Effects of Stroke Education Using an Animated Cartoon and a Manga on Elementary School Children Yuki Sakamoto, MD, Chiaki Yokota, MD, Fumio Miyashita, MD, Tatsuo Amano, MD, Yuya Shigehatake, MD, Satoshi Oyama, MD, Naruhiko Itagaki, MD, Kosuke Okumura, MD, Kazunori Toyoda, MD, and Kazuo Minematsu, MD

Background: Stroke education for the youth is expected to reduce prehospital delay by informing the bystander of appropriate action to take and providing knowledge to prevent onset of stroke in future. Previously, we developed effective teaching materials consisting of an animated cartoon and a Manga for junior high school students. The aim of this study was to evaluate the feasibility and effectiveness of our educational materials for stroke education taught by schoolteachers to elementary school children. Methods: Using our teaching materials, a 30-minute lesson was given by trained general schoolteachers. Questionnaires on stroke knowledge (symptoms and risk factors) and action to take on identification of suspected stroke symptoms were filled out by school children before, immediately after, and at 3 months after completion of the lesson. Results: A total of 219 children (aged 10 or 11 years) received the stroke lesson. Stroke knowledge significantly increased immediately after the lesson compared with before (symptoms, P ,.001; risk factors, P , .001); however, correct answer rates decreased at 3 months immediately after completion of the lesson (symptoms, P 5.002; risk factors, P 5.045). The proportion of the number of children calling emergency medical service on identifying stroke symptoms was higher immediately after the lesson than baseline (P 5 .007) but returned to the baseline at 3 months after the lesson. Conclusions: Stroke lesson by schoolteachers using our teaching materials consisting of an animated cartoon and a Manga that was previously used for junior high school students was feasible for elementary school children. However, revision of the materials is required for better retention of stroke knowledge for children. Key Words: Stroke education— elementary school children—Manga—animated cartoon. Ó 2014 by National Stroke Association

Time is critical in acute stroke management because acute thrombolytic therapies should be performed within 4.5 hours of symptom onset.1,2 In these settings, the From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. Received February 12, 2014; accepted February 21, 2014. This study was supported by the Intramural Research Fund of the National Cerebral and Cardiovascular Center (22-4-1). Address correspondence to Chiaki Yokota, MD, Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.02.015

symptom onset to hospital arrival time (onset-to-door time) is a key factor for increasing the number of patients with acute stroke who can undergo reperfusion therapy because only one fourth of the patients with acute ischemic stroke arrive at the hospital within 3.5 hours after the onset.3 Stroke education is expected to reduce the onset-todoor time by increasing the knowledge of warning signs for stroke. Moreover, stroke education for the youth is anticipated to contribute to stroke prevention. Campaigns using mass media4-6 aimed at the population at high risk of stroke,7 have improved the knowledge of warning signs and risk factors of stroke, and have increased the number of emergency department visits6

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or corresponding frequencies of using emergency medical service (EMS)8 for patients suspected with acute stroke. However, these studies were intended for adults, and there are a few studies targeted at younger individuals. Moreover, the optimum means of how to educate adolescents on stroke knowledge is not completely clear. We showed that stroke education performed by a stroke neurologist using the ‘‘FAST’’ mnemonic, derived from the Cincinnati Prehospital Stroke Scale (F 5 facial drooping, A 5 arm numbness or weakness, S 5 slurred speech or difficulty in speaking or understanding, T 5 time),9 improved stroke knowledge for junior high school students and their parents.10 We also confirmed that a schoolteacher could deliver the FAST message lesson to junior high school students with a similar outcome as a stroke neurologist using our stroke education system.11 For wide dissemination of stroke knowledge, we developed effective teaching materials, such as an animated cartoon and a Manga for junior high school students.12 In the present study, we aimed to determine the feasibility and utility of our stroke education program using our teaching materials delivered by a schoolteacher for elementary school children.

