FAST stroke prevention educational Program for Middle School Students: pilot study results.

Abstract: This pilot study evaluated the effects of FAST Stroke Prevention Educational Program for Middle School Students, a 2-month stroke prevention educational program targeted to middle school students. The FAST program focused on improving knowledge of stroke signs and symptoms; risk factors;

treatment-seeking behaviors (call 911); overall attitude toward stroke, including perceived self-efficacy in identifying stroke warning signs and dealing with a stroke victim; stroke risk-reduction behaviors; and other risk factors for stroke, such as hypertension and diabetes. The FAST program evaluation consisted of a pretest, an educational intervention, immediate posttest, and a long-term posttest at 2 months. A convenience sample of 72 students with a mean age of 13.25 years was used. After obtaining school, parental, and student consent, the FAST program was implemented by the school nurse, health teachers, and research nurses. Results indicated significant increases in knowledge of stroke risk factors and warning signs and in attitudes of self-efficacy among middle school students that were sustained from pretest to long-term posttest; data supported the effectiveness of this novel intervention. Additional research using a variety of educational strategies and a longer time frame of intervention is recommended to further expand use of this program.

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Stroke remains the third leading cause of death in the United States and a major cause of long-term disability (Rosamond et al., 2007). Public awareness of stroke warning signs remains low. The Greater Cincinnati/Northern Kentucky Stroke Team (GCNKST) has conducted population-based research on public awareness of stroke and found that only 70% of surveyed adults could name a single stroke warning sign (Schneider et al., 2003). The need for new and creative strategies for educating the public is clear. Public knowledge of stroke warning signs may be low in part because of the complicated nature of the messages promoted thus far. Currently, public awareness campaigns by national organizations, such as the American Heart Association (AHA) and American Stroke Association (ASA), use a list of stroke signs and symptoms beginning with the word "sudden" that were developed by a panel of experts from the Brain Attack Coalition. In our experience, this list is long and difficult for patients, families, and healthcare providers to remember.

The GCNKST developed another educational method using the mnemonic FAST (Face, Arm, Speech, Time to call 911) that was derived from the core elements of the National Institutes of Health (NIH) Stroke Scale and the Cincinnati Prehospital Scale (Brott et al., 1989; Kothari, Pancioli, Brott, & Broderick, 1999). A prospective, observational cohort study of 299 emergency department admissions identified three items (facial palsy, motor arm, and dysarthria) that accounted for 100% of the patients with stroke and had a sensitivity of 100% and a specificity of 92% (Kothari, Hall, Brott, & Broderick, 1997). The Out-of-Hospital NIH Stroke Scale was based on facial palsy, motor arm, and a combination of dysarthria and best language (Face, Arm, Speech) and had a sensitivity of 100% and a specificity of 88% (Kothari et al., 1997). Because treatment options such as tissue plasminogen activator (TPA) are available for patients who experience an ischemic stroke and receive treatment ideally within 3 hours of presentation of symptoms, the "T" element (Time to call 911) was added later to create the final component of the mnemonic FAST.

Despite treatment advances, the most effective way to treat stroke is to prevent it from occurring (Rosamond et al., 2007). Prevention strategies should be implemented in childhood, before behaviors such as unhealthy eating, sedentary lifestyle, and smoking take hold and other prominent stroke risk factors, notably hypertension, diabetes, and obesity, occur. In spite of the urgent need for early childhood prevention programs, middle school textbooks and curricula have little or no stroke-related information (Dressman & Hunter, 2002; Kelly, 2005). Schools are missing an opportunity to educate young people about stroke and the potential to intervene by calling 911 at a time when they might witness another individual (e.g., a parent, grandparent, or teacher) having a stroke. In addition, during middle school, children are developing their own health habits; this time is critical to educate young people about health behaviors that may increase risk for stroke.

