ARTICLE IN PRESS Transferring Stroke Knowledge from Children to Parents: A Systematic Review and Meta-Analysis of Community Stroke Educational Programs D1X XDaudet Ilunga Tshiswaka, D2XPhD, X * D3X XLaura E. Sikes, BS, D4X X * D5X XJuliet Iwelunmor, PhD, D6X X † D7X XGbenga Ogedegbe, MD, D8X X MPH,‡ and D9X XOlajide Williams, D10XMD, X MS§ Background: The purpose of this systematic review and meta-analysis on child-to-parent communication of stroke information (Child-Mediated Stroke Communication, CMSC) is to provide the highest levels of evidence supporting the role of this approach in community education. Methods: Databases such as PubMed, Google Scholar, PsycINFO, Web of Science, MEDLINE, and CINHAL were searched to gather information on CMSC followed by a meta-analysis. The eligibility criteria were as follows: (a) children aged 9-15 years and parents, (b) randomized or nonrandomized trials, and (c) outcome variables that included the proportions of parents answering the pretest and post-test on stroke knowledge regarding risk factors, symptoms, and what to do in the event of stroke. Results: Of the 1668 retrieved studies, 9 articles were included. Meta-analytical ﬁndings yielded that the proportions of correct answers for stroke symptoms and its risk factors among parents were 0.686 (95% CI: 0.594-0.777) at baseline and increased to 0.847 (95% CI: 0.808-0.886) at immediate post-test and 0.845 (95% CI: 0.804-0.886) delayed post-test. The proportions of correct answers for behavioral intent to call 911 when witnessing stroke was 0.712 (95% CI: 0.578-0.846) at baseline, rising to 0.860 (95% CI: 0.767-0.953) at immediate post-test, and 0.846 (95% CI: 0.688-1.004) at delayed post-test. Conclusions: CMSC is effective for educating families. More work is needed to increase the use of validated stroke literacy instruments and behavioral theory, and to reduce parental attrition in research studies. Key Words: Child-mediated stroke communication—tissue plasminogen activator— Hip-Hop stroke—stroke symptoms—stroke risk factors—911 behavioral intent— systematic review—meta-analysis. © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. Introduction On average, every 40 seconds, someone in the United States will experience a stroke.1 Indeed, stroke ranks among the leading causes of long-term disability and death globally.2 Reducing the time between stroke symptom onset and hospital arrival improves patient outcomes by enabling the administration of acute stroke treatments such as intravenous tissue plasminogen activator (t-PA) within the critical 4.5-hour treatment window3,4 and mechanical thrombectomy. However, due to cognitive and physical debilitation, victims are often unable to reach out for help, relying instead on witnesses and bystanders to take appropriate action, which is to call 911.5 One of the priorities of stroke center designation programs, which have also been outlined in stroke guidelines, is community education on stroke prevention, awareness of stroke symptoms, and calling 911. Yet, there From the *Department of Public Health, University of West Florida, Pensacola, Florida; †Department of Behavioral Science and Health Education, Saint Louis University; Saint Louis, Missouri; ‡Department of Population Health, Department of Medicine, New York University, New York, NY; and §College of Physicians and Surgeons, Columbia University, New York, NY. Received May 31, 2018; revision received June 14, 2018; accepted July 4, 2018. Address correspondence to Daudet Ilunga Tshiswaka, PhD, Department of Public Health, University of West Florida, 11000 University Parkway, Pensacola, FL 32570. E-mail: email@example.com 1052-3057/$ - see front matter © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.07.014 Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2018: pp 1-13 1 ARTICLE IN PRESS D. ILUNGA TSHISWAKA ET AL. 2 is a dearth of evidence supporting best practices for accomplishing these goals. Mass media communication is one commonly adopted strategy by health departments and stroke associations, but the costs of this method make it difﬁcult to embrace or sustain by stroke hospitals. Since children may be the only ones present during an acute stroke involving a parent, grandparent, or guardian, they may be uniquely positioned to inﬂuence time to treatment by recognizing stroke and immediately calling 911.6 Moreover, children may be able to positively inﬂuence a family's stroke knowledge, lifestyle behaviors, and support parental self-management of illness.7 9 Indeed, as much as 45% of stroke knowledge has been reported to originate from family and friends, some of whom may be children.10 12 These reports create a favorable environment for the design and rigorous evaluation of community stroke education programs targeting children. School-based stroke education efforts have been shown to be effective in increasing children's stroke knowledge.13 A number of studies have found statistically signiﬁcant improvement in children's stroke knowledge and behavioral intent to call 911 during immediate post-tests.11,14 20 The incorporation of an age-appropriate, culturally relevant intervention with appealing design components, such as video games, manga comics, visual arts projects, and Hip-Hop music, has been included in multiple studies as core components of the interventions.11,17,19 23 The importance of stroke knowledge transfer from child to parent