptoms and the need for emergency response, but these results do not appear to have been published in peer reviewed journals. Acknowledgements We thank Martin Eccles for advice on methods and for comments on drafts, and Terry Lisle for clerical support. This work is part of a research Conclusions programme - Developing and Assessing Services for Hyperacute stroke In conclusion, although some studies showed increases (DASH) - funded by the National Institute for Health Research (Ref: RP-PG- in symptom awareness and awareness of need for emer- 0606-1241). The views and opinions expressed here are those of the authors gency response, and increased use of emergency trans- and do not necessarily represent those of the NHS, National Institute for Health Research and Department of Health. port, none show a full picture of increased awareness, increased use of emergency response, shorter time to Author details arrival and increased use of thrombolysis following a Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. Institute for Ageing and Health (Stroke Research Group), Newcastle mass media campaign. There is clearly a need for more University, Newcastle upon Tyne, UK. Medical and Social Care Education, robust evaluation of such campaigns using studies with Leicester University, Leicester, UK. at least a controlled before and after design, and includ- Authors’ contributions ing qualitative methods to support understanding of any JL conducted the searches and electronic sifting of titles and abstracts. JL demonstrated impact and to help unpick the elements and HR independently reviewed the retained papers and extracted data. JL of any campaign that might be important. The nation- and RT wrote the first draft of the manuscript. All authors commented on the first draft and all revisions. wide campaign in England implemented in February 2009 offered an opportunity to do this, but unfortu- Competing interests Authors JL, MM, HR, MW and RT have no competing interests. GF has nately there is no such robust evaluation in progress, consultancy relationships with Boehringer Ingelheim and Lundbeck, grants/ despite considerable investment of public resources [20]. grants pending from Servier Pharmaceuticals, Lundbeck and Mitsubishi, The Department of Health website reports a 55% payment for development of educational presentations including service on speakers’ bureaus from Boehringer Ingelheim and travel/accommodations increase in emergency calls for stroke following cam- expenses covered or reimbursed by Boehringer Ingelheim that might have paign implementation but no further details are pro- an interest in the submitted work in the previous 3 years. vided [41]. When campaigns are evaluated, such as Received: 2 July 2010 Accepted: 23 December 2010 those using the Stroke Heroes Act FAST materials [40], Published: 23 December 2010 there is a need for the results to be published in peer reviewed journals. 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Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan W: 2001, 21(4S):48-65. Sustained benefit of a community and professional intervention to 14. Wakefield MA, Loken B, Hornik RC: Use of mass media campaigns to increase acute stroke therapy. Archives of Internal Medicine 2003, change health behaviour. Lancet 2010, 376:1261-1271. 163:2198-2202. 15. Caldwell MA, Miaskowski C: Mass media interventions to reduce help- 37. Cochrane Effective Practice and Organisation of Care Review Group. seeking delay in people with symptoms of acute myocradial infarction: Data Collection Checklist. [http://epoc.cochrane.org/sites/epoc.cochrane. time for a new approach? Patient Education and Counseling 2002, 46:1-9. org/files/uploads/datacollectionchecklist.pdf]. 16. Kainth A, Hewitt A, Sowden A, Duffy S, Pattenden J, Lewin R, Watt R, 38. Pope C, Mays N: Critical reflections on the rise of qualitative research. 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Prevention&sid=Eeohhs2&b=terminalcontent&f=dph_com_health_heart_ 19. Department of Health. National Stroke Strategy. Department of Health stroke_c_stroke_signs_symptoms&csid=Eeohhs2]. Publications, London; 2007. 41. Department of Health. Stroke calls up by over half following ACT F.A.S.T. 20. Department of Health. Stroke: Act F.A.S.T. awareness campaign. [http:// Campaign. [http://www.dh.gov.uk/en/News/Recentstories/DH_107996]. www.dh.gov.uk/en/News/Media/DH_108503]. 21. Wilson DL, Beyth RJ, Linn P, Berger P: Systematic review of public Pre-publication history education and policy for stroke prevention. Current Drug Targets 2007, The pre-publication history for this paper can be accessed here: 8:847-879. http://www.biomedcentral.com/1471-2458/10/784/prepub 22. Payne GH, Fang J, Fogle CC, Oser CS, Wigand DA, Theisen V, Farris RP: doi:10.1186/1471-2458-10-784 Stroke awareness: surveillance, educational campaigns and public health Cite this article as: Lecouturier et al.: Systematic review of mass media practice. Journal of Public Health Management and Practice 2010, interventions designed to improve public recognition of stroke symptoms, 16:345-358. emergency response and early treatment. BMC Public Health 2010 10:784. 23. Medical Research Council. Developing and evaluating complex interventions: new guidance. [http://www.mrc.ac.uk/ complexinterventionsguidance]. 24. The Editorial Team. Cochrane Stroke Group. About The Cochrane Collaboration (Cochrane Review Groups (CRGs)). 2009, , 4: STROKE. 25. MRC Health Services and Public Health Research Board. A framework for Submit your next manuscript to BioMed Central development and evaluation of RCTs for complex interventions to and take full advantage of: improve health. Medical Research Council; 2000. 26. Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T: • Convenient online submission Community-based education improves stroke knowledge. Cerebrovascular Diseases 2001, 11:34-43. • Thorough peer review 27. Hodgson C, Lindsay P, Rubini F: Can mass media influence emergency • No space constraints or color figure charges department visits for stroke? Stroke 2007, 38:2115-2122. • Immediate publication on acceptance 28. Marx JJ, Nedelmann M, Haertle B, Dieterich M, Eicke BM: An educational multimedia campaign has differential effects on public stroke • Inclusion in PubMed, CAS, Scopus and Google Scholar knowledge and care-seeking behavior. Journal of Neurology 2008, • Research which is freely available for redistribution 255:378-384. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Public Health Springer Journals

Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

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Springer Journals
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Copyright © 2010 by Lecouturier et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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1471-2458
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10.1186/1471-2458-10-784
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21182777
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Abstract

Background: Mass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear. Methods: Systematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development. Results: Ten studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised. Conclusions: Campaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated. Background the general public, stroke patients and those at increased Given the evidence of effectiveness of thrombolysis for risk of stroke [6,7] have concluded that knowledge of acute stroke and of stroke units, stroke should be trea- stroke symptoms is generally poor and although most ted as a medical emergency in the same way as myocar- recognise the need for an emergency response this may dial infarction [1-3]. However, many patients are seen not translate into action. A recent study reported that too late to benefit from early treatment, often because an adequate knowledge of stroke symptoms (i.e. three of a lack of knowledge or awareness of stroke symp- correct signs) is not associated with the intention to call toms, or lack of emergency response to them, on the emergency services in response to stroke [8]. part of both the public and professionals [4]. Other fac- A number of different interventions to improve tors such as a belief that the symptoms will subside or knowledge of stroke symptoms and the appropriate that nothing can be done may also play a part in delay action have been tested, for example, community stroke to presentation at hospital [5]. Reviews of studies asses- screening events, patient education programmes and sing levels of stroke knowledge and awareness among mass media campaigns. A drawback of screening events and patient education programmes is they often target * Correspondence: [email protected] small numbers of people from a specific group such as Institute of Health and Society, Newcastle University, Newcastle upon Tyne, those who have suffered, or are at risk of, a stroke when UK it is argued there is a need to target wider demographic Full list of author information is available at the end of the article © 2010 Lecouturier et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lecouturier et al. BMC Public Health 2010, 10:784 Page 2 of 10 http://www.biomedcentral.com/1471-2458/10/784 groups [9] and those who may be a witness to a stroke and, more importantly, behaviour (calling an emergency [10]. Mass media interventions, although more costly, ambulance to ensure rapid access to treatment). have the potential to reach a much larger audience. In light of the recent national stroke awareness cam- Mass media interventions have been successful in paign in the UK and the continued use of mass media reducing the use of tobacco [11], in improving road campaigns in other countries it is timely to review the safety by reducing drink and driving [12], and increasing effectiveness and development of these interventions. the use of safety belts [13]. However, in other health Other reviews in the area of stroke education have focused related areas they have had a small to moderate impact on stroke prevention [21] or have included a combination on behaviour change [14]. Considering acute myocardial of different types of interventions [22]. We were unable to infarction - similar to stroke in that the event should be identify any reviews examining the effectiveness and regarded as an emergency - the success of mass media design of mass media interventions to improve knowledge campaigns in changing behaviour at the onset of symp- of stroke symptoms and awareness of the need for an toms was mixed. Two reviews concluded that mass emergency response. In terms of reviewing the develop- media interventions had little impact on reducing delay ment of the intervention, we believe mass media cam- to presentation at hospital and the findings are difficult paigns are complex interventions - where often the aim is to interpret as most studies were methodologically to change behaviour and improve knowledge - and should flawed [15,16]. Neither review commented on the qual- adhere to the structured development and evaluation as ity of, or theoretical base for, intervention development. suggested by the MRC Framework [23]. The evidence base for mass media campaigns more The aims of this study are to: widely is itself limited; a Cochrane systematic review included 15 studies evaluating mass media campaigns � conduct a systematic review to assess the effective- designed to increase health service utilisation, all inter- ness of mass media campaigns in changing knowl- rupted time series, and of variable methodological qual- edge (stroke symptoms/signs and need for ity [17]. The authors concluded that, despite limitations, emergency access), behaviour (access to emergency there was evidence that such campaigns may have “an services) or early treatment with thrombolysis. important role in influencing the use of health care � examine the methods and theoretical basis for interventions” but that “further research... is needed on development of the interventions using the MRC whether mass media coverage brings about appropriate Framework guidance. use of services in those patients who will benefit most”. It has been argued that adhering to the principles of Methods effective campaign design has led to an increase in the Search strategy success of mass media campaigns over the years [18]. The Cochrane Stroke Group search terms for stroke The major principles of good design are as follows: gain [24] were used along with other terms developed, tested an understanding of the target audience in terms of the and then agreed by the study team