Stroke Education Using an Animated Cartoon and a Manga for Junior High School Students Yuya Shigehatake, MD, Chiaki Yokota, MD, Tatsuo Amano, MD, Yasuhiro Tomii, MD, Yasuteru Inoue, MD, Takaaki Hagihara, MD, Kazunori Toyoda, MD, and Kazuo Minematsu, MD
Background: We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge. Methods: We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 1213 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as ‘‘training.’’ Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training. Results: The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly. Conclusions: Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students. Key Words: School-based training—stroke education—FAST—Manga. Ó 2014 by National Stroke Association
Introduction From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan. Received December 6, 2013; revision received January 6, 2014; accepted January 7, 2014. Grant support: Intramural Research Fund of the National Cerebral and Cardiovascular Center (22-4-1). Disclosure: None. 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.2014.01.001
Although stroke mortality has dramatically declined to the fourth leading cause of death in Japan, the number of stroke survivors has been increasing along with a rapid increase in the elderly population for the past 25 years. Disability of stroke survivors produces a great burden to society and individual patients and their families. The advantage of using acute thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA), also known as alteplase, for reducing stroke morbidity and mortality is well known.1,2 However, the actual rates of rt-PA treatment were reported to be as low as 3%-5%,3-5 mostly because of the lack of knowledge regarding stroke and of the delay in transport to a
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-5
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Y. SHIGEHATAKE ET AL.
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hospital after onset of stroke. On September 2008, the European Co-operative Acute Stroke Study III extended the treatment time of rt-PA from 3 to 4.5 hours after the onset of symptoms in patients with acute ischemic stroke.6 However, few patients with acute ischemic stroke can receive rt-PA in the extended time window.7 The most important factor limiting the use of acute ischemic stroke therapy with rt-PA is the transit time to the hospital.8 Wein et al9 reported that only 4.3% of stroke patients called the emergent medical service (EMS) by themselves, and the remaining 95.7% of calls were made by family member, paid caregiver, coworkers, or others. Therefore, knowledge of stroke is important for individuals, family members, and the general population. Many researchers have reported that public education using mass media or EMS instructors improved public awareness of stroke for adults.10-15 However, there were only a few studies of stroke education for juveniles.16-18 We developed a stroke education system performed by stroke neurologists for junior high school students.19 In our study, we showed that our education system was beneficial for the students’ parents/guardians and the students themselves. As the next step, we investigated whether junior high school students could acquire the knowledge taught only by teaching materials such as an animated cartoon and a Manga that we produced for the purpose of wide dissemination of this knowledge. The aim of this study was to evaluate the effectiveness of an animated cartoon and a Manga in providing information about stroke risk factors, stroke signs and symptoms, and to train junior high school students to call for EMS immediately on identification of stroke signs and symptoms.
Methods Stroke Education Items We produced a Manga (148 3 210 mm; Fig 1) and a 10minute animated cartoon (Fig 2), providing instructions on stroke signs and symptoms, stroke risk factors, and awareness to immediately contact the EMS on identification of stroke signs and symptoms. For identifying stroke signs and symptoms, we used the ‘‘FAST’’ criteria derived from the Cincinnati Prehospital Stroke Scale: F, face numbness or weakness; A, arm numbness or weakness; and S, speech slurred or difficulty speaking or understanding.20 Other stroke symptoms besides ‘‘FAST’’ such as severe headache, visual impairment, and dizziness were also included in the Manga. The Manga and the animated cartoon involved 3 stories. The first one was a case of acute ischemic stroke treated successfully with hyperacute thrombolytic therapy. The remaining 2 stories were cases of transient ischemic attack: a case of successful prevention of stroke with the appropriate action of the patient’s family and the other was a case of suffering from a completed stroke
with delayed hospital admission because of the lack of stroke symptom knowledge.