This article describes pilot testing of the 2-month FAST Stroke Prevention Educational Program for Middle School Students. The FAST program was designed to address a gap in middle school students' health education and increase their knowledge of stroke signs and symptoms; modifiable stroke-risk factors; treatment-seeking behaviors (calling 911); overall attitudes toward stroke, including perceived self-efficacy in identifying stroke warning signs and dealing with a stroke victim; and stroke risk-reduction behaviors (particularly diet and activity pattern) and other disease-related risk factors (e.g., hypertension and diabetes).

Background and Significance

Traditionally, stroke prevention programs have been designed for adults and have concentrated on expanding knowledge of stroke signs and symptoms and risk factors. Given the doubling rates of obesity and inactivity of children in the United States in the last 20 years, data strongly suggest that these behaviors will place school-aged children at higher risk for stroke in adulthood (Hayman et al., 2004; Kelly, 2005; Rosamond et al., 2007). Because middle school children have frequent contact with adults who are at risk for stroke, they may be able to affect the health behaviors (i.e., exercise, diet) of adults in their families. Furthermore, middle-school-aged children should be educated to call 911 as a first response if a family member has a stroke. Therefore, the development and evaluation of the effectiveness of stroke prevention programs expanding the middle school age groups' knowledge and reduction of stroke risk behaviors has become a national priority (Kelly, 2005; Rosamond et al., 2007).

In one of only a few studies involving children and stroke prevention, Dressman and Hunter (2002) described a brief educational effort to educate a convenience sample of 561 students from kindergarten to eighth grade. The primary focus of this 3-week program was to test knowledge retention of stroke signs and symptoms and the appropriate response when stroke is suspected. Results of this initial effort indicated that the children had a significant and immediate improvement in their stroke-symptom knowledge and response. Although the researchers indicated that they had diversity in sample characteristics pertaining to age, race, and socioeconomic status, this specific information was not actually provided. Moreover, the program was only 3 weeks long, which raises the issue of long-term knowledge retention. The researchers concluded that a nationwide program should be implemented immediately in school systems to increase public awareness and stroke prevention.

Preliminary data from another study involving a convenience sample of seventh-grade students and their parents in Corpus Christi, TX, indicated that students in the educational intervention group (n = 142) had improved knowledge of stroke pathophysiology and treatment, as well as recognition of stroke symptoms, compared to a control group (n = 182) at the end of the second year (Morgenstern et al., 2006). In addition, the intervention group had a significantly improved intention to call 911 for a witnessed stroke than the control group, which had not received the stroke educational content in their health and science school curriculum. Although the data from this pilot study provided evidence that educational programs can increase students' knowledge and intention to call 911 when a stroke is suspected, it neither tested strategies to reduce stroke risk behaviors in middle school students nor assessed students' attitudes about stroke or self-efficacy in identifying stroke warning signs.

With 58 third graders, Skybo and Ryan-Wenger (2002) compared Heart Power, a focused, school-based educational curriculum that concentrated on coronary heart disease (CHD) and risk factors, to a broad-based school health program that concentrated on general health knowledge. The year-long program significantly increased knowledge about CHD and behaviors associated with obesity, sedentary lifestyle, and hypertension; parental participation in the program also increased, compared to the control group with the broad-based health program.

In another quasi-experimental study by Powers, Struempler, Guarino, and Parmer (2005), a nutrition education program directed toward expanding dietary knowledge and improving dietary selections was evaluated with 1,100 second- and third-grade students over a 2-month period. Children in the intervention group exhibited significantly greater improvement in nutrition knowledge and dietary selections compared to the control group. Results suggest that nutritionally focused programs that teach positive dietary messages can improve dietary behavior and increase children's knowledge.

Ogden, Flegal, Carroll, and Johnson (2002), in a study of 4,722 children from birth to 19 years of age that was part of the National Health and Nutrition Examination Survey (NHANES), discovered the prevalence of overweight children between the ages of 12 and 19 was 15.5%, with an additional 10% increase in African American and Mexican American adolescents. Ogden and colleagues identified the following communication strategies as helpful interventions with adolescents:

* having parental involvement

* building upon existing communication channels

* focusing on immediate positive aspects of healthy eating and physical activity

* considering cultural differences to account for variation between white adolescents and African American and Mexican American adolescents (e.g., differing perceptions of health and weight)

* emphasizing that present habits may affect future health

* making messages succinct, realistic, positive, and uplifting.