and adapted for each problem behaviour, their preferred message and the database (Additional File 1). Searches were conducted in most effective means of delivering that message, through ten electronic databases (MEDLINE, EMBASE, exploratory research; use theory to identify the focus of CINAHL, Web of Knowledge, CSA Ilumina - ASSIA, the campaign message; to achieve maximum effective- Sociological Abstracts -, PsycInfo, ZETOC, AgeInfo and ness, segment the audience to create groups with similar FRANCIS) from 1980 to 2010, the Cochrane Library message preferences; design the message from the find- (1980-2010), EPPI-Centre database and National ings of the exploratory research and choose the channels Research Register. Manual searches through the refer- most widely viewed by the target group; evaluate and ence lists of papers were also carried out. monitor the process of campaign activities; use a rigor- ous design to evaluate the intervention such as time ser- Inclusion and exclusion criteria ies and controlled before and after designs [18]. Primary studies in English evaluating the effectiveness of In England, as part of the national stroke strategy [19], mass media interventions were included; where relevant, the Department of Health recently implemented a related papers were obtained to gather information on the national mass media campaign to promote public aware- methods of intervention development. Studies were ness of stroke symptoms and of the need for emergency selected according to the following criteria: (a) targeted response using the FAST (Face, Arm Speech, Time) test groups: the general public aged 18 or over; (b) outcomes: [20]. Implementation of this campaign begs an impor- knowledge of stroke symptoms and, awareness of the need tant question about the evidence base for the effective- for an emergency response, rates of acute stroke treat- ness of mass media campaigns in this specific area in ments, andtimeto presentationathospital; (c)design: changing knowledge of stroke (signs and symptoms) randomised controlled trials (RCTs), quasi-experimental Lecouturier et al. BMC Public Health 2010, 10:784 Page 3 of 10 http://www.biomedcentral.com/1471-2458/10/784 studies, controlled (CBA) and uncontrolled before and controlled before and after design [30,31]. Campaign after (BA) studies and interrupted time series (ITS). Inter- population coverage ranged from 80,000 to 5 million. ventions aimed solely at health professionals were The minimum duration of the intervention was two 10 excluded, but those that targeted both the general public week periods, the maximum 18 months. The longest and health professionals were included. period between the end of the campaign and outcome measurement was six months [27], the shortest one Data extraction month [26]. The majority collected post-intervention Titles and abstracts were screened to identify studies of data at only one point but one did so during and imme- likely relevance and full papers obtained. A structured diately following two campaigns and then six months form was used to determine study inclusion. Two later after the end of the second campaign [27]. One reviewers (JL, HR) extracted data from the final papers study [29] appears to have repeated their intervention in into structured tables. The results are presented as a nar- a different county in USA with the addition of the dis- rative synthesis as the interventions varied in their format tribution of written educational materials and a control and presentation, were evaluated using different methods group [31]. and outcomes, and included a range of study populations. Controlled before and after studies In Ontario, Canada, Silver et al. [30] evaluated an 18 Review of intervention development using the MRC month campaign of continuous high level TV advertis- Framework ing, intermittent TV advertising and newspaper adver- Intervention development for each study was classified tisements in each of three communities. A fourth using the five key phases suggested in the MRC Frame- community acted as a control and received only Heart work for evaluating complex interventions [25] as follows. and Stroke Foundation Public Service Announcements. Telephone interviews were conducted using random Preclinical phase to identify the evidence to support digit dialling; only residents aged 45 and over were the type of intervention: this could be from a sys- interviewed. Quota sampling was used to ensure equal tematic review or identifying or developing relevant numbers of males and females and that at least one theory third of participants were aged 65 and over. The Phase 1 Modelling the processes and outcomes of authors hoped to target men, older people and those the intervention in lower socioeconomic groups and hypothesised that Phase 2 Exploratory trial to test out the intervention television would be the most appropriate medium. The and outcome measures outcome of interest was knowledge of symptoms and Phase 3 Definitive RCT signs, but not emergency response. At three months Phase 4 Long term implementation post-intervention there were significant improvements in groups exposed to both high intensity and low level These phases were entered into a matrix. Each study television advertising but not to newspaper inserts. was examined, using the information from all relevant There was a significant decrease in the control group, published articles, to determine how the intervention an unexpected finding and one which the authors were was developed and evaluated; a summary of the process unable to explain. The television interventions had a was recorded into the matrix under the appropriate significant positive impact on younger (aged 45-64 phase. This enabled the team to examine across studies years) respondents (p = 0.0001) and those with less the extent to which the intervention development and than a secondary school education (p < 0.05), but did evaluation was in line with the guidance recommended not increase knowledge of stroke symptoms in those in the MRC Framework. aged 65 or over, the age group at greatest risk of stroke and most likely to witness a stroke. The low Results intensity television intervention was the most cost- Ten mass media intervention studies met the inclusion effective method of raising awareness (measured by the criteria and