Published online before print July 17, 2008, doi: 10.1161/STROKEAHA.107.513143
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(Stroke. 2008;39:2809.)
© 2008 American Heart Association, Inc.
Original Contributions |
‘Hip-Hop’ Stroke
A Stroke Educational Program for Elementary School Children Living in a High-Risk Community
From the Department of Neurology (O.W.), Harlem Hospital and Columbia University Medical Center, New York, NY; and the Department of Neurology and GH Sergievsky Center (J.M.N.), Columbia University Medical Center, New York, NY.
Correspondence to Olajide Williams, MD, MSc, Department of Neurology, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037. E-mail ow11{at}columbia.edu
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Abstract |
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Background and Purpose— Public stroke recognition is poor and poses a barrier to acute stroke treatment. We describe a stroke literacy program that teaches elementary school children in high-risk communities to recognize stroke and form an urgent action plan; we then present results of an intervention study using the program.
Methods— "Hip-Hop" Stroke uses culturally and age-appropriate music and dance to enhance an interactive didactic curriculum including the FAST mnemonic (Facial droop, Arm weakness, Speech disturbance, Time to call 911). The program occurred in central Harlem, New York City, a community with high stroke risk. During the 2006 to 2007 school year, 582 fourth, fifth, and sixth graders (9 to 11 years of age) participated in 1-hour sessions over 3 consecutive days. Stroke knowledge was tested before and after the program with a 94% group participant retention.
Results— Students learned and retained knowledge well for stroke localization (20% correct before intervention, 93% correct immediately afterward, and 86% correct after 3-month delay; P<0.001 both posttests versus baseline), the term "brain attack" (16% pretest, 95% immediate, 86% delayed; P<0.001), and to call 911 for stroke (78% pretest, 99.8% immediate, 98% delayed; P<0.001). FAST stroke symptoms (facial droop and slurred speech) were better retained than non-FAST symptoms (headache and blurred vision) at 3 months (P<0.001). For stroke prevention measures, dietary change and exercise were better learned than concepts of diabetes, hypertension, and cholesterol.
Conclusions— Elementary school children are educable about stroke, retain their knowledge well, and may be able to appropriately activate emergency services for acute stroke. Incorporating cultural elements such as hip-hop music may improve retention of stroke knowledge among the youth.
Key Words: African-Americans • cerebrovascular accident • child • health education • health literacy
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Introduction |
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Stroke is the leading cause of adult disability and the third leading cause of death in the United States. Appropriately selected patients with stroke can benefit from time-dependent treatments such as tissue plasminogen activator (tPA). More than 10 years after the National Institute of Neurological Disorders and Stroke (NINDS) tPA trial, typically only 3% of all patients with ischemic stroke seen in community hospitals receive tPA.1
Methods to improve the frequency of tPA administration focus on reducing prehospital time (symptom onset to hospital arrival) and intrahospital delays (hospital arrival to tPA delivery).2,3 Prehospital delay has been identified as the greatest barrier to thrombolytic therapy often because of poor public recognition of stroke symptoms and urgency.2 Internationally, the median prehospital stroke delay ranges between 3 and 6 hours.4 In 2002, NINDS targeted expediency of stroke recognition to increase tPA use with a goal by 2008 of 50% of patients with stroke arriving at the hospital within 3 hours.2 Public education programs can improve timely care for patients with acute stroke. One suburban community quadrupled tPA rates through adult-directed mass media.5 Expanding these strategies, NINDS suggested that stroke-educated children could improve their own stroke risk and possibly educate their parents and relatives about stroke.2
Historically, public health initiatives using children to improve adult health have focused on smoking cessation (Great American Smoke-Out [GASO], American Cancer Society) and cardiopulmonary resuscitation training in high school-aged children, but have been limited in application either due to insufficient data reporting (GASO) or discouraging retention.6 However, a recent asthma education program directed toward young children positively influenced parental health behaviors.7
Considering that up to 45% of public stroke knowledge is derived from family and friends,8 children may be an underused conduit for stroke education in their homes and communities.2 The Kids Identifying and Defeating Stroke (KIDS) program taught a predominantly Mexican-American sixth grade cohort about stroke over 2 years using simulations and computer-based vignettes.9 Encouragingly, children were educable on basic stroke concepts, including symptom recognition and stroke urgency, and, to a lesser extent, stroke pathophysiology.
