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j.jstrokecerebrovasdis.2018.07.014

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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: daudeti@uwf.edu
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
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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.
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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
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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.
Supplementary Material
Supplementary data to this article can be found online
at doi:10.1016/j.jstrokecerebrovasdis.2018.07.014.
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