is heightened by its potential as a community stroke awareness strategy owing to the diffusion of information from the children to parents, and then from parents to extended family and friends. While educational interventions directly targeting adults have been shown to reduce prehospital delays and increase acute stroke treatment rates,24 harnessing the power of children to inﬂuence their parents may be a more sustainable approach due to the captive audience schools provide and may have broader effects on stroke knowledge by imparting knowledge and behavioral skills to a generation before they develop risk. This strategy provides an additional channel through which public health professionals may reach their target populations. A prior metaanalysis6 found improvements in stroke knowledge among children who participated in stroke education. However, the rigor of the methodological approaches used to form conclusions is often challenged due to a lack of attention to the validity of stroke knowledge instruments used, theoretical underpinnings, and absence of control groups, creating a need to critically review these programs and their effects on parental stroke knowledge. While this meta-analysis explores these areas, it also shifts attention towards parental knowledge gained from their children. The purpose of this study is to examine the existing evidence supporting the premise that stroke knowledge can be effectively transferred from children to parents. The review compares the stroke knowledge scores of parents who were educated by their children, and examines the multiple modes through which children were educated (by neurologists versus nonstroke expert such as Emergency Medical Technicians, teachers and Lay Health Workers). Since this child-to-parent educational model is relatively new, a review of the existing studies will provide insights into factors inﬂuencing successes and failures and the efﬁcacy of these interventions. This study is designed to address the knowledge gap regarding metaanalytical data focused on the transfer of stroke knowledge from children-to-parents—a critical component for the community-level success of school-based stroke education programs. Methods Our study was prospectively designed but not registered. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used as the template. A systematic literature review was conducted to gather relevant studies focused on child-mediated stroke communication using PubMed (548 manuscripts), Google Scholar (289 manuscripts), PsycINFO (179 manuscripts), Web of Science (310 manuscripts), CINAHL (112 manuscripts), and MEDLINE (230 manuscripts). Given the relatively small number of studies focused on this topic, the search was not limited by year of publication. The following index terms were used to capture relevant studies: “stroke and children,” “stroke education through children,” “child-mediated stroke education,” “parent and children stroke,” and “cerebrovascular accident, children, knowledge.” Unlike prior reviews,6,13 this study included index terms in the descriptors such as “parent” and “cerebrovascular accident” to ensure that all potential studies were retrieved and included in the analysis. Data collection occurred from September 1, 2017 to April 18, 2018. We also evaluated the reference lists of identiﬁed studies to ensure that all relevant studies were included in this review of the literature. Selection of Studies We limited the inclusion criteria to peer-reviewed articles published in English, randomized or nonrandomized child-mediated stroke communication interventions, with children aged 9-15 years and their parents. The outcome variable associated with the inclusion criteria included the proportions of parents responding to the pretest and post-test on stroke knowledge instruments regarding risk factors, symptoms, and what to do in the event of stroke. Studies that did not report the proportions of parents responding to the above stroke knowledge items were excluded. In the context of this review, the term “parent” refers to any adult or caregiver living in ARTICLE IN PRESS TRANSFERRING STROKE KNOWLEDGE FROM CHILDREN TO PARENTS Figure 1. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Symptoms and risk factors (baseline test). Note: G1=group 1 and G2=group 2. 3 ARTICLE IN PRESS D. ILUNGA TSHISWAKA ET AL. 4 the same household with the child who has been exposed to stroke education program. The initial search yielded a total of 1668 articles (Fig. 1: please see the Supplementary Material). After screening all such studies, we eliminated duplicates and articles that did not exclusively report on child-mediated stroke communication. This yielded a total of nine studies that met the inclusion criteria. Assessment of Risk of Bias in the Included Studies Two independent extractors selected the studies using the predetermined criteria, with each rating the methodological quality of a given study using the Methodological Index for Non-Randomized Studies (MINORS) (Table 1).25 For discrepancies in assessment, a third person was brought in as a tie-breaking procedure. MINORS—a valid instrument that has been successfully used in a similar review study13—comprises 12 items, with the ﬁrst 8 items focusing on noncomparative studies and the remaining 4 items dealing with comparative studies. The instrument has following three possible scores: 0 indicating that the item was not