Australian Public’s Awareness of Stroke Warning Signs Improves After National Multimedia Campaigns
Background and Purpose—The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia.
Methods—A total of 12 439 surveys were performed across 6 states during 6 years on random state–weighted samples of Australians ≥40 years old.
Results—Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 (P<0.001), as did the unprompted recall of ≥2 most common stroke warning signs 20% to 53% (P<0.001). Awareness of stroke advertising was independently associated with recalling ≥2 common signs (adjusted odds ratio=1.88, 95% confidence interval [1.74–2.04]; P<0.001). Awareness was not greater in respondents with previous stroke or risk factors, except atrial fibrillation.
Conclusions—The Australian public’s awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.
- health knowledge, attitudes, practice
- health promotion
- mass media
- signs and symptoms
Stroke is a significant public health issue. Early recognition of stroke signs, combined with prompt presentation to hospital, provides the best opportunity for effective management to reduce mortality or morbidity after stroke.1 An important first step is to ensure public awareness of the common warning signs of stroke.2
In 2003, a nationwide survey showed that only 49% of Australian adults were able to correctly name a stroke warning sign unprompted. Subsequently, the National Stroke Foundation (NSF) designed a mass media campaign to improve awareness of the stroke warning signs and the need to seek urgent medical attention. The first national campaign was launched in September 2004, with annual modifications to improve the key message (Table I in the online-only Data Supplement). From 2006, the campaign focused on the 3 most common symptoms featured in the FAST (Face, Arm, Speech and Time) campaign: facial weakness, arm weakness, and speech difficulties. During this time, the NSF has monitored changes in the Australian public’s awareness of stroke warning signs through annual surveys in 6 of 7 Australian States.
The aim of this study was to examine the reach and impact of the stroke advertising on the Australian public’s awareness of stroke warning signs between 2004 and 2010.
Materials and Methods
The surveys, performed using a computer-assisted telephone (CATI) program and drawn randomly from an electronic telephone directory, were designed to capture representative samples of the 10 million Australian residents ≥40 years old (the target population of the campaigns). The surveys occurred ≈6 weeks after the annual NSF campaign launch during National Stroke Week in September or October. Complete details of the campaigns, sampling, and surveys are described in the Methods in the online-only Data Supplement.
Changes in awareness and demographics of the sample with time were examined using χ2 analysis. Campaign awareness is also reported weighted by State to reflect the distribution of the Australian population. Multivariate logistic regression was used to determine factors related to awareness of ≥2 most common warning signs (ie, limb weakness or paralysis; face weakness or paralysis or numbness of face, arm, or leg; facial or eye droop; speech disturbance). This is because Mosley et al3 found awareness of ≥2 of these signs to be associated with early ambulance use. Data were analyzed using SPSS version 19. Results are presented as adjusted odds ratios (aOR) and 95% confidence intervals (CI). Statistical significance was defined as probability value of <0.05.
The study was reviewed by the Monash University Human Research Ethics Committee who granted an exemption from full ethical review (nonidentifiable data).
There were 12 439 Australian residents >40 years old who were surveyed during the 6 years (58% from metropolitan locations; 66% female; annual sample size: minimum of 1480 and maximum of 2572). The demographics of the annual samples varied slightly for age, education level, and stroke risk factors (Table II in the online-only Data Supplement).
Awareness of the Campaign Advertisements
The proportion of respondents who had recollection of the advertising increased during the study period (31% in 2004 to 50% in 2010; P<0.001), particularly from 2006 (Figure 1).
Recall of Stroke Warning Signs
The proportion of respondents who were able to name stroke warning signs improved between 2004 and 2010 (Figure 2): ≥1 correct from 69% to 81% (P<0.001); ≥2 correct from 43% to 63% (P<0.001); ≥3 correct from 19% to 32% (P<0.001). Corresponding decreases were seen in the proportion of respondents who replied they did not know any stroke warnings signs (16% in 2004 to 11% in 2010; P<0.001) or gave incorrect responses (45% in 2004 to 33% in 2010; P<0.001). Pain in the arm (≈13%), chest pain (≈10%), and shortness of breath (≈7%) were the most common incorrect symptoms reported.
The significant improvement seen with time for both awareness of the campaign and for the number of correctly identified warning signs remained significant after adjusting for differences in the demographics of the annual samples (data not shown).