Subjects and Study Design This study was exempted approval from the institutional review board based on our domestic guidelines because only anonymous and untraceable data sets were used. We enrolled 493 students in 15 classes of the first grade of 3 private junior high schools (age 12-13 years) from December 2011 to March 2012. The students had no teacher-led lessons but watched the 10-minute animated cartoon and read the Manga for stroke education for 10 minutes in the class. For assessments, questionnaires on stroke knowledge (a total of 12 items for stroke signs and 10 items for risk factors) were attempted by all the students before (baseline), immediately after, and 3 months after the training. All data were collected without personal identifiers. The questionnaire comprised multiple-choice and closeended questions that assessed the knowledge of stroke signs and risk factors. The 12 items for stroke signs included 6 on symptoms of stroke (‘‘headache,’’ ‘‘facial weakness,’’ ‘‘vision loss,’’ ‘‘speech disturbance,’’ ‘‘numbness on 1 side of the body,’’ and ‘‘weakness on 1 side on body’’) and 6 atypical symptoms (‘‘chest pain,’’ ‘‘dyspnea,’’ ‘‘weakness on 4 limbs,’’ ‘‘abdominal pain,’’ ‘‘edema in feet,’’ and ‘‘joint pain’’). The 10 items for risk factors consisted of 7 stroke risk factors (‘‘alcohol intake every day,’’ ‘‘smoking,’’ ‘‘hypertension,’’ ‘‘dyslipidemia,’’ ‘‘hyperglycemia,’’ ‘‘obesity,’’ and ‘‘arrhythmia’’) and 3 atypical risk factors (‘‘constipation,’’ ‘‘urinary frequency,’’ and ‘‘stiffness of neck’’). Furthermore, knowledge of adequate action at the onset of stroke onset and the meaning of the FAST mnemonic, such as each word of F, A, S, and T, were also examined by a single choice test. Statistical analyses were performed using JMP7.0 (SAS Institute, Inc., Cary, NC). Data are presented as frequencies (%). Data were compared among the 3 groups of results with the Fisher exact test, namely baseline, immediately after, and 3 months after the training. A value of P less than .05 was considered to indicate a significant difference.
Results Because a few students were absent from school on occasions, the number of questionnaires collected at immediately after and 3 months after the training was 491 (99%) and 480 (97%), respectively. The results of the questionnaires on stroke knowledge are shown in Table 1. In the questionnaires on stroke signs and symptoms, the proportions of correct answer in all questions except headache and numbness on 1 side were higher at immediately after the training than at baseline, and this difference remained until 3 months after the training except for answers related to vision loss. At 3 months, the correct
STROKE EDUCATION BY TEACHING AIDS OF THE MANGA
3
Figure 1. Manga for stroke education. When the family was having supper, the aged man dropped suddenly from the chair. His son was surprised but recognized the symptoms as stroke and reacted quickly to call the emergent medical service (EMS). The aged man was transferred to the emergency room of the hospital by the EMS.
answer rates of facial palsy (75% versus 33%), speech disturbance (91% versus 60%), numbness on 1 side (58% versus 51%), and weakness on 1 side (79% versus 52%) were higher than those at baseline. The proportions of correct answer for questions of atypical stroke signs and symptoms, such as chest pain, dyspnea, edema in foot, and joint pain, were significantly higher at 3 months than at baseline. For stroke risk factors, correct answer rates of alcohol intake every day, smoking, obesity, and stiffness of neck as an atypical risk factor were significantly higher at 3 months after the training than at baseline. More students answered correctly the questions related to contacting the EMS for stroke immediately after the training than at baseline (95% versus 85%) and at 3 months after the training (90%). The proportion of students who understood the meaning of the FAST mnemonic correctly at 3 months after the training was significantly less than that at immediately after the training (56% versus 75%).
which we produced, improved stroke knowledge among junior high school students. We have reported that stroke education delivered by stroke neurologists for junior high school students improved their stroke knowledge.19 In the present study,
Discussion We showed that stroke education with the aid of teaching materials of an animated cartoon and the Manga,
Figure 2. Animated cartoon for stroke education. A stroke neurologist made a decision to administer recombinant tissue-plasminogen activator to the aged man after the emergent computed tomography examination.