Davis, Davis, Northington, Moll, and Kolar (2002) reaffirmed these strategies in their review of school-based programs to reduce childhood obesity.

Additional evidence-based teaching strategies to optimize middle school students' learning and retention include participative learning activities, mnemonics connecting the learning to the life of the learner, photographs, and illustrations (Barman, 1997; Guillaume, 2003; Hammrich, 1998). Focus group research involving 98 eighth- and ninth-grade students contributed to the Campaign to Promote Healthy Weight Using Relevant Physical Activity and Nutrition Messages for Youth (Centers for Disease Control and Prevention [CDC], 2000). As a result of these focus groups, which were composed of 46 girls and 52 boys and included African American, Mexican American, and white students, strategies were identified about ways to frame health-related messages to American youth. It was also suggested, however, that young people learn healthy eating primarily from their parents and schools with some minor influence from peers. Another valuable finding was that healthy weight for these young focus group participants was not related to measured weight or appearance but to their attitude, perceptions of themselves, and self-esteem.

Research to test efficacy of stroke prevention education in middle school students remains inadequate. Findings from Morgenstern and colleagues (2006) and Skybo and Ryan-Wenger (2002) indicated that students can increase their intention to call 911 if a stroke is suspected and also increase their general knowledge about stroke risk behaviors and other risk factors, such as hypertension. These studies highlighted two issues that were incorporated in the design of the FAST program: (1) the importance of including treatment-seeking behaviors (calling 911) and identifying major stroke risk factors in the program, and (2) the importance of testing the ability of students in these convenience samples to retain the information over time. Because middle school students are developing health habits and often are exposed to adults at higher risk for stroke, additional investigations are needed to test the effectiveness of novel educational strategies aimed at reaching this younger school-aged group to improve their knowledge, attitudes toward stroke, self-efficacy in identifying stroke signs and symptoms and taking action, and other behaviors associated with stroke prevention.

The FAST Program

The 2-month FAST program reflected the combined efforts of a research team that included educators and practitioners with extensive stroke prevention knowledge and experience in educating younger students, as well as a collaboration with the school nurse and health teacher. The FAST program was developed to increase middle school students' knowledge, improve overall stroke attitudes and self-efficacy, enhance treatment-seeking behaviors (calling 911) when stroke is suspected, facilitate diet and exercise behavior changes, and promote recognition of other stroke risk factors such as hypertension, diabetes, and obesity. The FAST program evaluation consists of components that could easily be incorporated into a school health curriculum and implemented by a school nurse, health teacher, or other school faculty. The program included a pretest, presentation, posttest, student-generated personal goals, and long-term posttest.

Pretest

A pretest was used to assess the students' knowledge of stroke signs and symptoms, risk factors, attitudes toward stroke, and self-efficacy in identifying stroke signs and symptoms, and treatment-seeking behaviors. The section of the pretest assessing basic knowledge had two questions, one that assessed students' knowledge of stroke signs and symptoms and one that assessed students' knowledge of stroke risk factors. Both were developed from questions widely accepted by the AHA/ASA and National Stroke Association, written at the sixth-grade level, and then evaluated by a panel of four educational experts in stroke (100% interrater reliability). For this aspect of the pretest, students could achieve a maximum possible score of 10 for the signs and symptoms and a maximum possible score of 10 for risk factors. The attitudinal and self-efficacy scale was based on Bandura's social learning theory (Bandura, 1991; 2001). Specific items were derived from earlier studies conducted by Kandakai and King (1999); King, Price, Telljohan, and Wahl (1999a, 1999b); and Vaughan, King, and Cottrell (2004). To ensure content validity, the instrument was reviewed by four panelists who had expertise in stroke prevention, child health, and survey research. Suggested revisions and modifications were incorporated into the final five-item instrument for assessing stroke attitude and self-efficacy. For this 5-item Likert-type instrument, total scores ranged from 5 (the lowest) to 25 (the highest). This pilot study was the first testing of this instrument.