were included in the review (Figure 1). Six gross rating points per percentage point change in out- targeted the public [26-31] and four both public and come). This study was interesting in that, unlike the professionals [32-35]. Study characteristics for the ten other studies, the team were able to examine the effec- included studies are summarised in Additional File 2 tiveness of different media. One shortcoming was that and the results of evaluations in Additional File 3. the advertisements did not promote the need for an emergency response and numbers calling emergency Public only interventions services or attending hospital with suspected stroke Six mass media campaigns with patient reported out- were not measured. The study was underpowered and comes were reviewed [26-31]. Two studies used a this precluded examination of the effects of past Lecouturier et al. BMC Public Health 2010, 10:784 Page 4 of 10 http://www.biomedcentral.com/1471-2458/10/784 Records identified through Additional records identified database searching through other sources (n =4959) (n =3) Records after duplicates removed (n = 3940) Records screened Records excluded (n =3825) (n=3780) Full-text articles excluded, Full-text articles assessed as not mass media for eligibility interventions (n =45) (n =35) Studies included in qualitative synthesis (n =10) Studies included in quantitative synthesis (meta-analysis) (n =0) Figure 1 PRISMA flow diagram of search results. medical history or presence of stroke risk factors on weekly newsprint advertisements for the duration of the stroke knowledge. intervention. The television advertisements covered: Fogle et al. [31] compared awareness of stroke warn- stroke warnings signs and the need for an emergency ing signs and of the need for an emergency response response; a three step stroke test on identifying a stroke; between a group in Flathead County, exposed to 2 × 10 hospital staff reinforcing the need for an emergency week mass media campaigns, and a control group in a response to stroke; and brain cell death following a Gallatin County, Montana. There was a two-month gap stroke when treatment is delayed. The radio and news- between the end of the first and beginning of the second print advertisement ran along similar lines. Educational campaign. The target audience for the campaign was materials were posted to community doctors and phar- those aged 45 years and over. The campaign consisted macies, churches and care homes for older people; a of four television and three radio advertisements and stroke information brochure and magnet were posted to Eligibility Included Screening Identification Lecouturier et al. BMC Public Health 2010, 10:784 Page 5 of 10 http://www.biomedcentral.com/1471-2458/10/784 households with residents in the target age group. The witnessed a stroke, despite this being a major focus of control county received no campaign information. Tele- the campaign. Post-intervention outcomes were col- phone surveys were conducted with residents aged 45 lected at one month after the end of the campaign so years and older in both counties, using sequential ran- little can be said about the impact of the intervention in dom digit dialling, before and after the campaign. It was the longer term. In addition, although the message was not clear at what point pre- and post- campaign the tel- to promote an emergency response to stroke, only a ephone surveys were conducted. Following the campaign change in a person’s intention to act rather than an there was a statistically significant increase in those in actual change in behaviour could be measured. the intervention group (regardless of sex or age) who In Mainz, Germany Marx et al. [28] reported the could correctly identify twoormorestrokewarning impact of a mass media campaign of three months’ signs (p ≤ 0.05): this increase was significant for those duration. The intervention consisted of: billboard and who had two or more self reported risk factors for poster advertisements with short slogans; stroke interest stroke (p ≤ 0.05). There was no significant change in stories, slogans and interviews in local newspapers; stor- intention to call emergency services should they experi- ies, reports and interviews on television and radio; pub- ence or witness a stroke. A higher proportion post-cam- lic events; flyers sent to every household; and a stroke paign would call emergency services if they experienced guide distributed at the public events and through hos- or witnessed the symptom of numbness (p ≤ 0.05) or pital and family doctors. Telephone surveys were con- any of the three symptoms (speech difficulties, numb- ducted two months pre- and three months post- ness or paralysis) (p ≤ 0.05). There were no statistically intervention with German speaking residents, using ran- significant increases of awareness of stroke warning dom digit dialling. There was no change in spontaneous signs or need for an emergency response in the control recall of symptoms or signs but when presented with a county group between the first and second surveys. list (non-spontaneous recall) there was a significant There was a statistically significant increase in recall increase in the proportion who, could correctly identify across all stroke campaign media (television, radio and ‘paresis or weakness’ as astrokesymptom (p <0.01). newsprint) regarding stroke warning signs and the Therewas littlechangeinthose whowould respondto stroke test after the campaign but a smaller percentage a stroke as an emergency, albeit with a high baseline recalled the advertisement for stroke test (television (82%). This was the most comprehensive campaign 32%; radio 16%; newsprint 21%) than the one for warn- using a greater variety of media than the other studies, ing signs (television 71%; radio 32%; newsprint 43%). but it is not possible to determine which component Although this campaign promoted an emergency had the greatest impact. Respondents were asked which response to stroke, as with the previous controlled study information source they remembered but this may not they did not measure whether this had any impact on have been the medium that was effective in increasing behaviour when a stroke was suspected: in time to pre- awareness. A strength of this study was the use of both sentation to hospital or increased