reported, 1 indicating that the item was reported but inadequate, and 2 indicating that the item is reported and adequate. The scores, therefore, range from 0 to 16 for the ﬁrst part and 0 to 24 for the last part of the instrument, with higher scores suggesting methodological soundness. As reported, the range of the inter-rater reliability coefﬁcient of the instrument is between 0.61 and 0.87 and test retest reliability coefﬁcients of 0.59-1.00.26 Data Extraction and Management A predesigned form was used to extract data. For discrepancies, a third person was invited as a tie-breaking. The extraction of data included various activities, including the complete name of the ﬁrst author, publication year, location of the study, aims of the study, proportions of child and parent participants, intervention overview, reported theoretical framework, and ﬁndings of the study highlighting proportions of parents with scores of stroke knowledge and what to do in the event of stroke. Data Synthesis The analysis consisted of a random-effects model due to the differences in the true effect size in all the selected studies. Speciﬁcally, we calculated the proportion of correct answers for stroke knowledge at baseline, immediate post-test, and delayed post-test from parents who were exposed to child-mediated stroke information. Our metaanalysis results are expressed as estimate of proportions with 95% conﬁdence interval. The between-study heterogeneity including the Q statistic—with P < .05—and I2 was estimated. We also performed meta-analysis for behavioral intent to call 911 when witnessing stroke. Open Meta Analyst was used to perform meta-analysis. Results The proportions of parents answering a stroke knowledge instrument that included risk factors, symptoms, and what to do in the event of stroke were used as the outcome variables in the selected studies. Parents who completed both a pretest and post-test were analyzed for stroke literacy. All parents answered the pretest before their children shared stroke knowledge/information with them. Parental post-tests were administered immediately following the intervention on their children, and up to 3 months after the intervention. While a number of published studies targeted middle school students aged 12-15 years, other studies focused on elementary students aged 9-12 years.18,27 Most studies only required one parent in the study.27,28 In general, experts—neurologists, health behavior specialists, emergency medical technicians, and teachers—were involved in the interventions, although some studies used trained Lay Health Workers.11,27 Cross-sectional studies were the most common study design, and only two studies were randomized controlled trial studies.12,28 Several studies used repeated individual measures rather than group performance comparisons. The goals of most studies were twofold: (1) to educate students about stroke and (2) to leverage educated students as a conduit for conveying stroke information to parents. Most interventions consisted of a set of approximately 2050-minute courses targeting children, who were then responsible for educating their parents.2,29 There was a conspicuous absence data on the psychometric properties supporting the reliability and validity of stroke questionnaires used. However, only one reviewed study reported the psychometric measures.12 While interventions used several different educational strategies to impart knowledge, the use of the FAST mnemonic (Facial weakness, Arm weakness, Speech disturbance, Time to call 911) as a stroke identiﬁcation tool was commonly reported in most studies. All studies were done in a school setting (public or private). Parents were typically exposed to stroke information via homework brought home by their children. Some studies used cartoons and other forms of multimedia to convey stroke education messages. A few studies employed theoretical models of behavior change in their development.12,18 Finally, as a concept, we note that child-mediated stroke communication began emerging as a topic of interest in the early 2000s. We compared stroke knowledge and intent to call 911 in the event of a witnessed stroke among parents whose children received information from medical professionals (e.g., neurologists or other medical personnel) versus those who learned from nonmedical professionals (e.g., schoolteachers or multimedia formats including art, music, cartoons, and video games through Lay Facilitators). For the most part, stroke knowledge of parents Studies without comparison groups Study Design Score* Limitations Single group with pretest and post-test 11 Amano et al.2 Single group with pretest and post-test 12 Matsuzono et al.29 Tomari et al.27 Single group with pretest and post-test Single group with pretest and post-test 12 11 Kato et al.35 Single group with pretest and post-test 12 Lack of estimates of power calculation, no intention-to-treat test, only 1 week of follow up, parental declining to participate Lack of estimates of power calculation, no intention-to-treat test, loss to follow up more than 5% in parents Lack of estimates of power calculation, no intention-to-treat test, no specific follow up determined No reported power analysis, no intention-no-treat test, loss to follow up more than 5% in both children and parents No reported power analysis calculation, no intention-to-treat test Williams et al. 18 Score** Limitations Marto et