NINDS: Stroke Proceedings: Public Education

Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

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RECOMMENDATIONS:
Public Education Panel

Public education is probably the most important process in the global effort to improve access to treatment for acute stroke and probably the most difficult to achieve. The scope of public education regarding stroke is huge, but our goal is to uncover the specific public health messages that will most effectively produce immediate recognition of stroke and immediate health-seeking behaviors.

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• Lessons Learned From Previous Successful Public Education Campaigns
• What Are the First Steps We Should Take?
• How Do We Get From Here to There?

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Lessons Learned From Previous Successful Public Education Campaigns

Public education works. Examples of successful public education efforts include increasing the use of seat belts, decreasing smoking, and changing dietary habits, especially with respect to low-fat diets.

Change is slow. As we begin to educate patients we can't expect an immediate influx of patients into emergency departments, so we must be persistent and patient.

Big, comprehensive programs are the most effective. We need to use many communication formats, identify different audiences and tailor the message to those audiences, and seek a wide range of sponsors and funding agencies.

Defining our audience as the "general population" is not useful. The general population contains many subgroups, with different backgrounds and different methods of learning. Different messages must be developed for these varied subgroups. In the open discussion following the formal presentations at the symposium it was suggested that we avoid limiting the target audience to the stroke-prone population. Because many patients generally call family members--especially sons and daughters--upon first experiencing symptoms, all age groups should be included in the target audience.

Having an effective message and successfully delivering that message do not guarantee behavior change. Motivation to change behavior occurs when the public perceives that the benefits exceed the cost of the change. Our message must be simple, clear, and repeated often.

We need more sophisticated research on behavior modification and its links to public education programs. Another audience comment concerned the issue of fear. Some stroke patients are fearful of contacting a doctor when experiencing stroke symptoms. The issue of fear, and its motivating factor, needs to be addressed in a research setting. We have already begun to gather some data on behaviors that delay treatment. There are multiple theories we can use to guide us in creating the best message.

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What Are the First Steps We Should Take?

We must understand our audience and craft a message that they think is important to act upon. Focus groups are one route to achieving this understanding. We need to understand how and why individuals currently seek health care and what contributes to delay time in seeking care.

There are many different models of health-seeking behaviors that we could use to guide our efforts. The Health Belief Model (HBM) was the one we chose to present to the symposium attendees. This model was selected because it is based on the premise that an individual's unique perception of his or her world determines what actions he or she will take. The basic concepts of the HBM are seriousness, susceptibility, barriers, and benefits: Individuals must understand the seriousness of the health risk, their own personal susceptibility to this risk, and the benefits of seeking health care if they experience (or witness) symptoms. Barriers to achieving the above goals must be identified by scientists; they may include cognitive barriers, physical limitations, or situational factors (for example, when stroke occurs during sleep or the stroke victim lives alone). We must develop ways to intervene when these barriers exist and make the system work despite them.

Audience comments also included the subject of accomplishing public education through initially educating primary care physicians and family practitioners such as internists. These are typically the health professionals first contacted by patients experiencing symptoms. One approach might be to send the most appropriate public education message to professional meetings attended by primary care and family physicians or to place ads in medical journals targeted to primary care physicians.

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How Do We Get From Here to There?

If we do all of the above, the result will be an effective approach to public education and the development of a model for producing the best decision-making possible. The Public Education Panel agreed that the Madison Avenue approach to successfully delivering messages is the one we should follow. In this approach, strategy always precedes execution and the tool we must use is the creative brief, a document that defines the target audience, identifies the desired actions to be taken by that audience, presents current consumer beliefs and barriers to taking action, and establishes long-term goals. All of this information will be used to create the best messages, using the best available communications vehicles and delivering these messages in the most effective manner possible.

One audience suggestion concerned the use of TV, in particular TV dramas, to convey our messages about rapid treatment of stroke. The idea was summarized as "Show, don't tell." Presenting dramas that show doctors treating acute stroke patients in emergency situations is likely to be a powerful way to educate the public.

We need to seek help from experienced professionals in advertising to create public service announcements, print ads, and broadcast messages that will deliver our message. Finding money for accomplishing our goals will be a great challenge. We need to approach the groups and organizations that will benefit most from the shift in stroke care. This means pharmaceutical companies, private industry paying benefits for employee disabilities, government agencies, insurance companies, and health maintenance organizations.

We will need a central access point for information--a clearinghouse for both health professionals and the public. One obvious possibility is an Internet site that links the various organizations so that our message will remain consistent.

The panel discussed the timing of our educational efforts. Although some staging in the timing of our educational efforts is desirable, we know that education is a long, continuous process. And it is a parallel process--the health care system will be changing while we are educating the public--so the timing of our programs will change as the systems change.

Finally, to pull together all of these threads, the Public Education Panel strongly recommends developing a core leadership group to lead the effort. We need strong national leadership to move this initiative forward, and our recommendation is that the National Institute of Neurological Disorders and Stroke should take that leadership role.

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Last Edited: July 01, 1999

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892