Caminiti, C., Schulz, P., Marcomini, B., Iezzi, E., Riva, Silvia 
ORCID: https://orcid.org/0000-0003-2153-0169, Scoditti, U., Zini, A., Malferrari, G., Zedde, M.L., Guidetti, D., Montanari, E., Baratti, M., Denti, L., Castellini, P., Zanferrari, C., Tanzi, A., Diodati, F., Olivato, S., Barbi, F., Bigliardi, G., Dell'Acqua, M.L., Vandelli, L., Rosafio, F., Pentore, R., Picchetto, L., Monaco, D., Perticaroli, E., Iafelice, I., Imovilli, P., Vaghi, L. and Guareschi, A.
(2017)
Development of an education campaign to reduce delays in pre-hospital response to stroke.
BMC Emergency Medicine, 17 (1).
DOI: https://doi.org/10.1186/s12873-017-0130-9
Abstract
Background: Systematic reviews call for well-designed trials with clearly described intervention components to
support the effectiveness of educational campaigns to reduce patient delay in stroke presentation. We herein
describe the systematic development process of a campaign aimed to increase stroke awareness and preparedness.
Methods: Campaign development followed Intervention Mapping (IM), a theory- and evidence-based tool, and was
articulated in two phases: needs assessment and intervention development. In phase 1, two cross-sectional surveys
were performed, one aiming to measure stroke awareness in the target population and the other to analyze the
behavioral determinants of prehospital delay. In phase 2, a matrix of proximal program objectives was developed,
theory-based intervention methods and practical strategies were selected and program components and materials
produced.
Results: In phase 1, the survey on 202 citizens highlighted underestimation of symptom severity, as in only 44% of
stroke situations respondents would choose to call the emergency service (EMS). In the survey on 393 consecutive
patients, 55% presented over 2 hours after symptom onset; major determinants were deciding to call the general
practitioner first and the reaction of the first person the patient called. In phase 2, adult individuals were identified
as the target of the intervention, both as potential “patients” and witnesses of stroke. The low educational level
found in the patient survey called for a narrative approach in cartoon form. The family setting was chosen for the
message because 42% of patients who presented within 2 hours had been advised by a family member to call
EMS. To act on people’s tendency to view stroke as an untreatable disease, it was decided to avoid fear-arousal
appeals and use a positive message providing instructions and hope. Focus groups were used to test educational
products and identify the most suitable sites for message dissemination.
Conclusions: The IM approach allowed to develop a stroke campaign integrating theories, scientific evidence and
information collected from the target population, and enabled to provide clear explanations for the reasons behind
key decisions during the intervention development process.
Trial registration: NCT01881152. Retrospectively registered June 7 2013
Keywords: Stroke, Public campaign, Pre-hospital delay, Media, Cartoon, Intervention mapping