use of emergency ser- spontaneous and non-spontaneous recall, as it may be vices. Because of the design of the study the team are argued that the former may underestimate and the latter unable to demonstrate whether or not one particular may overestimate levels of knowledge; the authors could media is more successful at increasing awareness of compare the responses using both methods. stroke symptoms. In Ontario, Canada, Hodgson et al. [27] assessed the Uncontrolled before and after studies impact of two television advertising campaigns, of nine Becker et al. [26] assessed the impact of a five month and eight months’ duration, conducted by the Heart and campaign on Washington, USA, residents’ level of stroke Stroke Foundation. The campaigns were aimed at people knowledge and on proposed action on witnessing a age 45 years and older and illustrated five stroke warning stroke. The five month campaign targeted people aged signs (weakness, trouble speaking, vision, headache and 65 years and over and consisted of: public service dizziness) with an overlaying stamp reading “sudden”.A announcements and public interest stories on television; voiceover encouraged viewers to call 911 or their local advertisements and stroke interest stories in newspapers; emergency number if they experienced any of the symp- and public stroke screenings and flyers. Telephone inter- toms. Six telephone surveys were conducted with a sam- views were conducted with residents who could speak ple of Ontarians aged 45 and over using random digit English. Participants were selected using random digit dialling. These were carried out: two months prior to, dialling. One month after the end of a campaign, using during and immediately following the first campaign; and both television and newspapers, respondents were more during, immediately following and six months after the likely to know at least one symptom of stroke than one second campaign. The team also recorded emergency month before the campaign (p = 0.032). However, fewer department visits from three months pre- to six months (non-significant) would call emergency services if they post-intervention (31 months). There was an increase in Lecouturier et al. BMC Public Health 2010, 10:784 Page 6 of 10 http://www.biomedcentral.com/1471-2458/10/784 those who could name two or more symptoms (p < The community intervention consisted of billboard 0.001) and in the mean number of symptoms named (p < advertising, radio and television public service 0.001). However, six months after the end of the second announcements, news stories, brochures and posters. campaign, there was a decrease in those who could name Also, volunteers were trained in stroke recognition and two or more symptoms and in the mean number of appropriate action; these volunteers then trained others. symptoms named (p < 0.001). There was also a signifi- The intervention did not appear to target any specific cant increase in the mean number of emergency depart- group. A comparison control community was selected ment visits for stroke and TIA in campaign months with hospitals matched with the intervention commu- compared to non-campaign months (p < 0.01), but the nity and with similar demographic characteristics but in individual contribution of thecampaigntothisina a different media area. The health professional interven- regression model for stroke was small, explaining 9% of tion consisted of news stories and newsletters, highlight- the variance for total visits, 15% for visits within five ing successes and accomplishments in stroke treatment. hours, 5% for visits within 2.5 hours, although 30% for In addition hospital teams developed emergency depart- TIAs. Due to the decrease in awareness of symptoms in ment protocols, scheduled continuing medical education the five month period following the end of the interven- and mock ‘stroke codes’ for staff. Outcome measures tion the authors conclude that continuity of exposure to were rtPA treatment rates and time to presentation, and the campaign is important in maintaining and increasing data were collected at baseline and during the stroke awareness. interventions. Fogel et al. [29] conducted a study in Missoula The use of rtPA increased in all patients in the inter- County, USA of television, radio and newsprint adver- vention community (p = 0.01) with no change in the tisements targeting residents aged 45 and over. There control (p = 1.00). There was no change in time to hos- were four different television advertisements: warning pital presentation that could be ascribed to the interven- signs and the need for an emergency response; a three tion. Time to presentation to hospital decreased in both step test if a stroke is suspected; stroke risk factors; and communities, yet treatment rates increased only in the what happens to the brain when treatment is delayed. community receiving the intervention. This would sug- Radio and newsprint advertisements contained messages gest that the main impact may have been on profes- on stroke signs, the stroke test and the need for an sionals rather than on the public. However, it may be emergency response. The campaign ran for two 10 week that the community mass media campaign, which was periods, three months apart. Telephone surveys were inextricably linked to the professional campaign, also conducted before and after the campaign (times not contributed to the professional behaviour change, specified) using random digit dialling with residents though this is not possible to disentangle. A later study aged 45 and over. There was a significant increase in showed no significant increase in presentation within the mean number of correctly identified symptoms (p < two hours of onset, but did show increases in rtPA 0.05), and the ability to name two or more in both treatment rates that were sustained beyond the interven- women and men, and in those aged 45 and over (total tion, suggesting that the impact was on professional 84% after compared to 67% before). There was a signifi- awareness and service organisation rather than public or cant increase (p < 0.05) in those reporting that they patient awareness, despite a well developed public cam- would call emergency services if they experienced sud- paign[36] den speech problems (p < 0.05), numbness or loss of Uncontrolled before and after