Y. SHIGEHATAKE ET AL.
4
Table 1. Changes over time on the percentage of correct answers to questions about stroke knowledge
Questions 1. Stroke signs and symptoms Headache Facial palsy Vision loss Speech disturbance Numbness on 1 side of body Weakness on 1 side of body Chest pain Dyspnea Weakness of 4 limbs Abdominal pain Edema on foot Joint pain 2. Adequate action when on stroke onset Calling the EMS 3. Stroke risk factors Alcohol intake Smoking Hypertension Dyslipidemia Hyperglycemia Obesity Arrhythmia Constipation Urinary frequency Stiffness of neck 4. FAST mnemonic F 5 face droop A 5 arm weakness S 5 speech T 5 time All corrected
P*
3 mo after the intervention (n 5 480), %
P*
18 85 28 96 37 89 1 2 36 1 3 1
,.0001 ,.0001 .001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 .011 ,.0001 ,.0001
33 75 20 91 58 79 5 13 52 2 6 4
,.0001 ,.0001 ns ,.0001 .0460 ,.0001 ,.0001 ,.0001 ns ns .008 ,.0001
85
95
,.0001
90
.027
72 54 76 55 52 22 67 1 6 6
99 80 86 86 79 39 67 0 5 0
,.0001 ,.0001 .0002 ,.0001 ,.0001 ,.0001 ns ns ns ,.0001
96 69 78 61 55 35 66 1 4 3
— — — — —
86 90 89 96 75
— — — — —
79 78 81 87 56
,.0001 ,.0001 ns ns ns ,.0001 ns ns ns .010 Py ns ,.0001 .0002 ,.0001 ,.0001
Baseline (n 5 492), %
Immediate after the intervention (n 5 491), %
55 33 19 60 51 52 14 31 56 3 11 8
Abbreviations: EMS, emergent medical service; ns, nonsignificant. *Fisher exact test, compared with baseline. yFisher exact test, compared with immediately after.
students read the Manga followed by watching the animated cartoon in the class without receiving instructions by either stroke neurologists or schoolteachers. In both studies, that is, the previous and the present one, correct answer rates of stroke symptoms other than FAST, such as headache or vision loss, were not recalled by the students at 3 months after the training. On the other hand, stroke symptoms involved in the FAST message and risk factors of alcohol intake, smoking, and obesity were readily recalled for 3 months after the training in both studies. However, only 56% of students answered correctly the meaning of the FAST mnemonic 3 months after the training in the present study, which was low compared with the 96% rate observed in the previous study.19 These findings indicate that stroke education using the FAST mnemonic can be effective for remembering
to call the EMS promptly on stroke warning signs; however, stroke education only by the aid of teaching materials, such as that used in the present study, could not produce the same result as that obtained when training was given by a stroke neurologist. The reason for getting the same results for items related to risk factors between the 2 studies is unclear. Risk factors of alcohol intake, smoking, and obesity may be commonly known among junior high school students. To shorten the delay time to hospital admission after the onset of stroke symptom, it is essential to encourage people to call the EMS promptly on recognition of stroke warning signs. The target population is one of essential factors for effective stroke education. School-based training was shown to indirectly deliver the FAST message to the students’ parents or grandparents because the students
STROKE EDUCATION BY TEACHING AIDS OF THE MANGA
shared their knowledge gained by this training with these family members at home.17,19 Moreover, stroke education for the youth could be expected to play an important role for a bystander who encounters the stroke warning signs. Teaching materials is another essential factor for effective stroke education. Our comic book, using ‘‘Manga’’, is likely to win general acceptance in Japan as did ‘‘HipHop’’ stroke in the African-American population in the United States.16,17 Manga is a part of the Japanese culture. We believe our teaching materials using the Manga could deliver this important message of acting fast on observation of stroke signs not only nationwide in Japan but also all over the world. There were several limitations in this study. The study was not a randomized controlled study, and the sample size was small, although the improvement of stroke knowledge was confirmed by the high proportion of correct answers in follow-up examinations. In the present study, the training was conducted at private junior high schools that enroll students of the upper socioeconomic status who might possess with a higher level of stroke knowledge at baseline as indicated previously.21 The behavioral change of calling the EMS on recognition of stroke after the training was not determined because this was a cross-sectional study. Multiple-choice and closed-type questionnaires in the present study may have caused an overestimation of stroke knowledge compared with if open-ended questions were used. In conclusion, school-based training with our teaching materials using the Manga for stroke education was beneficial for imparting this knowledge to junior high school students. Manga could spread stroke knowledge not only in the youth but also in the elderly population. Furthermore, Manga could be used universally without the need of language just by visual presentation. Further revision of our teaching materials using the Manga to improve retention of stroke knowledge can be a promising tool for prompting the appropriate action on recognition of stroke symptoms all over the world. Acknowledgment: We express our deepest gratitude to professor Keiko Takemiya (Department of Manga, Kyoto Seika University, Kyoto, Japan) and the teachers in Tezukayama, Kinransenri, and Iwata junior high schools.