Factors Related to the Recall of ≥2 Stroke Warning Signs
The Table provides the factors independently associated with recall of the ≥2 common stroke warning signs. With the exception of history of atrial fibrillation, no differences were seen in individuals with important stroke risk factors (hypertension, diabetes mellitus, hypercholesterolemia) or in those reporting a previous stroke. Significant improvements with time were seen in recall of common warning signs (Figure 2); however, improvements were the greatest in those aware of the stroke advertising (Figure 3). This finding was confirmed in the multivariable analysis (aOR=1.88, 95% CI [1.74–2.04]).
For the first time, we present important data on stroke awareness for the Australian population and the impact of stroke educational campaigns. Our data provide evidence of a steady improvement in awareness of stroke warning signs among Australian adults since commencement of the NSF campaigns in 2004. Most significantly, those with recollection of the stroke advertising were 88% more likely to be aware of ≥2 most common signs than those not recalling the campaigns.
Our findings are difficult to compare with other published Australian studies, performed either before the NSF campaign began4 or in selected populations.5,6 Our findings are comparable with international population-based studies reporting awareness of stroke warning signs and demographic factors associated with lower awareness of warning signs.7,8 Although we acknowledge that self-reported risk factors are prone to inaccuracy,9 it is alarming that only atrial fibrillation was associated with increased awareness of stroke warning signs, and that no difference was seen in other high-risk respondents who reported having previous stroke or hypertension. Perhaps a generic campaign is not effective for reaching these groups who may benefit from targeted education and interventions.
The linear increase in awareness of warning signs with time may be explained by several factors. First, to aid in the recall of the content, the campaign was simplified in 2006 to feature the FAST symptoms, which from 2009 were portrayed in the campaign materials though pictures. Second, paid and probono support for the campaign varied annually but increased considerably after 2005, which is the same period when awareness of the campaign also increased. It is difficult to distinguish the individual impact of these factors; however, the changes made to the campaign content and greater levels of funding, thus exposure,10 will all have contributed to the increased awareness in warning signs. This highlights the necessity for simplified messages and for appropriate funding for awareness campaigns.
Several limitations are relevant to this study. First, the data collected in the surveys potentially represent maximal knowledge because they were performed close to campaign saturation and coverage. Second, because of resource limitations, the campaign materials were not multilingual, and surveys were only performed with English-speaking respondents. Third, the surveys were also limited to the population ≥40 years old. This age group was the target population of the campaigns and reflected that campaign (media) viewing times are more likely to be accessed by this age group. Therefore, we are uncertain about the impact of the campaigns on younger adults and children. A fourth limitation was that the survey study did not take into account the 3% of Australian households without a telephone. Finally, no control group was used, and we are unable to explain the improvements in those who could not recall stroke advertising. It is possible that some of this group did not recall exposure to stroke advertising and that future surveys may like to consider prompting with campaign slogans or major messages.
It is also acknowledged that there are challenges in measuring a concurrent change in behavior as a result of public stroke education and improved awareness.11 However, a recent study provided evidence of an increase in calls to ambulance for stroke in the State of Victoria (Australia) after the commencement of the NSF campaigns.12 The increase in calls to ambulance parallels the increases in the awareness of stroke advertising seen in Victoria from 2006 in our surveys (data not shown). It is also probable that these campaigns have reduced prehospital delays for stroke13 and have contributed to the improvement seen in Australian thrombolysis rates in recent years.14
In summary, the Australian public’s awareness of stroke warning signs has improved since commencement of the NSF awareness campaigns. Significant increases were noted in specific demographic groups and in those aware of the stroke advertising. Future efforts to target groups with lower awareness, along with consistent exposure of the campaigns, could see further improvements.
Sources of Funding
Dr Bray is supported by the National Health and Medical Research Council Center for Research Excellence: Australian Resuscitation Outcomes Consortium (grant# 1029983). Dr Cadilhac is supported by research fellowships from the National Health and Medical Research Council cofunded with National Heart Foundation (grant# 610313) and support funding by the National Stroke Foundation (grant# PH 09M 4599).
Drs Bray, Mosley, and Cadilhac are members of the National Stroke Awareness Survey Working Group of the National Stroke Foundation. R. Johnson, K. Trobbiani, and Dr Lalor are employed by the National Stroke Foundation.
Published elsewhere as an abstract for conference presentation (Stroke Society of Australasia Scientific Meeting and the National Heart Foundation Conference).
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.113.002987/-/DC1.
- Received August 28, 2013.
- Accepted September 4, 2013.
- © 2013 American Heart Association, Inc.
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