Methods Study Setting and Population Suita City is located in the urban area of Osaka prefecture in Japan and has around 350,000 residents. Almost all the residents are Asian. The research was in partnership with the Suita City Board of Education (SCBE) and included all the public elementary schools (20,000 pupils) and junior high schools (9000 students) in Suita City. The present study was a preliminary examination for investigating the utility of the stroke education program for fifthgrade children in 2 public elementary schools selected at random. The SCBE approved this study, and the study was exempted from the institutional review board approval based on our domestic guidelines because only anonymous and untraceable data sets were used.

Educational Program We previously produced an animated cartoon and a Manga for junior high school students that provided instruction on the signs and symptoms of stroke, its risk factors, and increased awareness to immediately contact the EMS on identification of signs and symptoms of stroke.12 Using these materials, a 30-minute tutorial was given by general schoolteachers for elementary school children. We developed the entire content of the lesson in cooperation with SCBE. The schoolteachers delivered the lesson within 2 weeks after receiving instructions from a stroke neurologist (T.A.) on educating the children on stroke knowledge. The lesson consisted of 2 parts: a didactic session on stroke knowledge including risk fac-

tors, signs and symptoms, and treatments, followed by a review session using our animated cartoon and a Manga. Educational items consisting of a magnet poster printed with the FAST message were distributed to all the students after the lesson. Schoolteachers asked the children to place the magnet poster on the kitchen refrigerator. The quality of the lesson was checked by 2 neurologists (Y.S. and F.M.) by reviewing a video recording of the class.

Assessment of Education Program Multiple-choice and closed-type questionnaires on stroke knowledge (including a total of 6 correct answers from 12 items for the signs and symptoms of stroke and 7 correct answers from 14 items for risk factors) were filled out by school children before, immediately after, and 3 months after the lesson (Table 1). The children scored 1 point if they chose a correct answer or did not choose an incorrect answer. Therefore, the scores of questionnaires on signs and risk factors of stroke ranged from 0 to 12 and 0 to 14, respectively. How to act on recognition of suspected signs or symptoms of stroke was asked in single-choice and closed-type manner as described in Table 1.

Statistical Analyses All data were collected without personal identifiers. Data are presented as mean 6 standard deviation or frequencies (%). A general linear model repeated-measures analysis of variance was used to compare the composite score over time from baseline to 3 months after the lesson. Post hoc analyses using Bonferroni correction for multiple comparisons were performed to interpret the significant effects. The proportion of students selecting ‘‘calling EMS’’ on identification of the signs or symptoms of stroke was also assessed with chi-square test. All statistical analyses were performed using PASW for Windows version 17.0 software (SPSS, Inc., Chicago, IL). Results were considered significant at P less than .05.

Results In February 2012, 249 school children of 7 classes from 2 public elementary schools received the stroke lesson. Of these, 30 students of 1 class were excluded from the analyses because the last assessment test at 3 months was not conducted because of concern about 1 student who lost his or her father because of stroke 2 weeks before the test. Figure 1 shows the composite score of stroke symptoms (left panel, maximum score of 12) and risk factors (right panel, maximum score of 14) before, immediately after, and 3 months after the lesson. The mean composite score changed significantly over 3 months after the stroke lesson (stroke symptoms, P , .001; risk factors, P , .001). On the post hoc analysis, both the scores

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Table 1. Questionnaire (originally written in Japanese) Question 1: What do you think is the likely condition of people who have ‘‘stroke’’? A: Severe headache B: Weakness in both arms and both legs D: Visually impaired E: Speak unclearly G: Without feeling in one H: Facial weakness in one side of the body side J: Weakness of arm and leg K: Become swollen in one side Question 2: What do you think is the likely cause of ‘‘stroke’’? A: Stiff neck B: Heavy drinking of alcohol D: Frequent urination E: Hypertension G: Speed-eating H: High cholesterol level J: Loud noise K: Overweight M: Driving long time N: Irregular heart rhythm Question 3: What do you do if you find a person who is having a stroke attack? A: Take him/her to the nearest B: Take him/her to his/her hospital with taxi. personal doctor. D: Tell him/her to take a rest. E: Nothing

C: Feel like choking F: Chest pain I: Stomach ache L: Joint pain

C: Smoking F: Constipation I: High blood glucose level L: Watching television for a long time

C: Call an ambulance

Correct answers are in bold.