We describe the novel stroke education program, "Hip-Hop Stroke," and present data on its ability to rapidly teach elementary school children living in a community with high stroke risk. Our primary objective was to examine the program’s delivery of important concepts, including basic stroke localization, cardinal stroke symptom recognition, and the correct urgent course of action when stroke is suspected. Secondary outcomes included measurement of delivery of basic stroke prevention information, distinction of test performance between grades, and the influence of a stroke rap song in reinforcing educational objectives.
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Materials and Methods |
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Educational Model/Intervention
"Hip-Hop Stroke" (HHS) was developed to teach school children important stroke concepts and to motivate them to deliver the message to their families and adult caregivers. HHS uses dance and music as motivating tools to enhance a simple didactic stroke education program delivered over 3 days.
HHS uses a culturally appropriate curriculum with age-appropriate modules and uses a youth-oriented theme—hip-hop, which is a type of music popular among the targeted age groups—as a supplemental means of engaging the children. Along with conventional didactic sessions, HHS includes multimedia strategies, "hip-hop" music, interactive raps, and dance to deliver a clear and simple message that teaches children to recognize stroke symptoms and take urgent action. The "FAST" mnemonic—"F" (face droop), "A" (arm weakness), "S" (speech affected/slurred), and "T" (time to call 911)—that was developed from the 3-item Cincinnati Prehospital Stroke Scale10 is emphasized within each program module and incorporated into the chorus of a stroke-relevant rap song that formed the theme music of the 3-day program (A video clip is available in QuickTime format at www.stroke.org/site/DocServer/Hip_Hop_DougE_Fresh.mov?docID=3462 or Windows Media video format at www.stroke.org/site/DocServer/cv_93_45544.wvx?docID=3461.). Children are also taught stroke risk reduction strategies and are given take-home information packages designed to trigger child–parent discussion about stroke and enhance parental stroke knowledge. Supplemental Table I (available online at http://stroke.ahajournals.org) outlines the curriculum that was presented in 1-hour sessions over the course of 3 consecutive days.
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Grouped by grade, the students were educated in the schools’ auditoriums. On each intervention day, the educational team included at least 2 stroke education professionals and 2 community health professionals responsible for teaching the curriculum. These individuals were not involved with other aspects of the study, including test development and grading. The tests were graded by a separate research coordinator, who did not participate in the education program. A hip-hop artist named Doug E. Fresh, who is well-known in the targeted age groups, created a rap song specifically for the program, which included FAST stroke symptoms, calling 911, and the term "brain attack." Non-FAST stroke symptoms were not included in the rap. The song was performed by him at the first school and its performance was broadcast for the second school.
Study Setting and Population
Central Harlem is one of 42 neighborhoods in New York City (NYC). It is an inner-city community in northern Manhattan with 151 100 residents who are mostly African-American (67%) with Hispanics composing the greatest minority (19%) above whites (8%).11 The area is socioeconomically disadvantaged with a median income of $22 122, which is approximately half that of Manhattan or NYC.12 Thirty-five percent live below the poverty level and 20% have a college degree, which is worse than overall Manhattan and NYC profiles. Despite equal access to health care in Harlem compared with other NYC neighborhoods, vascular risk factors have greater prevalence in Harlem than Manhattan or NYC profiles.11 Stroke disproportionately affects this population with a high proportion of annual deaths due to stroke (4.2%), which is 90% higher than the NYC average.13
In central Harlem, there are approximately 6800 children enrolled in 13 elementary schools (kindergarten through sixth grade, approximate ages 5 to 11 years). Similar to the overall population, 61% of the students are African-American, although Hispanics comprise a larger minority group within schools (37%) than in the whole community.14 Of these elementary schools, 10 have school-based clinics staffed by Harlem Hospital employees and were identified as the potential setting for this study. A convenience sample selected 2 of these 10 schools based on the large number of student body and not based on individual school demographics. Overall, in the participating schools, 36% were African-American and 61% were Hispanic, and these proportions are the opposite of community demographics. The curricula in these 2 schools are taught in English; 32% of all students are nonnative English speakers.
