Development of an education campaign to reduce delays in pre-hospital response to stroke

On behalf of the Educazione e Ritardo di Ospedalizzazione (E.R.O.I) study group

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


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.

Original languageEnglish
Article number20
JournalBMC Emergency Medicine
Issue number1
StatePublished - 24 Jun 2017

Bibliographical note

Funding Information:
The work presented here is part of a multicenter, randomized trial funded by the Emilia-Romagna Region in the framework of the “Programma di ricerca Regione-Università 2010-2012” grant, aiming to assess the effectiveness of a population-based information-education campaign, in terms of reduction of delay in hospital admissions for acute stroke. The project, promoted by the volunteer association ALICe (Associazione per la Lotta all’Ictus Cerebrale – Association for Fighting Cerebral Stroke) [14], was approved in 2012 by the Ethics Committees of all participating centers. All involved subjects gave written informed consent to participate. The duration of the entire study is three years, and this first part was conducted between February and August 2013.

Funding Information:
This work has been supported by the Programma di ricerca Regione-Università, Regione Emilia-Romagna, bando "ricerca per il governo clinico" 2010-2012 to Licia Denti, "Effectiveness of a Public Campaign to Increase Stroke Awareness in Reducing Prehospital Delay"

Publisher Copyright:
© 2017 The Author(s).


  • Cartoon
  • Intervention mapping
  • Media
  • Pre-hospital delay
  • Public campaign
  • Stroke


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