Response to Letters by Chiti et al and You et al
I certainly applaud Chiti et al for their enthusiasm in this often-overlooked arena of public awareness in stroke. I want to clarify, however, that our article was not intended to promote the use of one message over another but instead to examine the sensitivity of either message to detect stroke within a population. Chiti et al is very concerned about the lower sensitivity of the FAST message, but we found that for ischemic stroke patients, that sensitivity was 92%, which we consider reasonable. Whether FAST is remembered better by the lay public is as of yet unproven. This is the key point, and we cannot recommend one message over another until they are tested against each other in the public arena.
The revised FAST message, “SHOUT-FAST”, is interesting, in that it maintains the sense of urgency by teaching that these symptoms are something to “shout” about. However, I have several concerns about this public awareness message: (1) it expands the message to 9 letters to remember, instead of 4, and 2 words to remember, instead of 1. Social learning theory emphasizes that “chunking” of memory best works with chunks of <4 to 5 objects. (2) It mixes concepts of severity (Severe) and symptom, and uses the word “trouble” for one of the letters, which is neither a specific symptom or severity. Consistency is key, and by mixing concepts we further dilute the message. (3) Reading level of the message is too high: the word “ocular” is not in the common vernacular, at least not in the United States. Public awareness messages should be at or below the third grade reading level. (4) By adding the additional symptoms, the message is now including nearly as many symptoms as is usually listed in the “SUDDENS” message (usually ≈12 to 13 symptoms in most versions). This defeats the purpose of a short, focused message.
This brings up a point mentioned in the thoughtful editorial by Dr Hodges: consistency. If all the major organizations are using different educational tools, then perhaps that will backfire, and people won’t remember any of them. Perhaps the “SUDDENS” message is the best one to be using? Perhaps FAST is? We don’t know. But I would discourage the creation of hundreds of new mnemonics until we know whether even one of them is better remembered than the status quo, which has at least been consistently presented.
Regarding the idea presented by Dr You et al, this is an excellent example of thinking “outside the box”. Cellular phones are certainly an innovative way to educate the public. It certainly seems to have reached a number of people in Korea regarding CPR. However, I would encourage Dr You and colleagues to scientifically study the impact of such a stroke awareness campaign. Too many times we see thoughtful, innovative public awareness campaigns that are introduced without any rigorous study regarding the impact of the campaign, especially regarding behavior changes. Does it really reduce delay? Does it improve treatment rates? Most of the time we have no idea. I would also make sure that however the stroke warning signs are presented in the Korean campaign, that a specific plan of action is taught as well (call 911!). Thank you for your interest.