Before school selection, the program gained approval from the NYC Board of Education and principals at the collaborating schools. All fourth through sixth grade children whose parents provided informed consent were considered eligible for enrollment. The study was approved by the Harlem Hospital Institutional Review Board.
In 2006, a total of 622 matriculating fourth, fifth, and sixth grade students (approximately aged 9 to 11 years) were identified as potential participants from the initial school rosters in 2 schools. Of these, 582 students (94%) agreed and received parental consent to participate in the first day of education and took the pretest. Participants were in the fourth (38%), fifth (35%), and sixth (27%) grades; and all 3 grades were similarly represented during each of the testing periods. Of the 582 who entered the study, 520 (89%) participated in the third (and final) day of education and took the immediate posttest; and 549 (94%) students completed the 3-month posttest. (The immediate posttest data from one fourth grade class at one school was missing due to disruptive behavior that precluded their participation.) The remaining dropouts were due to individual student absences.
Study Design and Program Assessment
Assessment of the program was done using a pretest/posttest study design. Due to the sensitive nature of acquiring personal data from children, all data were collected without personal identifiers and drawn from closed cohorts of each participating grade. Thus, for all analyses, we used group performance comparisons rather than repeated individual measures.
Before beginning the first day’s program, each child completed a 6-question pretest comprised of multiple choice, yes/no, and open-ended questions, which assessed baseline stroke knowledge. At the conclusion of the 3-day program, an immediate posttest was given to assess immediate recall. At 3 months, the same posttest was given in the classrooms to assess retained knowledge from the program. The 3-month test was given without warning so that the measure would reflect retention due to the program, not possible interim studying by the students.
Table 1 outlines the questions used and the methods for grading the tests derived from experience with our pilot program.15 Questions covered stroke localization, the term "brain attack," urgent actions, stroke prevention behaviors, and stroke recognition. Both posttests included an item in which the respondents were asked to explain the FAST mnemonic (FAST was not included in the pretest because pilot data indicated that the students were mostly unaware of the mnemonic before the educational intervention.). After completing the 3-month posttest, a brief knowledge booster session reviewed correct answers and reinforced key HHS concepts, including FAST. No evaluation was given once the booster session was done. On the posttests, children were asked to comment if they knew a family member or family friend with a history of stroke. The program was delivered in English. All test questions and responses were written in English; test questions were read aloud verbatim in English by one of the stroke educators and translated to Spanish by a native Spanish speaker.
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Analysis of data
The results of the pretest were compared against the immediate and 3-month posttests using Pearson’s 
2 or the Fisher exact test for nominal data, as appropriate. The Mantel-Haenszel extension test was used to analyze ordinal data by grade, and t tests and analysis of variance were used for continuous data. Multiple comparisons were subject to the Bonferroni procedure. Analyses were performed using SPSS v15.0 (SPSS, Inc, Chicago, Ill).
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Results |
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Baseline stroke knowledge was poor but significantly improved in all primary outcome measures, which focused on stroke localization, the term "brain attack," and identifying stroke as an emergency (Table 2). Stroke sign and symptom knowledge was assessed by several measures. We used a composite score of 8 yes–no possible stroke signs and symptoms (Table 1, Question 4) and demonstrated a significant improvement in the mean score from baseline to immediate follow-up, which persisted after 3 months (Table 2). Some differences in test performance were found between grades after 3 months but did not indicate that one grade consistently outperformed another. Intention-to-treat analysis of the missing fourth grade class during the immediate posttest period did not change these results.
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We separately analyzed performance relevant to learning and retention of FAST. We did not evaluate FAST in the pretest for reasons outlined previously, but at the conclusion of the program, FAST was learned and retained well; 406 (78%) and 386 (70%) described 3 or 4 FAST letters at the first and 3-month follow-ups, respectively. Further analyses suggest that dynamic and interactive portions of the program that used the FAST acronym significantly reinforced stroke recognition beyond conventional teaching measures. In the Figure, retention of all stroke symptoms significantly improved from baseline at 3 months (P
0.001). Stroke symptoms contained within FAST (facial droop and slurred speech) were significantly better retained than non-FAST symptoms (blurred vision and severe headache). Specifically, on the immediate posttest, FAST responses improved by 52%, whereas non-FAST responses improved by 36% (P<0.001) and this difference was more pronounced at 3 months compared with baseline: 45% FAST improvement versus 11.4% non-FAST improvement over baseline (P<0.001).