studies sensation (p < 0.05) or paralysis that did not go away (p In Durham, North Carolina, USA Alberts et al [32] eval- < 0.05) but not if they witnessed a stroke. uated the impact of interventions conducted to improve recruitment to a trial of t-PA (tissue-type plasminogen Interventions targeted at both the public and health activator). To target the community, features were professionals broadcast on television and radio where the use of t-PA Four papers evaluated studies where the public and was discussed, the need for early treatment was empha- health care professionals were both targeted [32-35]. sised and stroke symptoms were described. Newspaper Two studies were conducted as part of recruitment stra- articles were published covering the same points. For tegies in clinical trials of thrombolysis [32,33]. Only one health professionals, the intervention consisted of pre- study used a controlled before and after design [34], sentations about the t-PA study by specialists in local Controlled before and after studies and regional hospitals and at medical group meetings, In five East Texas counties, Morgenstern et al. [34,36] and letters (with the study protocol) sent to local and implemented two interventions of 15 months’ duration regional physicians. The interventions were of three to increase the proportion of patients treated with months’ duration. The outcomes of interest were time thrombolysis following licensing of rtPA in the USA. of presentation to hospital and data were collected from Lecouturier et al. BMC Public Health 2010, 10:784 Page 7 of 10 http://www.biomedcentral.com/1471-2458/10/784 14 months pre- to 12 months post-intervention. There significantly increased (from 42.2 to 45.8 minutes, p < was an increase in the number of patients with cerebral 0.01), as a result of increased time spent on scene and infarction who presented to hospital within 24 hours of time from scene to hospital, but overall the median symptom onset in the 12 months after the campaign (p increase was only 3.6 minutes. Impact on treatment < 0.00001). This study was conducted over 10 years ago rates was inconsistent across hospitals. Prior to the before the widespread availability of t-PA and they do intervention, two of the six study hospitals did not treat not report on presentation within the early hours fol- any strokes with rtPA; afterwards all hospitals did so lowing stroke. and treatment rates ranged from 6.8% to 17.2%. During Barsan et al’s [33] study, linked to the NIH Tissue the intervention four hospitals increased the number of Plasminogen Activator Pilot Study, evaluated a public rtPA treatments - in only one was this statistically sig- campaign and professional educational programme in nificant (p = 0.047) - and in two there was a reduction. three US states. The public campaign focused on stroke symptoms and the need for an emergency response, and Review of intervention development using the MRC entailed public service announcements and interviews Framework broadcast on television and radio and in newsprint. In None of the studies reported that the intervention had relation to health professionals, each participating centre an identified theoretical base. For the majority there was developed an educational programme. These included no description of intervention development and no informational mailings, training programmes and educa- mention of any modelling and exploratory or pilot work tional lectures. The duration of the interventions were to test the processes [26-30,32,33,35]. A number not specified. Outcome data on time to presentation selected the design as they believed it had been effective and number of stroke related emergency calls were col- in earlier campaigns of stroke education [28,30] or fol- lected for 30 months from the time the intervention lowed on from previous work [27,31]. Only one study commenced. They found a significant decline in the had conducted any developmental work prior to the mean time of presentation to hospital during the inter- launch of the campaign [34]; in Phase 1 of the study, vention (p < 0.05), but no change in time to first medi- focus groups with stroke patients and carers and a tele- cal contact. The authors argue that use of emergency phone survey of the general population were conducted telephone call was the most likely explanation for this; to identify factors that might delay hospital presentation; although this varied across sites. Those travelling by these study authors also created a community advisory ambulance arrived earlier than those using other trans- board to support intervention development. port. A number of hospitals joined the project during the measurement period complicating analysis and Discussion interpretation. Again this study was conducted over This review has focused on evaluations of mass media 10 years ago before the widespread availability of rt-PA interventions designed to increase public recognition of but they are able to report on time to presentation from stroke symptoms, the emergency response to stroke and under one hour to 24 hours. early intervention. This is particularly pertinent when In Houston, Texas, Wojner-Alexandrov et al. [35] national mass media campaigns, such as the stroke assessed the impact of a 12 month community and awareness campaign (FAST) in England [20], are being health professional education intervention. In the com- funded and widely implemented. munity intervention television, radio and newsprint were used to convey information on the identification of Public only interventions stroke warning signs and the designation of stroke cen- Included studies evaluating public only interventions tres. In addition community stroke screening events used a range of methods within their mass media cam- were held. No target group within the community was paigns. Out of the six studies only two had a control specified. For professionals, monthly education sessions group [30,31]; therefore it is not possible to determine if were held for paramedic and hospital staff; also the Los any changes were due to the campaign in the uncon- Angeles Pre-Hospital Stroke Scale was implemented trolled studies. Only two employed a representative with paramedics for use in diagnosing stroke. For six population sampling strategy to evaluate impact [27,30]. months prior to