al.28 Ishigami et al.21 Hino et al.30 Cluster randomized trial Nonequivalent comparison group Nonequivalent comparison group 20 22 14 Williams et al.12 Cluster randomized trial 22 No reported power analysis, no intention-to-treat test, loss to follow up more than 5% in parents No reported power analysis No reported power analysis, no intention-to-treat test, did not specify blinding, loss to follow up more than 5%, historical comparison, groups no completely similar Loss to follow up more than 5% in parents *Range of scores = 0-16. **Range of scores = 0-24. ARTICLE IN PRESS Studies with comparison groups Study Design TRANSFERRING STROKE KNOWLEDGE FROM CHILDREN TO PARENTS Table 1. Quality assessment of selected studies 5 ARTICLE IN PRESS 6 whose children participated in neurologist-led stroke lessons were higher than those whose children participated in a non neurologist-led stroke intervention, although this ﬁnding is confounded by the lack of uniformity in the stroke knowledge instruments used.21,28 Conversely, a study30 found that parents whose children participated in schoolteacher-led stroke lessons had higher stroke knowledge compared with those whose children were instructed by the medical professional-led cohort. Different intervention outcomes were noted throughout the review. In particular, most studies analyzed stroke knowledge at baseline, immediately after the lesson, and at 3 months following the lesson.2,21 Stroke knowledge was assessed with pre-/post-test results that included stroke signs and symptoms, stroke risk factors, and intent to call 911 when witnessing stroke. In general, most interventions focused on children rather than their parents. Studies show that stroke education programs targeting children are an effective means for improving stroke literacy among children. However, regarding parents, signiﬁcant challenges related to attrition remains, although most studies showed improved parental stroke literacy as a result of targeting their children.2,29,12 Formal mediation analyses was conducted in one study to determine whether their child's stroke knowledge scores mediated a gain in parental stroke knowledge scores. This study did not ﬁnd a direct mediation effect, but did ﬁnd an intervention effect for sharing stroke information.12 Our meta-analyses yielded that the proportions of correct answers for the knowledge of stroke symptoms and its risk factors in parents were 0.686 (95% CI: 0.594-0.777) at baseline, 0.847 (95% CI: 0.808-0.886) at immediate posttest, and 0.845 (95% CI: 0.804-0.886) at delayed post-test. Likewise, improvement in behavioral intent—urgently calling 911 when witnessing stroke—was noted in parents following child-mediated stroke communication. Speciﬁcally, the proportions of correct answers for the behavioral intent at baseline were 0.712 (95% CI: 0.578-0.846), improving to 0.860 (95% CI: 0.767-0.953) and 0.846 (95% CI: 0.688-1.004) at immediate and delayed post-tests, respectively. The I2 statistics—estimating the total variation in random effects—indicated signiﬁcant heterogeneity in all reviewed studies; that is, the proportions were greater than 75%, as the suggested cutoff value by scholars31 for the determination of heterogeneity (see Table 2 and Figs. 1-6). Discussion An increasing number of studies have targeted children in the chain of stroke response. These studies have identiﬁed children as potential conduits of stroke knowledge into homes and proposed this school-based approach as an alternative to mass media campaigns. Our systematic literature review and meta-analysis found that most stroke education interventions targeting parents via their D. ILUNGA TSHISWAKA ET AL. children produced statistically signiﬁcant improvements in parental stroke knowledge. The most successful interventions included the following core components: (1) cultural and age-appropriate tailoring, (2) the use of multimedia to simplify stroke concepts and engage students, and (3) were developed using validated theoretical models of behavior change. We found slightly larger effects when the intervention was carried out directly by neurologists compared to Lay Facilitators, although we note that dispatching neurologists to schools for the purpose of stroke education may not be a sustainable or scalable approach for many communities. In addition, retention of stroke knowledge by students appeared to hinge upon age- and culturally-appropriate entertaining curriculums such as the use of Hip Hop music, video games, manga cartoons, and visual art projects, suggesting the importance of incorporating these components.11,17,20,21,23,32 Community leader appearances and interactive live action demonstrations also enhanced learning and retention among children.14,19,21,22 The most common barrier encountered across studies was the problem of parental attrition, which in some cases impaired statistical power for key outcome measures or prohibited analysis altogether. Moreover, parental stroke knowledge was considered less frequently than student stroke knowledge, and only a few studies focused on the efﬁcacy of stroke knowledge transfer from children to parents as a primary outcome.5 To this end, we found modest effect sizes among parents relative to the large effects seen among children. The clinical signiﬁcance of improved stroke knowledge scores alone remains controversial since knowledge is necessary but often insufﬁcient for