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Of all the stroke prevention concepts taught, healthy lifestyle changes were most likely to be retained (Table 3). Approximately half of students mentioned dietary choices and a third named exercise 3 months after program conclusion in comparison to 20% or less on the pretest (P<0.001 for both). Identification of tobacco avoidance also significantly increased. In contrast, concepts of diabetes mellitus, hypertension, serum cholesterol, and regular physician visits were poorly retained at program conclusion.
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Approximately one fourth of the students knew a close relative or family friend with stroke. A subgroup analysis comparing children with and without a close relative or family friend with stroke revealed no significant differences in posttest performance on our primary outcome measures regarding stroke localization and knowledge of "brain attack." However, for knowledge of stroke symptoms, a significant difference with better performance was found in those without a family history of stroke or close family friend with stroke on immediate posttesting (P=0.007), although at 3 months, no difference was found. Moreover, activation of 911 was better retained in those without a family history of stroke or close family friend with stroke at 3 months (P=0.04).
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Discussion |
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HHS proved to be an effective tool for educating young students concerning stroke identification and urgent action. Test scores improved significantly for our primary outcome measures at the immediate follow-up and remained significantly improved over baseline at the 3-month follow-up. Thus, HHS led to learning during the 3-day course and retention several months later. The FAST stroke mnemonic, which was included in a stroke rap song with dance, was an important tool to enhance learning of key program messages.
Before this study, we conducted a pilot program of HHS,15 which used the same stroke educators, involved 477 other students attending different schools than the ones presented here, and only differed academically by inclusion of a stroke-specific rap theme song in the current curriculum. In a post hoc analysis, we compared responses in the study presented here with identical questions from the earlier pilot program. Knowledge of the term "brain attack" improved on the immediate posttest from 306 (70%) in the pilot to 496 (95%) correct in the revised program (P<0.001); however, this difference was not evident at 3 months (both programs 86%). FAST mnemonic retention was also higher in the revised program. Three months after program completion, 219 (75%) of pilot participants named facial droop as a possible stroke sign compared with 468 (85%) in current study (P<0.001). Similarly, recognition of slurred speech also improved from 174 (59%) to 466 (85%; P<0.001).
Overall, inclusion of the hip-hop song may have enhanced long-term retention of some stroke concepts such as FAST stroke symptoms, further supporting our initial hypothesis that music and dance likely enhances program objectives through activities perceived as fun rather than uninteresting or primarily educational. To our knowledge, this program is the first to formally evaluate the effect of a health message incorporated into a hip-hop song. Planned studies will evaluate a hip-hop stroke cartoon and an interactive stroke rap video as standalone units.
Hip-hop is a music genre that strongly emphasizes rhyme and dance and is popular among diverse socioeconomic and ethnic groups.16 Integrated rhyme and dance have been used as educational tools in efforts to improve vocabulary in eleventh graders17 and math skills in second graders,18 enable behavioral changes in homeless children,19 and prevent obesity in African-American preschoolers.20 Health initiatives that incorporate readily learned or familiar fast-paced music and dance activities have significant impact19 and could improve the potential for sustained learning. The use of hip-hop music has been suggested as a strategy for health education programs related to HIV and AIDS in adolescents21 and could represent a fun, culturally and age-appropriate method to introduce health education initiatives of any type21 to younger children.
Although anecdotal, this program suggested that increased stroke knowledge in young children may affect behavior. Subsequent to the program, 2 children, one from each school, reported witnessing sudden onset of stroke symptoms and appropriately activated the emergency medical system. One sixth grade child called 911 when a grandparent experienced stroke symptoms, and we confirmed this story. During the 3-day program delivery period, one fourth grade child was present when an older woman at a subway station suddenly dropped her groceries and developed slurred speech. On his own, he called 911 from a pay phone on the subway platform.