Presentation

A 50-minute class presentation immediately followed the pretest and provided content related to stroke signs and symptoms, risk factors, and behaviors that contribute to development of stroke in later life, such as a high-fat diet and sedentary lifestyle. Included in this presentation was the FAST mnemonic, interaction with a stroke survivor, class discussion related to stroke risk factors and ways for the middle school students to realistically improve health (i.e., increase exercise, eat a balanced diet low in fat), and role playing to determine whether students could identify stroke symptoms following the introduction of the FAST mnemonic. Students also were asked to identify one stroke risk factor and individually complete a one-page form that listed their personal risk reduction goal that was realistic and measurable within the next 8-week period. In addition, students were asked to list two specific actions that they would take to achieve this goal. For example, the personal health goal could be "I will exercise 30 minutes three times a week for the next 8 weeks," and then the two actions that would enable them to do this could be "play basketball with my friends three times a week" and "go for a 30-minute walk with my friends around the local park every other day." Students then placed the completed forms of their personal health goals and action plans into self-addressed envelopes.

The mnemonic FAST introduced during this 50-minute class emphasized three key stroke signs and symptoms and actions to take:

* Face numbness or weakness, especially on one side (ask the individual to smile)

* Arm numbness or weakness, especially on one side (ask the individual to raise both arms and hold this position for 10 seconds)

* Speech slurring, or difficulty speaking or understanding (ask the individual to repeat a simple phrase, such as "the sky is blue in Cincinnati")

* Time to call 911 if any of these symptoms occur suddenly, are accompanied by the loss of vision, the loss of balance, dizziness, or "the worst headache of your life."

Following this presentation, students were also given two laminated cards (3 inches x 4 inches) with the FAST mnemonic on one side and stroke risk factors listed on the other. The students were instructed to keep one card for themselves and give the other to a parent.

Posttest

A posttest identical to the pretest, except for omission of demographic information, was administered immediately following the 50-minute presentation.

Goals

Six weeks after the 50-minute presentation, the personal behavior goal forms that each student prepared during the class were mailed. Information relevant to the student's predetermined goal was also enclosed. For instance, if the student was interested in exercise, age-appropriate and gender-appropriate information from the CDC (two sheets) and a bookmark with an exercise theme were included.

Long-Term Posttest

Eight weeks after the 50-minute class, students completed a long-term posttest that was identical to the pretest and posttest with the addition of one item for which they were asked to check one of three responses: 1 = completely achieved personal health goal, 2 = made progress, but did not completely achieve personal health goal, 3 = did not achieve personal health goal--no progress made.

Theoretical Framework for the FAST Program

Social cognitive theory underpins the FAST program. A central component of social cognitive theory is that an individual's behavior is dynamic and depends on aspects of the environment and the person, all of which simultaneously influence each other (Bandura, 2004). The FAST mnemonic and creative learning experiences were incorporated into the middle school students' learning environment to enhance their ability to develop knowledge, skill, and self-efficacy in identifying stroke signs and symptoms and risk factors, as well as increase their confidence to change one modifiable risk factor. Examples of the FAST program's learning experiences included identifying stroke signs and symptoms experienced by different individuals, having firsthand contact with a stroke survivor experiencing residual language and motor deficits, and discussing with other students how they could feasibly reduce modifiable stroke risk factors, such as improper diet and lack of exercise at home and school.

Pilot Study Purpose and Methodology

The purpose of this pilot study was to evaluate the FAST program. Evaluation objectives were twofold: (1) determine whether students improved in the self-reported stroke knowledge, attitudes (self-efficacy), stroke risk-reduction behaviors, and other stroke risk factors, and (2) examine whether students' intention to modify their stroke risk factor increased.

Before implementation of the FAST program, approval was granted by a university institutional review board (IRB). In accordance with the IRB approval, permission was obtained from the school, parents, and students who participated before initiation of the FAST program. Cooperation of the school nurse and health teacher to assist in the teaching and to reinforce the FAST program content was also obtained.

