BACKGROUND: If carried out correctly and without delay, activation of emergency services by stroke bystanders could improve mortality and disability from stroke. This paper describes the development of a school-based intervention using the Intervention Mapping approach. It aims to improve the appropriate activation of emergency medical services for suspected stroke by 12-15-year-old children. METHODS: The development of the intervention was guided by Intervention Mapping approach. The logic model of the problem was created through analysis of the existing literature and semi-structured interviews with stakeholders. Based on these findings, performance objectives and their determinants were determined and matched to create a model for changing emergency medical services activation behavior. Behavior change methods and their practical applications were then determined. Based on them, intervention messages and materials were designed, the intervention was drafted, pretested, and finalized. RESULTS: It was found that the main performance objectives for the activation of emergency medical services were (1) recognizing symptoms, (2) communicating with the victim, and (3) calling an ambulance immediately. Their main determinants were knowledge, social influence, risk perception, self-efficacy, outcome expectations, and skills. Determinants were then matched with performance objectives to create the matrices of requested behavior changes. The following change methods were chosen: modeling, elaboration, belief selection, providing cues, scenario-based risk information, and cultural similarity. Methods were translated into practical applications in the form of a short educational film. The production company created, pretested, and finalized the film. As a result, a 5-minute entertainment-education video was created modeling an acute stroke with a child as the main bystander. CONCLUSION: The Intervention Mapping approach guided the development of a school-based program to improve Emergency medical services activation in stroke by 12-15 year old children. Our process and approach can serve as a model for researchers and health promotion professionals aiming to improve help-seeking behavior for stroke to improve stroke help-seeking behavior as well as other acute diseases.

1st Department of Neurology St Anne's University Hospital Brno and Faculty of Medicine Masaryk University Brno Czech Republic

Department of Health Promotion Care and Public Health Research Institute Maastricht University Maastricht the Netherlands

International Clinical Research Center St Anne's University Hospital Brno Brno Czech Republic

Zobrazit více v PubMed

Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World Stroke Organization (WSO): global stroke fact sheet 2022. Int J Stroke. 2022;17(1):18–29. PubMed

The Stroke Patient Voice in Europe. The burden of stroke in the Czech Republic. 2017. https://www.safestroke.eu/wp-content/uploads/2017/12/SAFE_STROKE_CZECHREPUBLIC.pdf.

Saver JL. Time is brain - quantified. Stroke. 2006;37(1):263–6. PubMed

Nagao Y, Nakajima M, Inatomi Y, Ito Y, Kouzaki Y, Wada K, et al. Pre-hospital delay in patients with acute ischemic stroke in a multicenter stroke registry: K-PLUS. J Stroke Cerebrovasc Dis. 2020;29(11):1–7. PubMed

Seo AR, Song H, Lee WJ, Park KN, Moon J, Kim D. Factors associated with delay of emergency medical services activation in patients with acute stroke. J Stroke Cerebrovasc Dis. 2021;30(1):105426. 10.1016/j.jstrokecerebrovasdis.2020.105426. PubMed

Teuschl Y, Brainin M. Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge. Int J Stroke. 2010;5(3):187–208. PubMed

Faiz KW, Sundseth A, Thommessen B, Rønning OM. Prehospital delay in acute stroke and TIA. Emerg Med J. 2013;30(8):669–74. PubMed

Fladt J, Meier N, Thilemann S. Reasons for prehospital delay in acute ischemic stroke. J Am Heart Assoc. 2019;8(20):e013101. PubMed PMC

Dombrowski SU, White M, Mackintosh JE. The stroke ‘Act FAST’ campaign: remembered but not understood? Int J Stroke. 2014;10(3):324–30. 10.1111/ijs.12353. PubMed

Mackintosh JE, Murtagh MJ, Rodgers H, Thomson RG, Ford GA, White M. Why people do, or do not, Immediately Contact Emergency Medical Services following the onset of Acute Stroke: qualitative interview study. PLoS ONE. 2012;7(10):e46124. PubMed PMC