The results concerning the learning of stroke prevention concepts were not as encouraging. An estimated 20% of the program was dedicated to stroke prevention measures. In contrast to stroke recognition, stroke prevention teaching used didactic and interactive strategies (see Supplemental Table I). Tobacco education involved pathological lung specimens. It is possible that multimedia and music reinforcement was responsible for the greater retention of stroke knowledge compared with prevention concepts; however, the data do not permit a strong inference regarding this difference.
Greater understanding of health behavior concepts (eg, healthy diet, exercise, and tobacco avoidance/cessation) over early detection and control of vascular risk factors (Table 3) could be due to other NYC school health initiatives22 with HHS only reinforcing these efforts. Although we attempted to use age-appropriate language for these more complicated health concepts, these topics may be too complex for these age groups to learn them rapidly. Health literacy of diabetes and hypertension among well children is not widely reported; adult health literacy is the lowest in those with only elementary level education.23 Despite minimal emphasis on drug and alcohol abuse, nearly 10% of children identified drugs and alcohol as important for stroke prevention, and this proportion was greater than all 4 medical prevention categories 3 months after the program. We speculate that students are independently aware of substance abuse from other health programs and high neighborhood prevalence of substance abuse.24
Stroke incidence is higher in African-Americans and Hispanic-Americans compared with non-Hispanic whites.25,26 African-Americans have the highest stroke mortality and are less likely than whites to arrive within 3 hours and receive thrombolytic therapy.26 Stroke is a major health problem in central Harlem adults13 and an estimated 15% to 20% of children are raised by their grandparents (Mindy T. Fullilove, MD, unpublished data, 2007), who are at risk for stroke. Improving stroke recognition and awareness within these and other high-risk communities can increase acute stroke treatment.5 By targeting at-risk adults through their children, HHS may represent a novel approach to improving stroke recognition and symptom urgency in high-risk communities. Moreover, our anecdotal evidence supports the idea that young children can be taught to recognize stroke and rapidly activate emergency services.
Several limitations are present in this study. First, given the sensitive nature of acquiring personal data from children, we opted for anonymous testing and data analysis using group comparisons, which precluded tracking learning of individual students across the test sequence. An alternative comparison strategy to independent groups analyses would be matched-pair analyses (either comparing an individual’s performance across the test sequence or in a case–control design), which would have a smaller variance and greater power than the methods we used. Although we do not know which individuals were present during each testing day, 94% of enrolled subjects within this fixed cohort completed the course (ie, no new subjects enrolled after initial parental consent was obtained before the program start). The high retention rate was likely related to testing all participants of each grade simultaneously in the school auditorium. Individual or class absences on any day of the program did not undermine our findings according to intention-to-treat analysis.
Similar rates of attrition across the grades and high retention rate suggest a high level of comparability across the test sequence overall and when stratifying by grade. Although our pilot study indicated that sixth graders consistently outperformed other grades, this was not replicated in this current study. We performed post hoc power calculations to determine our ability to detect a difference between grades with similar scores on delayed posttesting. On these comparisons, we were consistently underpowered to find a difference.
Another limitation in our study is lack of a control group. Although we considered randomly assigning separate schools to a control group, we instead compared test performance with baseline measures for several reasons. First, increasing the number of participating schools was not readily feasible. Second, participation in a control program would have disrupted classroom activity without anticipated educational gain. Finally, in an elementary school population otherwise unexposed to public stroke education, test performance would not be expected to change without answer reinforcement. As evidenced by the eighth grade control subjects in KIDS, stroke pathophysiology knowledge declined, and only slight improvement was found for stroke symptom knowledge or behavioral intent to call 911.9
The questionnaire used in the program has not been validated beyond our pilot, but the language was age-appropriate, several question styles were used, and results were consistent by grade among key stroke concepts. In addition, similar questions have been used in other multiethnic adult,27 Hispanic youth,28 white middle school,29 and suburban parochial elementary school30 stroke literacy studies. Given that test development, education delivery, and grading were independent, we believe our test evaluates key learning points of this focused stroke education program rather than simply improving test performance alone. Furthermore, our results were not uniformly positive, and analysis of stroke prevention measures revealed poor test performance.