and for the duration of the interven- Effectiveness was evaluated by telephone surveys, tion, paramedic diagnostic accuracy, time of presenta- thereby excluding members of the community without tion to hospital and thrombolysis rates were measured. access to, or unable to use, a telephone, possibly older There was an increase from 74 patients admitted per people and those with communication difficulties. Only month to 89 per month during the intervention phase one of the studies collected data on stroke admissions (p < 0.001). Paramedic diagnostic accuracy also and time to presentation [27]; the rest were not able to increased (statistics were not reported). Transport times demonstrate whether increased knowledge translated Lecouturier et al. BMC Public Health 2010, 10:784 Page 8 of 10 http://www.biomedcentral.com/1471-2458/10/784 into the appropriate action on witnessing or experien- Given the complexity of interventions and the dual cing a stroke. All used free recall of stroke symptoms nature (public and professional) of these four studies it which may underestimate the level of awareness; how- is very hard to disentangle any active components that ever one study also used assisted recall and found might explain any reported impact. This is a feature increased knowledge of only one specific symptom post- noted in the Cochrane systematic review evaluating intervention [28]. Some campaigns may have been con- mass media campaigns designed to increase health ser- taminated by other low level stroke education, such as vice utilisation, incorporating 15 interrupted time series public service announcements, making it difficult to studies [17]; nonetheless this concluded that “those attribute any changes to the intervention [26,28-30]. engaged in promoting better uptake of research infor- As stated earlier, only two studies used a more robust mation in clinical practice should consider mass media design and included a control arm. Unfortunately, one as one of the tools that may encourage the use of effec- was underpowered and did not target or measure aware- tive services and discourage those of unproven effective- ness of the need for an emergency response [30]. The ness”. As with our conclusions specific to stroke, the other controlled study was a repeat of an earlier cam- authors stated that it was “difficult to determine extent paign [29] in a different county but with the addition of [of change] attributable to changes in health care provi- distributed written educational materials and a control ders or consumers” given that many targeted both pub- county [31]. The second controlled campaign revealed a lic and professionals. lower percentage point increase in awareness of stroke symptoms and intention to call emergency services if Intervention design they experienced or witnessed specific stroke symptoms Despite the importance of a theoretical base and early than in the first uncontrolled study (Additional File 3). stage research in the design of the intervention [18] As there were no significant changes in the control only one study described conducting exploratory work community it can be concluded that any increases to identify factors that may have influenced people from demonstrated, albeit modest, were more likely to be as a seeking emergency medical care at the onset of stroke result of the intervention. symptoms [34]. Nevertheless the findings from that Data on the longer term retention of stroke knowledge study indicate that any increase in thrombolysis rates of symptoms and signs was poor in most of the studies. were most probably due to the component of the inter- Only one study collected outcomes six months after the vention targeting health professionals rather than those end of the campaign to assess longer term impact and in the community. Had the team carried out an explora- found that knowledge declined post- intervention [27]. tory trial to test the intervention in the community they It is impossible to assess the longer term impact, or to may havebeen abletorefineit accordinglyand influ- know whether or when an intervention should be ence time to presentation at hospital. repeated, unless evaluations measure impact at a range A few conducted their community campaigns based of time points following intervention. on the results of earlier ones [28,30] even when the Overall, the impact of these interventions was incon- impact on the community was not determined [34] and sistent. Nonetheless, all showed some significant any improvement in awareness of stroke symptoms was increase in awareness of symptoms but little impact on not measured beyond one month post-intervention [26]. the awareness of the need for, or intention to call, an emergency response, although baseline levels were high. Limitations In view of the fact that these campaigns have failed to There are limitations to this review as a result of the increase awareness of the need for an emergency range of methods and study designs employed in the response to stroke [26,28,29,31] or prompt those experi- included studies. Only three studies used a controlled encing a stroke to present at hospital immediately [27] before and after design [30,31,34], limiting the conclu- further research is warranted to explore people’svalues sions that can be drawn. Of the ten studies only the lat- and beliefs in relation to stroke. ter three would be accepted as valid for inclusion in a systematic review by the Cochrane Effective Practice Public and professional interventions and Organisation of Care Group [37]. Therefore it is The public and professional campaigns largely focused not possible to state with any degree of confidence on outcomes of time to hospital and thrombolysis rates whether any changes identified were attributable to the [32-35]. Measures of time to arrival varied across stu- intervention or to other factors. Few studies had pre- dies. Two of the studies were over 10 years old and specified primary outcome measures and several used were part of a drive to increase recruitment into trials multiple analyses. None of the studies used qualitative of r-PA and most of the professional intervention methods (such as interviews with participants) to help appeared to be aimed at raising awareness of the trial. understand their findings [38]. There was very little Lecouturier et