Mosley I, Nicol M, Donnan G, Patrick I, Dewey H. Stroke symptoms and the decision to call for an ambulance. Stroke. 2007;38(2):361–6. PubMed

Robinson TG, Reid A, Haunton VJ, Wilson A, Naylor AR. The face arm speech test: does it encourage rapid recognition of important stroke warning symptoms? Emerg Med J. 2013;30(6):467–71. PubMed

Nordanstig A, Asplund K, Norrving B, Wahlgren N, Wester P, Rosengren L. Impact of the Swedish National Stroke Campaign on stroke awareness. Acta Neurol Scand. 2017;136(4):345–51. PubMed

Hickey A, Mellon L, Williams D, Shelley E, Conroy RM. Does stroke health promotion increase awareness of appropriate behavioural response? Impact of the face, arm, speech and time (FAST) campaign on population knowledge of stroke risk factors, warning signs and emergency response. Eur Stroke J. 2018;3(2):117–25. PubMed PMC

Worthmann H, Schwartz A, Heidenreich F, Sindern E, Lorenz R, Adams HA, et al. Educational campaign on stroke in an urban population in Northern Germany: influence on public stroke awareness and knowledge. Int J Stroke. 2013;8(5):286–92. PubMed

Heuschmann PU, Zweynert S, Sobesky J, Nolte CH, Audebert HJ, Hantke C, et al. Effects of a Public Awareness Campaign on Time to and way of Hospital Admission after Stroke. SAGE Open. 2021;11(1):2158244021989275.

Vondráčková L, Mikulík R. Public stroke education: current status worldwide and projects to increase awareness in the Czech Republic. Cor Vasa. 2017;59(6):e546–552.

Morrow A, Miller CB, Dombrowski SU. Can people apply ‘FAST’ when it really matters? A qualitative study guided by the common sense self-regulation model. BMC Public Health. 2019;19(1):643. PubMed PMC

Dombrowski SU, Mackintosh JE, Sniehotta FF, Araujo-Soares V, Rodgers H, Thomson RG, et al. The impact of the UK Act FAST stroke awareness campaign: content analysis of patients, witness and primary care clinicians’ perceptions. BMC Public Health. 2013;13(1):915. PubMed PMC

Bray JE, O’Connell B, Gilligan A, Livingston PM, Bladin C. Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms? Int J Stroke. 2010;5(6):440–6. PubMed

Dombrowski SU, Sniehotta FF, Mackintosh J, White M, Rodgers H, Thomson RG, et al. Witness response at acute onset of stroke: a qualitative theory-guided study. PLoS ONE. 2012;7(7):e39852. PubMed PMC

Bray JE, Straney L, Barger B, Finn J. Effect of Public Awareness Campaigns on Calls to Ambulance Across Australia. Stroke. 2015;46(5):1377–80. 10.1161/STROKEAHA.114.008515. PubMed

Mellon L, Hickey A, Doyle F, Dolan E, Williams D. Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign. Emerg Med J. 2014;31(7):536–40. PubMed

Nishijima H, Ueno T, Kon T, Haga R, Funamizu Y, Arai A et al. Effects of educational television commercial on pre-hospital delay in patients with ischemic stroke wore off after the end of the campaign. J Neurol Sci. 2017;381:117–8. https://www.sciencedirect.com/science/article/pii/S0022510X17337334. PubMed

Masztalewicz M, Nowacki P, Kotlęga D, Bajer-Czajkowska A. Early Emergency Medical Service calls for stroke: was the Long-Term Education Program based on the experience of West Pomerania successful? J stroke Cerebrovasc Dis Off. J Natl Stroke Assoc. 2016;25(2):254–8. PubMed