The generalizability of this version of HHS to other ethnic groups or to suburban and rural areas is uncertain. The majority of central Harlem’s elementary school students are African-American or Caribbean-Hispanic. Given the adaptability of HHS to popular culture, it may be effective among diverse groups.
HHS could potentially be delivered to many children using trained school-based health professionals. In our study, primary educational objectives were delivered by 2 trained stroke educators. Most elementary public schools in Manhattan have school-based clinics staffed by health professionals from local hospitals or the department of health. Similar systems are in place throughout the United States at 1500 centers in 43 states serving over one million students in diverse settings and neighborhoods.31 Health professionals in these centers could be trained as stroke educators by local stroke centers to enhance community outreach efforts required for primary stroke center certification.
Summary
The use of hip-hop music may be an effective medium for public health stroke education among a youth population. In this HHS program, elementary school children aged 9 to 11 years can learn to recognize stroke and retain their knowledge for at least 3 months. These children can also activate emergency services when stroke is suspected. Further study in other settings is needed to verify our findings. Moreover, additional studies are needed to determine whether young children can be used as effective conduits of stroke education into their homes and whether these efforts can translate into reduced prehospital delay.
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Acknowledgments |
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We thank the students, teachers, and principals for their participation in the classes as well as Benjamin Wowo, MD, MPH, Bernadette Boden-Albala, DrPH, John C.M. Brust, MD, William Gerin, PhD, Mitch S.V. Elkind, MD, MS, W. Allen Hauser, MD, Karen S. Marder, MD, MPH, Richard Benson, MD, PhD, Jeannie Price, Brian Kolonick, Diane Mulligan-Fairfield, Niambi Nicholes, Eugenia Graham, MS, LPN, Naomi Griffin, Camille Phaire, RN, Loretta Chisolm, NP, and Doug E. Fresh for their assistance in development of the project and these data.
The following persons contributed to the work reported but do not fulfill authorship criteria: Benjamin Wowo, MD, MPH, is employed by Harlem Hospital as a stroke center coordinator; Dr Wowo assisted with data management and collection.; Bernadette Boden-Albala, DrPH, assisted with modification of the questionnaire used in this program.; John C.M. Brust, MD, and William Gerin, PhD, assisted with editorial review.; Mitch S.V. Elkind, MD, MS, Karen S. Marder, MD, MPH, W. Allen Hauser, MD, and Richard Benson, MD, PhD, provided helpful comments and suggestions for manuscript development; Jeannie Price, Brian Kolonick, BA, Diane Mulligan-Fairfield, BA, and Niambi Nicholes, BA, are employed by the National Stroke Association. Three of these 4 persons were present as stroke educators at every session and assisted with conduct of the study and collection of data. No member of the National Stroke Association, including Mr Kolonick, Mrs Price, Ms Nicholes, or Mrs Mulligan-Fairfield, were involved with management, grading, analysis, or interpretation of this data or preparation, review, or approval of the manuscript. Eugenia Graham, MS, LPN, Naomi Griffin, BA, Camille Phaire, RN, and Loretta Chisolm, NP (all from Harlem Hospital Center), and Maurice Selby (City College of New York) assisted with stroke prevention education and demonstrations; Doug E. Fresh is a "hip-hop" artist and children’s book author who created a song for this program, visited one school, and this performance was broadcast at the second school. He received personal compensation in excess of $10 000 from the National Stroke Association for participation in the program but did not receive specific compensation for the creation of the song. He was not involved with any other aspects of the program or with manuscript preparation.
The National Stroke Association is an internationally recognized nonprofit health organization that created Hip-Hop Stroke and designed the pilot phase of this study. In working with the National Stroke Association, Drs Williams and Noble created a revised model of the pilot phase program and tests, and the data presented in this manuscript reflect these changes in the follow-up program. Drs Williams and Noble, along with members of the National Stroke Association, were involved in collection of the data.
Disclosures
JMN is supported by Public Health Service training grant 5 T32 NS07153-23 and by the Charles L. and Anne L. Saunders Brown Fellowship.
Received December 19, 2007; revision received March 3, 2008; accepted March 5, 2008.
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