Results

The sample consisted of 72 students, 92% Caucasian and 8% minority, with an average age of 13.25 years (range 10-14.5 years). Fifty-five percent were female, and 94% reported having either an A or B grade average in school during the previous 12 months. Results show that students had significantly greater knowledge of stroke signs and symptoms and risk factors at intermediate posttest and long-term posttest compared to pretest (Table 1). Students included in the FAST program also had a more positive attitude toward stroke and higher self-efficacy, which was sustained from pretest to long-term posttest (Table 2). The instrument that measures attitude toward stroke and self-efficacy had an internal consistency (Cronbach alpha) of .85.

Another salient finding was that 87% of the students knew to call 911 before the start of this educational program, but many did not believe that they were capable of modifying a stroke risk factor. More than 60% of participants reported at pretest that they had a family member who had suffered a stroke, but 95% of the students were not confident in identifying even one stroke symptom before introduction of the FAST mnemonic. At the initial and long-term posttest, their ability to identify stroke symptoms and warning signs had significantly increased (Table 1).

At long-term posttest, 27% of the students (n = 20) indicated that they had achieved their personal health goal, 61% (n = 45) had made progress toward their goal but had not totally achieved it, and 11% (n = 8) had made no progress. In the majority of cases, the students reported that their personal goals pertained to eating a more healthy diet, increasing their activity, and losing weight; two students indicated that they wanted to stop smoking.

Discussion

Results show that this innovative stroke education program improved middle school students' knowledge of stroke warning signs and risk factors, positively influenced their attitudes toward stroke and self-efficacy, and empowered them to change their health behaviors. At pretest, although most students in this sample knew to call 911 if a stroke was suspected, they indicated that they could not identify major stroke signs and symptoms and risk factors. The students' gains in knowledge in the long-term test were much more profound for warning signs than gains in knowledge about stroke risk factors. This change may be because of the FAST mnemonic used to teach the warning signs. However, it is also possible that the warning signs are easier to remember because they are more concrete, whereas risk factors are more difficult to remember since they are more abstract. Because the study had no control group, the finding that the stroke symptoms contained in the FAST message seemed to be more frequently remembered at long-term posttest is only suggestive. The mnemonic FAST is expected to be easier to remember than lists based on the research indicating that chunking several items into a single pattern through the use of mnemonics tends to increase recall (Fitzgerald, 2004; Rebok, 1987; Reese & Cherry, 2004). Hardiman (2001) identified that mnemonics can facilitate a tenfold increase in memory associated with specific tasks. Further study to test the ability of the public to remember FAST compared to other educational methods is underway.

For this sample, the FAST program also fostered many students' progress in reducing one self-determined stroke risk factor during the 2-month study period. Study results revealed that middle school students were capable of identifying a realistic and measurable behavioral goal and short action plan, and 27% of the middle school students achieved this goal. Sixty-one percent of the students indicated that they had made positive progress in their goal achievement. This finding acknowledges that middle school students are capable of retaining and applying information to improve their health behaviors, which is consistent with results in the Morgenstern et al. (2006) and Skybo and Ryan-Wenger (2002) studies.

Another notable finding is the apparent influence of the students' interaction with the stroke survivor on attitudes toward stroke. During this exchange with the stroke survivor, students asked questions such as "Did it hurt to have a stroke?" "Did you know that you were at risk for stroke?" and "Do you always need to wear your leg brace and sling?" This interaction provided the students with a unique learning experience that they referred to 2 months later during the administration of the long-term posttest, using the space provided for comments. In addition, most of the students, following the interaction with the stroke survivor, requested that their picture be taken with her; the photos were posted in their classroom several weeks later.

Limitations

Although the FAST program data resulted in positive outcomes, several limitations of this pilot study need to be acknowledged. The study had a convenience sample of primarily Caucasian middle school students from the Midwest, which affects generalizability of the results beyond this sample. Although the sample size was small, it was determined to be appropriate for initial pilot testing of the FAST program. Another study limitation was the lack of a control group. Because the FAST program was only 2 months long, retention of the positive changes in knowledge, overall attitude toward stroke (including perceived self-efficacy), and individual behavior change could not be assessed for a longer time period, such as 1 or 2 years.