Beal CC, Flanders SA, Bader SG. Can children reduce delayed hospital arrival for ischemic stroke? A systematic review of school-based stroke education. J Neurosci Nurs. 2016;48(3):E2–13. PubMed

Boden-Albala B, Quarles LW. Education strategies for stroke prevention. Stroke. 2013;44(SUPPL 1):48–51. PubMed

Ottawa C, Sposato LA, Nabbouh F, Saposnik G. Stroke preparedness in children: translating knowledge into behavioral intent: a systematic review and meta-analysis. Int J Stroke. 2015;10(7):1008–13. PubMed

Mikulik R, Vondráčková L, Pokorná H. Feasibility and efficacy of an educational programme to increase awareness of stroke and heart attack in children. Health Educ J. 2019;78(7):812–23. 10.1177/0017896919849080.

Ministry of Education, Youth and Sports. 2023. Framework educational program for basic education. Retrieved from https://www.edu.cz/rvp-ramcove-vzdelavaci-programy/ramcovy-vzdelavacici-program-pro-zakladni-vzdelavani-rvp-zv/.

Marto JP, Borbinha C, Filipe R, Calado S, Viana-Baptista M. Impact of stroke education on middle school students and their parents: a cluster randomized trial. Int J Stroke off J Int Stroke Soc. 2017;12(4):401–11. PubMed

Di Carlo A, Baldereschi M, Bovis F, Piccardi B, Linoli G, Orlandi G et al. Effect of an educational intervention to increase stroke awareness among Italian high school students: A prospective study in Tuscany. Eur Stroke J. 2023;23969873231175404. 10.1177/23969873231175405 PubMed PMC

Eldredge LKB, Markham C, Ruiter R. Planning health promotion programs. Emerg Nurse. 2018;25:15.

Bartholomew Eldredge LK, Markham CM, Ruiter RAC, Fernández ME, Kok G, Parcel GS. Planning health promotion programs: an intervention mapping approach. 4th ed. San Francisco: Jossey-Bass Inc; 2016.

Kok G, Gottlieb NH, Peters GJY, Mullen PD, Parcel GS, Ruiter RAC, et al. A taxonomy of behaviour change methods: an intervention mapping approach. Health Psychol Rev. 2016;10(3):297–312. PubMed PMC

Dokova KG, Feigin VL. Trends in stroke burden in central and eastern Europe from 1990–2019. Neuroepidemiology. 2022;56(5):333–44. 10.1159/000525880. PubMed

Bryndová L, Bar M, Herzig R, Mikulík R, Neumann J, Šaňák D, et al. Concentrating stroke care provision in the Czech Republic: The establishment of Stroke Centres in 2011 has led to improved outcomes. Health Policy (New York). 2021;125(4):520–5. Available from: https://www.sciencedirect.com/science/article/pii/S0168851021000282. PubMed

Yoon SS. Perceptions of stroke in the general public and patients with stroke: a qualitative study. BMJ. 2002;324(7345):1065–1065. 10.1136/bmj.324.7345.1065. PubMed PMC

Iversen AB, Blauenfeldt RA, Johnsen SP, Sandal BF, Christensen B, Andersen G, et al. Understanding the seriousness of a stroke is essential for appropriate help-seeking and early arrival at a stroke centre: a cross-sectional study of stroke patients and their bystanders. Eur Stroke J. 2020;5(4):351–61. 10.1177/2396987320945834. PubMed PMC

Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, et al. Activation of emergency medical services for acute stroke in a Nonurban population. Stroke. 2000;31(8):1925–8. 10.1161/01.STR.31.8.1925. PubMed

Mellon L, Doyle F, Rohde D, Williams D, Hickey A. Stroke warning campaigns: delivering better patient outcomes? A systematic review. Patient Relat Outcome Meas. 2015;61. http://www.dovepress.com/stroke-warning-campaigns-delivering-better-patient-outcomes-a-systemat-peer-reviewed-article-PROM. PubMed PMC

American Stroke Association. F.A.S.T. Materials. https://www.stroke.org/en/help-and-support/resource-library/fast-materials

Mbarek R, Zaddem F. The examination of factors affecting e-learning effectiveness. Int J Innov Appl Stud. 2013;2:2.