References 1. The National Institute of Neurological Disorders and Stroke rtPA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581-1587. 2. Yamaguchi T, Mori E, Minematsu K, et al. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37:1810-1815. 3. Gillum LA, Johnston SC. Characteristics of academic medical centers and ischemic stroke outcomes. Stroke 2001;32:2137-2142.
5 4. Barber PA, Zhang J, Demchuk AM, et al. Why are stroke patients excluded from tPA therapy? An analysis of patient eligibility. Neurology 2001;56:1015-1020. 5. Grotta JC, Burgin WS, El-Mitwalli A, et al. Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000. Arch Neurol 2001;58:2009-2013. 6. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-1329. 7. de Los Rios la Rosa F, Khoury J, Kissela BM, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: the effect of the European Cooperative Acute Stroke Study (ECASS) III trial. Stroke 2012;43:1591-1595. 8. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998; 51:427-432. 9. Wein TH, Staub L, Felberg R, et al. Activation of emergency medical services for acute stroke in a nonurban population: The T.L.L. Temple foundation stroke project. Stroke 2000;31:1925-1928. 10. Wall HK, Beagan BM, O’Neill J, et al. Addressing stroke signs and symptoms through public education: the stroke heroes act FAST campaign. Prev Chronic Dis 2008;5:A49. 11. Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007;38:2115-2122. 12. 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. 13. 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. 14. 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. 15. 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. 16. 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. 17. Williams O, DeSorbo A, Noble J, et al. Child-mediated stroke communication: findings from hip hop stroke. Stroke 2012;43:163-169. 18. 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. 19. Amano T, Yokota C, Sakamoto Y, et al. Stroke education program of act FAST for junior high school students and their parents [published online ahead of print October 2, 2013]. J Stroke Cerebrovasc Dis http:// dx.doi.org/j.jstrokecerebrovasdis.2013.08.021 20. Kothari RU, Pancioli A, Liu T, et al. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med 1999;33:373-378. 21. Alkadry MG, Wilson C, Nicholson D. Stroke awareness among rural residents: the case of West Virginia. Soc Work Health Care 2005;42:73-92.
Background: We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge. Methods: We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 1213 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as ‘‘training.’’ Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training. Results: The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly. Conclusions: Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students. Key Words: School-based training—stroke education—FAST—Manga. Ó 2014 by National Stroke Association
Introduction From the Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan. Received December 6, 2013; revision received January 6, 2014; accepted January 7, 2014. Grant support: Intramural Research Fund of the National Cerebral and Cardiovascular Center (22-4-1). Disclosure: None. 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.2014.01.001
Although stroke mortality has dramatically declined to the fourth leading cause of death in Japan, the number of stroke survivors has been increasing along with a rapid increase in the elderly population for the past 25 years. Disability of stroke survivors produces a great burden to society and individual patients and their families. The advantage of using acute thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA), also known as alteplase, for reducing stroke morbidity and mortality is well known.1,2 However, the actual rates of rt-PA treatment were reported to be as low as 3%-5%,3-5 mostly because of the lack of knowledge regarding stroke and of the delay in transport to a
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-5
1
Y. SHIGEHATAKE ET AL.
2 4
hospital after onset of stroke. On September 2008, the European Co-operative Acute Stroke Study III extended the treatment time of rt-PA from 3 to 4.5 hours after the onset of symptoms in patients with acute ischemic stroke.6 However, few patients with acute ischemic stroke can receive rt-PA in the extended time window.7 The most important factor limiting the use of acute ischemic stroke therapy with rt-PA is the transit time to the hospital.8 Wein et al9 reported that only 4.3% of stroke patients called the emergent medical service (EMS) by themselves, and the remaining 95.7% of calls were made by family member, paid caregiver, coworkers, or others. Therefore, knowledge of stroke is important for individuals, family members, and the general population. Many researchers have reported that public education using mass media or EMS instructors improved public awareness of stroke for adults.10-15 However, there were only a few studies of stroke education for juveniles.16-18 We developed a stroke education system performed by stroke neurologists for junior high school students.19 In our study, we showed that our education system was beneficial for the students’ parents/guardians and the students themselves. As the next step, we investigated whether junior high school students could acquire the knowledge taught only by teaching materials such as an animated cartoon and a Manga that we produced for the purpose of wide dissemination of this knowledge. The aim of this study was to evaluate the effectiveness of an animated cartoon and a Manga in providing information about stroke risk factors, stroke signs and symptoms, and to train junior high school students to call for EMS immediately on identification of stroke signs and symptoms.