Recommendations for Future Research

Results from this pilot study confirm the importance of performing further research to assess the effectiveness and sustainability of the FAST program on a more culturally diverse sample and over a longer period of time, preferably 1-3 years. Using the information obtained from this pilot study, the researchers have taken the next step to expand the FAST program to a 9-month program with the inclusion of an additional five 50-minute modules. This study will provide more detailed information about healthy eating, exercising, dealing with barriers and relapsing into unhealthy behaviors, and managing other stroke risk factors (e.g., hypertension and diabetes). The students will be encouraged to disseminate stroke-related knowledge to the broader community, which includes parents, teachers, and other citizens. The researchers' 9-month study is in progress in three schools (two interventions and one control school) with primarily African American middle school students, who are at higher lifetime risk for stroke compared to Caucasians. Although the findings from the present 2-month pilot study are encouraging, additional research involving middle school students is necessary. With an expanded body of research, more targeted interventions can occur, but key curricular changes that permit presentation of sustainable stroke educational content (knowledge, attitude, and behavior) in middle schools must also be identified and instituted.

Summary

As a result of the well-documented increases in obesity, poor diet, and sedentary lifestyle of American youth and other stroke risk factors (e.g., diabetes and hypertension), vigorous exploration of creative interventions is critical to increasing knowledge and health-promoting behaviors. These collective actions may contribute to the reduction of stroke, the third largest killer in the United States and also the primary cause of long-term disability. The purpose of this pilot study was to evaluate effects of the 2-month FAST Stroke Prevention Program for Middle School Students that consisted of five components and focused on expanding students' knowledge of stroke signs and symptoms, risk factors, attitudes toward stroke and self-efficacy, stroke risk-reduction behaviors, and treatment-seeking behaviors. Results from the study sample of 72 students indicated that the program increased students' knowledge and overall attitudes toward stroke and self-efficacy and produced positive changes in reducing one self-selected stroke risk behavior (e.g., diet, exercise). Findings also reaf-firm the necessity for continued research and the creation of sustainable stroke prevention programs in middle schools.

Acknowledgment

Rosie Miller, RN CCRC, was instrumental in the development of the FAST mnemonic and core elements of the FAST Stroke Prevention Educational Program that were later refined for this pilot study.

Questions or comments about this article may be directed to Elaine Tilka Miller, DNS RN CRRN FAHA FAAN, at Elaine.Miller@uc.edu. She is professor of nursing at the University of Cincinnati, College of Nursing, Cincinnati, OH.

Copyright [c] 2007 American Association of Neuroscience Nurses 0047-2606/07/3904/0236$5.00

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Keith A. King, PhD CHES, is an associate professor at the University of Cincinnati, College of Education, Cincinnati, OH.

Rosie Miller, RN CCRC, is central coordinator of Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) at Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Dawn Kleindorfer, MD, is an assistant professor in the neurology department of the University of Cincinnati, Cincinnati, OH.

Table 1. Effect of FAST Program on Knowledge, Intermediate
and Long Term Knowledge

Knowledge Subscal     M(SD)            t            p

Risk Factor
Score
Pretest            7.15 (1.69)       -6.23         .001
Posttest           8.56 (1.37)

Pretest            7.15 (1.69)       -2.13         .037
Long-term
posttest           7.64 (1.63)

Warning Sign
Scores
Pretest            6.36 (1.61)       -4.71         .001
Posttest           7.59 (1.36)

Pretest            6.36 (1.61)       -3.69         .001
Long-term
posttest           7.17 (1.38)

Table 2. Effect of FAST Program on Attitude, Intermediate and
Long Term

Attitude
Score                 M(SD)            t            p
Pretest           17.49 (2.05)       -10.54        .001
Posttest          21.00 (2.90)
Pretest           17.49 (2.05)        -3.8         .001
Long-term
posttest          19.33 (3.92)