increased significantly immediately after the lesson compared with those before the lesson (symptoms, 8.89 6 1.19 vs 7.59 6 1.64, P , .001; risk factors, 11.44 6 1.59 vs 10.56 6 1.89, P , .001). However, the mean composite score of either symptoms (8.52 6 1.39, P 5 .002) or risk factors (11.11 6 1.75, P 5 .045) decreased at 3 months, although the score was still higher than that before the lesson (symptoms, P , .001; risk factors, P 5 .009). The proportion of students selecting ‘‘calling EMS’’ on identification of signs and symptoms of stroke increased immediately after the lesson compared with that before

Figure 1. Changes of composite scores at 3 months after the stroke lesson. Composite scores of both symptoms and risk factors were significantly higher at 3 months after the stroke lesson compared with that before the lesson. However, both scores decreased significantly at 3 months compared with those immediately after the lesson.

the lesson (97% vs 91%, P 5.007) but returned to the baseline value (91%) at 3 months after the lesson (Fig 2).

Discussion We showed that the stroke lessongiven by the general schoolteachers using our teaching materials, an animated cartoon and a Manga, was feasible and improved the stroke knowledge immediately after the stroke lesson. However, the proportion of adequate action of ‘‘calling EMS’’ on recognition of signs or symptoms of stroke returned to the level of the baseline at 3 months after the lesson.

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Figure 2. Proportion of students selecting ‘‘calling EMS’’ on identification of any signs and symptoms of stroke at 3 months after the stroke lesson. Proportion of students selecting ‘‘calling EMS’’ immediately after the lesson significantly increased compared with that before the lesson; however, it returned to the baseline at 3 months after the lesson.

For junior high school students, stroke lesson given by a schoolteacher or a stroke neurologist using our educational materials can deliver the FAST message.11 Only watching an animated cartoon followed by reading a Manga without stroke lesson, which was referred to as ‘‘training,’’ also improved stroke knowledge even 3 months after the ‘‘training.’’12 In the present study for elementary school children, we designed a relatively brief lesson of 30 minutes compared with our previous studies10,11 or studies by others13,14 using our teaching materials, to be delivered by schoolteachers. Although stroke knowledge improved immediately after the stroke lesson, retention of the information especially that related to adequate action to be taken on identification of symptoms of stroke decreased in the present study. The magnet poster, which the schoolteachers had asked the children to place on the kitchen refrigerator, could not help improve the memory retention of the FAST message. A possible reason for this finding may be related to the difficulty for elementary school children to understand the meaning of our teaching materials developed for junior high school students. Our teaching materials, an animated cartoon and a Manga, use the ‘‘FAST’’ mnemonic. Because ‘‘FAST’’ is an acronym in the English language, elementary school children may not be able to memorize and use this mnemonic. Several public educational campaigns were reported to increase stroke awareness4,6,15-17; however, these studies were intended for adults. Stroke education for the youth would be expected to inculcate a healthy lifestyle from a younger age, resulting in the primary prevention of stroke in future, and in the case of these students playing the role of the bystander would be expected to lead to early arrival at hospital for the stroke victim.18,19

Moreover, our education program was not only beneficial for junior high school students but also their parents and grandparents.10 For effective school-based intervention, better retention of knowledge of the signs and symptoms of stroke, and action to be taken on the observation of its signs and symptoms, the educational material should be chosen according to the age of the target population. Incorporating cultural elements, such as hip-hop music, in the African-American population in the United States improved retention of knowledge of stroke among elementary school children.14 Manga, one of the cultural elements in Japan, may be a promising means of spreading the knowledge of stroke not only among junior high school students but also among elementary school children. There are several limitations to the present study. First, this is a preliminary observational study, and randomization or case–control comparisons were not conducted. Second, knowledge of stroke was assessed by multiplechoice and closed-type questionnaires, which may possibly be associated with an overestimation of knowledge of stroke compared with open-ended questions. Third, repeated lessons and not a single lesson, as used in the present study, are necessary to retain knowledge. Fourth, the sample size was relatively small because of exclusion of 30 students of 1 class for concern about a student who lost his or her father because of stroke 2 weeks before the test. In conclusion, the stroke lesson given by schoolteachers using an animated cartoon and a Manga was feasible; however, the FAST mnemonic was difficult for elementary school children to remember. Further study is needed to improve ease of understanding and retention of knowledge of stroke signs and symptoms for elementary school children. Acknowledgments: We express our deepest gratitude to Professor Keiko Takemiya (Department of Manga, Kyoto Seika University, Kyoto, Japan), all the members of the Suita City Board of Education, and the teachers in public elementary and junior high school in Suita City. We also thank Dr Haruko Yamamoto (National Cerebral and Cardiovascular Center) for her advice about ethical issues.