Methods Stroke Education Items We produced a Manga (148 3 210 mm; Fig 1) and a 10minute animated cartoon (Fig 2), providing instructions on stroke signs and symptoms, stroke risk factors, and awareness to immediately contact the EMS on identification of stroke signs and symptoms. For identifying stroke signs and symptoms, we used the ‘‘FAST’’ criteria derived from the Cincinnati Prehospital Stroke Scale: F, face numbness or weakness; A, arm numbness or weakness; and S, speech slurred or difficulty speaking or understanding.20 Other stroke symptoms besides ‘‘FAST’’ such as severe headache, visual impairment, and dizziness were also included in the Manga. The Manga and the animated cartoon involved 3 stories. The first one was a case of acute ischemic stroke treated successfully with hyperacute thrombolytic therapy. The remaining 2 stories were cases of transient ischemic attack: a case of successful prevention of stroke with the appropriate action of the patient’s family and the other was a case of suffering from a completed stroke
with delayed hospital admission because of the lack of stroke symptom knowledge.
Subjects and Study Design This study was exempted approval from the institutional review board based on our domestic guidelines because only anonymous and untraceable data sets were used. We enrolled 493 students in 15 classes of the first grade of 3 private junior high schools (age 12-13 years) from December 2011 to March 2012. The students had no teacher-led lessons but watched the 10-minute animated cartoon and read the Manga for stroke education for 10 minutes in the class. For assessments, questionnaires on stroke knowledge (a total of 12 items for stroke signs and 10 items for risk factors) were attempted by all the students before (baseline), immediately after, and 3 months after the training. All data were collected without personal identifiers. The questionnaire comprised multiple-choice and closeended questions that assessed the knowledge of stroke signs and risk factors. The 12 items for stroke signs included 6 on symptoms of stroke (‘‘headache,’’ ‘‘facial weakness,’’ ‘‘vision loss,’’ ‘‘speech disturbance,’’ ‘‘numbness on 1 side of the body,’’ and ‘‘weakness on 1 side on body’’) and 6 atypical symptoms (‘‘chest pain,’’ ‘‘dyspnea,’’ ‘‘weakness on 4 limbs,’’ ‘‘abdominal pain,’’ ‘‘edema in feet,’’ and ‘‘joint pain’’). The 10 items for risk factors consisted of 7 stroke risk factors (‘‘alcohol intake every day,’’ ‘‘smoking,’’ ‘‘hypertension,’’ ‘‘dyslipidemia,’’ ‘‘hyperglycemia,’’ ‘‘obesity,’’ and ‘‘arrhythmia’’) and 3 atypical risk factors (‘‘constipation,’’ ‘‘urinary frequency,’’ and ‘‘stiffness of neck’’). Furthermore, knowledge of adequate action at the onset of stroke onset and the meaning of the FAST mnemonic, such as each word of F, A, S, and T, were also examined by a single choice test. Statistical analyses were performed using JMP7.0 (SAS Institute, Inc., Cary, NC). Data are presented as frequencies (%). Data were compared among the 3 groups of results with the Fisher exact test, namely baseline, immediately after, and 3 months after the training. A value of P less than .05 was considered to indicate a significant difference.
Results Because a few students were absent from school on occasions, the number of questionnaires collected at immediately after and 3 months after the training was 491 (99%) and 480 (97%), respectively. The results of the questionnaires on stroke knowledge are shown in Table 1. In the questionnaires on stroke signs and symptoms, the proportions of correct answer in all questions except headache and numbness on 1 side were higher at immediately after the training than at baseline, and this difference remained until 3 months after the training except for answers related to vision loss. At 3 months, the correct
STROKE EDUCATION BY TEACHING AIDS OF THE MANGA
3
Figure 1. Manga for stroke education. When the family was having supper, the aged man dropped suddenly from the chair. His son was surprised but recognized the symptoms as stroke and reacted quickly to call the emergent medical service (EMS). The aged man was transferred to the emergency room of the hospital by the EMS.