producing behavior change. This is further compounded by the limited application of behavioral theory frameworks in the design of several interventions. We, however, acknowledge that studies have shown a positive effect on 911 behaviors in response to stroke preparedness interventions,12,24 but it remains unclear which intervention components drove these effects. Another important ﬁnding was the frequent absence of reporting on the psychometric properties of the stroke knowledge instruments used, raising questions about their reliability and introducing potential threats to the validity. This study has limitations. Our article selection process may have led to the exclusion of certain relevant studies, such as those unavailable in English. Additionally, the relative lack of ethnic or racial diversity within many of the available studies may limit generalizability. We also found that most study sample sizes were small and utilized single arm design. Analyses were conducted using within subject comparisons instead using a control group. Indeed, only two randomized studies were found, only one of which provided data on statistical power. The relatively short 3-month follow up period for parental posttests may also represent a limitation, although positive effects have been reported among children at 15 months in a long-term retention study.33 The variability and lack Study/Context Williams et al. /USA Study designs 18 Amano et al.2 /Japan Matsuzono et al.29 /Japan Marto et al.28 /Portugal Ishigami et al.21 /Japan Tomari et al.27 /Japan Aims/Participants Intervention/Theoretical frameworks To examine child-mediated stroke com- The HHS was a 3-day program that used music and dance, a cartoon music video, and a stroke munication among children who participated in a program called Hip-Hop comic book to increase stroke literacy in children and relied on them to convey the stroke stroke in transferring stroke message message to their parents. Parental stroke literacy to parents. A total of 182 elementary was assessed through pretest and post-test. Reastudents (aged 9-12 years) and 102 soned Action Theory (RAT) and Self-Efficacy parents participated in the program (SE) Theory were used as guiding frameworks underpinning the intervention In class, students received a 45-minute lesson Cross-sectional To evaluate efficacy of the education about stroke signs and symptoms, its risk facprogram for junior high school stutors, and what to do when witnessing it. Particidents and their parents. A total of 190 pants were tested at baseline, postintervention, junior high school students aged 12and at 3-month postintervention. The interven13 years and 183 parents tion was not situated within a theoretical framework All students received a stroke lesson, watched an Cross-sectional To assess communication of stroke animated stroke cartoon, and read the comic knowledge to parents by educating stroke Manga. Following these activities in the junior high school students about school-setting, students took the Manga back stroke. The study enrolled 1125 stuhome to discuss the contents and knowledge dents aged 13-15 years and 915 with parents. The intervention did not use a theparents oretical framework Cluster random- To evaluate the impact of stroke educa- Clusters were randomized for intervention and control. The intervention group received a ized trial tion on school students vis-a-vis stroke lecture—consisting of a 30-minute oral students’ and parents’ acquired stroke presentation by a neurologist—while the control knowledge. The cluster randomized group did not. There was no guiding conceptual trial had 764 middle school students framework associated with the intervention (aged 12-14 years) and 344 parents Cross-sectional To clarify the effectiveness of two edu- Students were divided into two groups: 323 children received stroke lesson from a stroke neuwith comparicational aids that include lessons with son group or without a neurologist developed for rologist (Group A) and 239 students watched an animated stroke cartoon (Group B). All groups elementary school children to convey took the stroke manga home to share with their information to their parents. The parents. There was no reported theoretical intervention consists of 562 children model guiding the intervention aged 11-12 years and 485 parents Cross-sectional To examine the effectiveness of Emer- Emergency Medical Technician provided stroke gency Medical Technician led lessons lesson to the children, who took the same stroke Cross-sectional Findings In general, parental stroke literacy improved at the conclusion of the intervention compared to the baseline knowledge Both groups scored higher at 3-month post-test compared to their baseline scores, indicating that child-mediated stroke message had been effective A post-test indicated that 91% and 92.7% of students and parents, respectively, understood the FAST mnemonic TRANSFERRING STROKE KNOWLEDGE FROM CHILDREN TO PARENTS Table 2. Study summary At the 3-month follow-up, the intervention group’s scores were significantly improved compared to the control group’s scores Increased mean scores were reported among the two groups at 3-month post stroke. Specifically, both children and parents scored higher in the FAST mnemonic test at 3-month follow-up The scores of stroke symptoms and its risk factors were higher at all post-tests compared to (continued on next page) 7 