Mayer RE. Multimedia learning. Cambridge University Press; 2001. https://www.cambridge.org/core/product/identifier/9781139164603/type/book.

Mayer RE, Moreno R. Nine Ways to Reduce Cognitive Load in Multimedia Learning. Educ Psychol. 2003;38(1):43–52.

Brame CJ. Effective educational videos: principles and guidelines for maximizing student learning from video content. CBE Life Sci Educ. 2016;15(4):es6. PubMed PMC

Moyer-Gusé E. Toward a theory of entertainment persuasion: explaining the persuasive effects of entertainment-education messages. Commun Theory. 2008;18(3):407–25 https://academic.oup.com/ct/article/18/3/407-425/4098715.

Lee JK, Hecht ML, Miller-Day M, Elek E. Evaluating Mediated Perception of Narrative Health Messages: The Perception of Narrative Performance Scale. Commun Methods Meas. 2011;5(2):126–45. Available from: http://www.tandfonline.com/doi/abs/10.1080/19312458.2011.568374. PubMed DOI PMC

Igartua JJ. Identification with characters and narrative persuasion through fictional feature films. Communications. 2010;35(4). Available from: https://www.degruyter.com/document/doi/10.1515/comm.2010.019/html DOI

Appel M, Gnambs T, Richter T, Green MC. The Transportation Scale-Short Form (TS–SF). Media Psychol. 2015;18(2):243–66. 10.1080/15213269.2014.987400.

Moyer-Gusé E. Toward a theory of entertainment persuasion: explaining the persuasive effects of entertainment-education messages. Commun Theory. 2008;18(3):407–25. 10.1111/j.1468-2885.2008.00328.x.

Deshpande AD, Thompson VLS, Vaughn KP, Kreuter MW. The Use of Sociocultural Constructs in Cancer Screening Research Among African Americans. Cancer Control. 2009;16(3):256–65. http://journals.sagepub.com/doi/10.1177/107327480901600308. PubMed DOI PMC

Hoddinott P. A new era for intervention development studies. Pilot Feasibility Stud. 2015;1(1):36. 10.1186/s40814-015-0032-0. PubMed PMC

Komolafe MA, Olorunmoteni OE, Fehintola FO. Effect of health education on level of awareness and knowledge of nigerian in-school adolescents on stroke and its risk factors. J Stroke Cerebrovasc Dis. 2020;29(5):104757 https://www.sciencedirect.com/science/article/pii/S1052305720301348. PubMed

Dressman LA, Hunter J. Stroke awareness and knowledge retention in children: the Brain Child Project. Stroke. 2002;33(2):623–5. PubMed

Miyashita F, Yokota C, Nishimura K, Amano T, Inoue Y, Shigehatake Y, et al. The effectiveness of a stroke educational activity performed by a schoolteacher for junior high school students. J Stroke Cerebrovasc Dis. 2014;23(6):1385–90. PubMed

Sakamoto Y, Yokota C, Miyashita F, Amano T, Shigehatake Y, Oyama S, et al. Effects of stroke education using an animated cartoon and a manga on elementary school children. J Stroke Cerebrovasc Dis. 2014;23(7):1877–81. 10.1016/j.jstrokecerebrovasdis.2014.02.015. PubMed

Amano T, Yokota C, Sakamoto Y, Shigehatake Y, Inoue Y, Ishigami A, et al. Stroke education program of act FAST for junior high school students and their parents. J Stroke Cerebrovasc Dis off J Natl Stroke Assoc. 2014;23(5):1040–5. PubMed

Enhancing stroke response in school children: Efficacy of the HOBIT program - a cluster randomized trial