answer rates of facial palsy (75% versus 33%), speech disturbance (91% versus 60%), numbness on 1 side (58% versus 51%), and weakness on 1 side (79% versus 52%) were higher than those at baseline. The proportions of correct answer for questions of atypical stroke signs and symptoms, such as chest pain, dyspnea, edema in foot, and joint pain, were significantly higher at 3 months than at baseline. For stroke risk factors, correct answer rates of alcohol intake every day, smoking, obesity, and stiffness of neck as an atypical risk factor were significantly higher at 3 months after the training than at baseline. More students answered correctly the questions related to contacting the EMS for stroke immediately after the training than at baseline (95% versus 85%) and at 3 months after the training (90%). The proportion of students who understood the meaning of the FAST mnemonic correctly at 3 months after the training was significantly less than that at immediately after the training (56% versus 75%).
which we produced, improved stroke knowledge among junior high school students. We have reported that stroke education delivered by stroke neurologists for junior high school students improved their stroke knowledge.19 In the present study,
Discussion We showed that stroke education with the aid of teaching materials of an animated cartoon and the Manga,
Figure 2. Animated cartoon for stroke education. A stroke neurologist made a decision to administer recombinant tissue-plasminogen activator to the aged man after the emergent computed tomography examination.
Y. SHIGEHATAKE ET AL.
4
Table 1. Changes over time on the percentage of correct answers to questions about stroke knowledge
Questions 1. Stroke signs and symptoms Headache Facial palsy Vision loss Speech disturbance Numbness on 1 side of body Weakness on 1 side of body Chest pain Dyspnea Weakness of 4 limbs Abdominal pain Edema on foot Joint pain 2. Adequate action when on stroke onset Calling the EMS 3. Stroke risk factors Alcohol intake Smoking Hypertension Dyslipidemia Hyperglycemia Obesity Arrhythmia Constipation Urinary frequency Stiffness of neck 4. FAST mnemonic F 5 face droop A 5 arm weakness S 5 speech T 5 time All corrected
P*
3 mo after the intervention (n 5 480), %
P*
18 85 28 96 37 89 1 2 36 1 3 1
,.0001 ,.0001 .001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 .011 ,.0001 ,.0001
33 75 20 91 58 79 5 13 52 2 6 4
,.0001 ,.0001 ns ,.0001 .0460 ,.0001 ,.0001 ,.0001 ns ns .008 ,.0001
85
95
,.0001
90
.027
72 54 76 55 52 22 67 1 6 6
99 80 86 86 79 39 67 0 5 0
,.0001 ,.0001 .0002 ,.0001 ,.0001 ,.0001 ns ns ns ,.0001
96 69 78 61 55 35 66 1 4 3
— — — — —
86 90 89 96 75
— — — — —
79 78 81 87 56
,.0001 ,.0001 ns ns ns ,.0001 ns ns ns .010 Py ns ,.0001 .0002 ,.0001 ,.0001
Baseline (n 5 492), %
Immediate after the intervention (n 5 491), %
55 33 19 60 51 52 14 31 56 3 11 8
Abbreviations: EMS, emergent medical service; ns, nonsignificant. *Fisher exact test, compared with baseline. yFisher exact test, compared with immediately after.