8 Table 2 (Continued) Study/Context Study designs Aims/Participants Intervention/Theoretical frameworks Findings D. ILUNGA TSHISWAKA ET AL. materials back home to share with parents. Both baseline scores, indicating that the intervention on stroke awareness for students and was effective the students and parents answered the pretest, their dissemination of stroke informapost-test, and a 3-month post-test. No theoretition. A total of 763 elementary stucal framework associated with the intervention dents (aged 9-10 years) and 489 was reported parents were enrolled in the study Schoolteachers taught children a lesson using the Parents whose children were instructed by Hino et al.30 /Japan Cross-sectional To assess the effectiveness of the schoolteachers on the stroke lesson showed sigstroke education slides for 15 minutes, then stuschoolteachers to deliver knowledge with comparinificant increases in the scores about stroke dents watched an animated cartoon for 10 of stroke to children aged 10-11 years son group symptoms and risk factors postintervention minutes, and read a Manga for 10 minutes. (1051 total) and their parents (a total Children took the Manga and a magnetic poster of 719) to a comparable level as that showing the FAST mnemonic and time to call demonstrated by medical staff (from ambulance to spark conversion with their previous studies) parents. The intervention was not underpinned by a theoretical framework Kato et al.35 /Japan Cross-sectional To determine the effect of a stroke edu- Students received a 45-min lesson that includes A significant increase in the percentage of parents who chose all correct symptoms and risk factors stroke risk factors and symptoms and animated cation intervention on elementary at 3 months compared to baseline was reported school students aged 11-12 years (268 cartoon delivered by adjunct instructors. After the lesson, students were instructed to use the participants) and their parents (267 Manga to instruct their parents. The interventotal) in rural area with high stroke tion did not highlight the use of a theoretical mortality framework Significant improvements were observed postWilliams et al.12 The intervention group received stroke knowlCluster random- To evaluate the effectiveness of a intervention in children and parents in the interedge using a Hip Hop based multimedia curric/USA ization trial stroke preparedness intervention vention group compared with the control group ulum. The control group received nutrition delivered to New York school students aged 9-12 years (a total of 3070) lessons. The intervention was delivered by Lay on the stroke knowledge/preparedness Health Facilitators. After that, students were encouraged to instruct their parents about of their parents (1144 adult stroke. Child-Mediated Health Communication, participants) which highlights the role played by children in transmitting health promotion interventions to parents and other caregivers, was the theoretical framework underpinning the intervention TRANSFERRING STROKE KNOWLEDGE FROM CHILDREN TO PARENTS Figure 2. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Symptoms and risk factors (immediate test). Note: G1=group 1 and G2=group 2. 9 10 Figure 3. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Symptoms and risk factors (delayed test). Note: G1=group and G2=group 2. D. ILUNGA TSHISWAKA ET AL. TRANSFERRING STROKE KNOWLEDGE FROM CHILDREN TO PARENTS Figure 4. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Behavioral intent (baseline test). Note: G1=group 1 and G2=group 2. Figure 5. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Behavioral intent (immediate test). Note: G1=group and G2=group 2. 11 ARTICLE IN PRESS D. ILUNGA TSHISWAKA ET AL. Figure 6. Forest plots of correct answers related to stroke knowledge in parents following child-mediated stroke education. Knowledge: Behavioral intent (delayed test). Note: G1=group 1 and G2=group 2. 12 of psychometric data of many instruments used to measure student and parental knowledge for stroke risk factors, symptoms, and appropriate action may have a confounding effect on our comparative analyses. Finally, we should note that while educating children may be a more sustainable method for improving community stroke preparedness, the risk of increased anxiety to the child needs to be considered in the development and evaluation of these interventions. These results suggest that targeting children with stroke education holds promise as a public education strategy. Indeed, child-to-parent transfer of critical public health information has implications beyond stroke, as exempliﬁed by past interventions aimed at children to inﬂuence a variety of parental behaviors such as salt consumption, tobacco smoking, asthma self-management, and cardiopulmonary resuscitation education programs.7,32,34 Future directions need to focus on long-term retention of stroke knowledge, reducing parental attrition, measuring the effects of these interventions on 911 call volume for suspected stroke, the length time between last known well and emergency room arrival of stroke patients, and the effect on thrombolytic rates. Conclusions Educating children is a viable method for improving a community's stroke preparedness; however, more research is needed to evaluate the impact of these interventions on prehospital delays and stroke outcomes. 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