al. BMC Public Health 2010, 10:784 Page 9 of 10 http://www.biomedcentral.com/1471-2458/10/784 reporting of the theoretical or empirical basis of inter- Unlike other interventions, such as stroke patient educa- ventions, or of their development methods, as recom- tion and community stroke screening programmes, mass mended by the MRC Framework for development and media campaigns have the potential to improve knowl- evaluation of complex interventions; it appears that few edge and awareness and change the behaviours of a studies have built upon earlier, potentially promising, large number of people. We would urge future develo- interventions. pers of mass media campaigns to consider a more struc- One published study not included in this review tured approach, such as that recommended in the MRC reported the development and piloting of an educational Framework for the Development and Evaluation of kit (Stroke Heroes Act FAST animation, brochure and Complex Interventions [23]. poster) designed to improve knowledge of the symptoms of stroke and the need for emergency action using the Additional material FAST acronym [39]. The materials from this educational kit have been used in 28 countries. In Massachusetts Additional File 1: Search Terms for Medline. they have been used in mass media campaigns and eval- Additional File 2: Characteristics of Included Studies. uated through telephone surveys [40] and claim to have Additional File 3: Results of Evaluations. significantly improved knowledge of symptoms and the need for emergency response, but these results do not appear to have been published in peer reviewed journals. Acknowledgements We thank Martin Eccles for advice on methods and for comments on drafts, and Terry Lisle for clerical support. This work is part of a research Conclusions programme - Developing and Assessing Services for Hyperacute stroke In conclusion, although some studies showed increases (DASH) - funded by the National Institute for Health Research (Ref: RP-PG- in symptom awareness and awareness of need for emer- 0606-1241). The views and opinions expressed here are those of the authors gency response, and increased use of emergency trans- and do not necessarily represent those of the NHS, National Institute for Health Research and Department of Health. port, none show a full picture of increased awareness, increased use of emergency response, shorter time to Author details arrival and increased use of thrombolysis following a Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. Institute for Ageing and Health (Stroke Research Group), Newcastle mass media campaign. There is clearly a need for more University, Newcastle upon Tyne, UK. Medical and Social Care Education, robust evaluation of such campaigns using studies with Leicester University, Leicester, UK. at least a controlled before and after design, and includ- Authors’ contributions ing qualitative methods to support understanding of any JL conducted the searches and electronic sifting of titles and abstracts. JL demonstrated impact and to help unpick the elements and HR independently reviewed the retained papers and extracted data. JL of any campaign that might be important. The nation- and RT wrote the first draft of the manuscript. All authors commented on the first draft and all revisions. wide campaign in England implemented in February 2009 offered an opportunity to do this, but unfortu- Competing interests Authors JL, MM, HR, MW and RT have no competing interests. GF has nately there is no such robust evaluation in progress, consultancy relationships with Boehringer Ingelheim and Lundbeck, grants/ despite considerable investment of public resources [20]. grants pending from Servier Pharmaceuticals, Lundbeck and Mitsubishi, The Department of Health website reports a 55% payment for development of educational presentations including service on speakers’ bureaus from Boehringer Ingelheim and travel/accommodations increase in emergency calls for stroke following cam- expenses covered or reimbursed by Boehringer Ingelheim that might have paign implementation but no further details are pro- an interest in the submitted work in the previous 3 years. vided [41]. When campaigns are evaluated, such as Received: 2 July 2010 Accepted: 23 December 2010 those using the Stroke Heroes Act FAST materials [40], Published: 23 December 2010 there is a need for the results to be published in peer reviewed journals. 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Payne GH, Fang J, Fogle CC, Oser CS, Wigand DA, Theisen V, Farris RP: doi:10.1186/1471-2458-10-784 Stroke awareness: surveillance, educational campaigns and public health Cite this article as: Lecouturier et al.: Systematic review of mass media practice. Journal of Public Health Management and Practice 2010, interventions designed to improve public recognition of stroke symptoms, 16:345-358. emergency response and early treatment. BMC Public Health 2010 10:784. 23. Medical Research Council. Developing and evaluating complex interventions: new guidance. [http://www.mrc.ac.uk/ complexinterventionsguidance]. 24. The Editorial Team. Cochrane Stroke Group. About The Cochrane Collaboration (Cochrane Review Groups (CRGs)). 2009, , 4: STROKE. 25. MRC Health Services and Public Health Research Board. A framework for Submit your next manuscript to BioMed Central development and evaluation of RCTs for complex interventions to and take full advantage of: improve health. Medical Research Council; 2000. 26. Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T: • Convenient online submission Community-based education improves stroke knowledge. Cerebrovascular Diseases 2001, 11:34-43. • Thorough peer review 27. Hodgson C, Lindsay P, Rubini F: Can mass media influence emergency • No space constraints or color figure charges department visits for stroke? Stroke 2007, 38:2115-2122. • Immediate publication on acceptance 28. Marx JJ, Nedelmann M, Haertle B, Dieterich M, Eicke BM: An educational multimedia campaign has differential effects on public stroke • Inclusion in PubMed, CAS, Scopus and Google Scholar knowledge and care-seeking behavior. Journal of Neurology 2008, • Research which is freely available for redistribution 255:378-384. Submit your manuscript at www.biomedcentral.com/submit

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