students read the Manga followed by watching the animated cartoon in the class without receiving instructions by either stroke neurologists or schoolteachers. In both studies, that is, the previous and the present one, correct answer rates of stroke symptoms other than FAST, such as headache or vision loss, were not recalled by the students at 3 months after the training. On the other hand, stroke symptoms involved in the FAST message and risk factors of alcohol intake, smoking, and obesity were readily recalled for 3 months after the training in both studies. However, only 56% of students answered correctly the meaning of the FAST mnemonic 3 months after the training in the present study, which was low compared with the 96% rate observed in the previous study.19 These findings indicate that stroke education using the FAST mnemonic can be effective for remembering
to call the EMS promptly on stroke warning signs; however, stroke education only by the aid of teaching materials, such as that used in the present study, could not produce the same result as that obtained when training was given by a stroke neurologist. The reason for getting the same results for items related to risk factors between the 2 studies is unclear. Risk factors of alcohol intake, smoking, and obesity may be commonly known among junior high school students. To shorten the delay time to hospital admission after the onset of stroke symptom, it is essential to encourage people to call the EMS promptly on recognition of stroke warning signs. The target population is one of essential factors for effective stroke education. School-based training was shown to indirectly deliver the FAST message to the students’ parents or grandparents because the students
STROKE EDUCATION BY TEACHING AIDS OF THE MANGA
shared their knowledge gained by this training with these family members at home.17,19 Moreover, stroke education for the youth could be expected to play an important role for a bystander who encounters the stroke warning signs. Teaching materials is another essential factor for effective stroke education. Our comic book, using ‘‘Manga’’, is likely to win general acceptance in Japan as did ‘‘HipHop’’ stroke in the African-American population in the United States.16,17 Manga is a part of the Japanese culture. We believe our teaching materials using the Manga could deliver this important message of acting fast on observation of stroke signs not only nationwide in Japan but also all over the world. There were several limitations in this study. The study was not a randomized controlled study, and the sample size was small, although the improvement of stroke knowledge was confirmed by the high proportion of correct answers in follow-up examinations. In the present study, the training was conducted at private junior high schools that enroll students of the upper socioeconomic status who might possess with a higher level of stroke knowledge at baseline as indicated previously.21 The behavioral change of calling the EMS on recognition of stroke after the training was not determined because this was a cross-sectional study. Multiple-choice and closed-type questionnaires in the present study may have caused an overestimation of stroke knowledge compared with if open-ended questions were used. In conclusion, school-based training with our teaching materials using the Manga for stroke education was beneficial for imparting this knowledge to junior high school students. Manga could spread stroke knowledge not only in the youth but also in the elderly population. Furthermore, Manga could be used universally without the need of language just by visual presentation. Further revision of our teaching materials using the Manga to improve retention of stroke knowledge can be a promising tool for prompting the appropriate action on recognition of stroke symptoms all over the world. Acknowledgment: We express our deepest gratitude to professor Keiko Takemiya (Department of Manga, Kyoto Seika University, Kyoto, Japan) and the teachers in Tezukayama, Kinransenri, and Iwata junior high schools.
References 1. The National Institute of Neurological Disorders and Stroke rtPA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581-1587. 2. Yamaguchi T, Mori E, Minematsu K, et al. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37:1810-1815. 3. Gillum LA, Johnston SC. Characteristics of academic medical centers and ischemic stroke outcomes. Stroke 2001;32:2137-2142.
5 4. Barber PA, Zhang J, Demchuk AM, et al. Why are stroke patients excluded from tPA therapy? An analysis of patient eligibility. Neurology 2001;56:1015-1020. 5. Grotta JC, Burgin WS, El-Mitwalli A, et al. Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000. Arch Neurol 2001;58:2009-2013. 6. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-1329. 7. de Los Rios la Rosa F, Khoury J, Kissela BM, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: the effect of the European Cooperative Acute Stroke Study (ECASS) III trial. Stroke 2012;43:1591-1595. 8. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998; 51:427-432. 9. Wein TH, Staub L, Felberg R, et al. Activation of emergency medical services for acute stroke in a nonurban population: The T.L.L. Temple foundation stroke project. Stroke 2000;31:1925-1928. 10. Wall HK, Beagan BM, O’Neill J, et al. Addressing stroke signs and symptoms through public education: the stroke heroes act FAST campaign. Prev Chronic Dis 2008;5:A49. 11. Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007;38:2115-2122. 12. 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. 13. 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. 14. 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. 15. 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. 16. 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. 17. Williams O, DeSorbo A, Noble J, et al. Child-mediated stroke communication: findings from hip hop stroke. Stroke 2012;43:163-169. 18. 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. 19. Amano T, Yokota C, Sakamoto Y, et al. Stroke education program of act FAST for junior high school students and their parents [published online ahead of print October 2, 2013]. J Stroke Cerebrovasc Dis http:// dx.doi.org/j.jstrokecerebrovasdis.2013.08.021 20. Kothari RU, Pancioli A, Liu T, et al. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med 1999;33:373-378. 21. Alkadry MG, Wilson C, Nicholson D. Stroke awareness among rural residents: the case of West Virginia. Soc Work Health Care 2005;42:73-92.