References 1. Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-1711.

STROKE EDUCATION FOR ELEMENTARY SCHOOL CHILDREN 2. Shinohara Y. For readers (stroke specialists and general practitioners) of the Japanese guidelines for the management of stroke. J Stroke Cerebrovasc Dis 2011;20:S1-S6. 3. Tong D, Reeves MJ, Hernandez AF, et al. Times from symptom onset to hospital arrival in the get with the guidelines—stroke program 2002 to 2009: Temporal trends and implications. Stroke 2012;43:1912-1917. 4. Miyamatsu N, Kimura K, Okamura T, et al. Effects of public education by television on knowledge of early stroke symptoms among a Japanese population aged 40 to 74 years: a controlled study. Stroke 2012;43: 545-549. 5. Silver FL, Rubini F, Black D, et al. Advertising strategies to increase public knowledge of the warning signs of stroke. Stroke 2003;34:1965-1968. 6. Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007;38:2115-2122. 7. Kleindorfer D, Miller R, Sailor-Smith S, et al. The challenges of community-based research: the beauty shop stroke education project. Stroke 2008;39:2331-2335. 8. Jurkowski JM, Maniccia DM, Spicer DA, et al. Impact of a multimedia campaign to increase intention to call 9-1-1 for stroke symptoms, upstate New York, 2006-2007. Prev Chronic Dis 2010;7:A35. 9. Kothari RU, Pancioli A, Liu T, et al. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med 1999;33:373-378. 10. Amano T, Yokota C, Sakamoto Y, et al. Stroke education program of act FAST for junior high school students and their parents. J Stroke Cerebrovasc Dis 2014. In press.

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11. Miyashita F, Yokota C, Nishimura K, et al. The effectiveness of a stroke educational activity performed by a schoolteacher for junior high school students. J Stroke Cerebrovasc Dis 2014. In press. 12. Shigehatake Y, Yokota C, Amano T, et al. Stroke education by using an animated cartoon and a Manga for junior high school students. J Stroke Cerebrovasc Dis 2014. In press. 13. Morgenstern LB, Gonzales NR, Maddox KE, et al. A randomized, controlled trial to teach middle school children to recognize stroke and call 911: the kids identifying and defeating stroke project. Stroke 2007;38:2972-2978. 14. Williams O, Noble JM. ’Hip-Hop’ stroke: a stroke educational program for elementary school children living in a high-risk community. Stroke 2008;39:2809-2816. 15. Tadros A, Crocco T, Davis SM, et al. Emergency medical services-based community stroke education: Pilot results from a novel approach. Stroke 2009;40:2134-2142. 16. Morimoto A, Miyamatsu N, Okamura T, et al. Effects of intensive and moderate public education on knowledge of early stroke symptoms among a Japanese population: the acquisition of stroke knowledge study. Stroke 2013; 44:2829-2834. 17. Bray JE, Johnson R, Trobbiani K, et al. Australian public’s awareness of stroke warning signs improves after national multimedia campaigns. Stroke 2013;44:3540-3543. 18. Iguchi Y, Wada K, Shibazaki K, et al. First impression at stroke onset plays an important role in early hospital arrival. Intern Med 2006;45:447-451. 19. Kim YS, Park SS, Bae HJ, et al. Stroke awareness decreases prehospital delay after acute ischemic stroke in Korea. BMC Neurol 2011;11:2.

Effects of stroke education using an animated cartoon and a manga on elementary school children.

Stroke education for the youth is expected to reduce prehospital delay by informing the bystander of appropriate action to take and providing knowledg...
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