In the JournalsPerspective

Hip-hop program improves stroke literacy in children

Children who underwent a stroke literacy intervention that incorporated hip-hop music had improved stroke preparedness compared with those who took nutrition classes, according to a study published in Stroke.

“The program’s culturally tailored multimedia presentation is particularly effective among minority youth or other groups among whom hip-hop music is popular,” Olajide Williams, MD, MS, associate professor of neurology at Columbia University Medical Center at New York Presbyterian Hospital, said in a press release. “One unique aspect of the program is that the children who receive the program in school are used as ‘transmission vectors’ of stroke information to their parents and grandparents at home. Our trial showed that this is an effective strategy.”

Researchers analyzed data from 3,070 children in fourth to sixth grade and 1,144 parents from 22 New York City public schools. Schools were assigned a stroke preparedness intervention or nutritional classes.

The stroke preparedness intervention — called Hip-Hop Stroke — was culturally tailored to target urban minority children and incorporated hip-hop music with stroke lyrics, a clotbuster stroke video game, animated narrative cartoons and a comic book. Children shared the information they learned with their parents through homework activities. Nutritional classes involved the United States Department of Agriculture My Pyramid nutritional program.

Primary outcomes included child and parental stroke knowledge and preparedness. Parents were assessed using in-person surveys at baseline and telephone interviews at follow-up. Children were assessed in the classroom. A secondary and exploratory outcome was the occurrence of and response to stroke-like symptoms after classes, including whether 911 was called and how the child participated in recognizing stroke.

Children who underwent a stroke literacy intervention that incorporated hip-hop music showed an increase in stroke preparedness
Photo credit: Shutterstock.com

At baseline, 1% of children in the control group (95% CI, 0-1) and 2% in the intervention group (95% CI, 1-4; P = .09) had optimal stroke preparedness. This increased to 57% in the intervention group (95% CI, 44-69) but was only 1% in the control group (95% CI, 0-1; P < .001) after the interventions. The intervention group better retained optimal preparedness at 3 months (24%; 95% CI, 15-33) vs. the control group (2%; 95% CI, 0-3; P < .001).

Parents in the intervention group improved their ability to identify all letters of the FAST acronym from baseline (3%; 95% CI, 2-4) to after completion of the intervention (20%; 95% CI, 16-24). This continued at 3 months (17%; 95% CI, 13-21; P = .0062). Parents in the control group had no significant changes between baseline and 3 months.

Four children in the intervention group called 911 for stroke events after completion of the program. One of those children overruled a parent’s suggestion to proceed with the wait-and-see approach.

“Children may be underused conduits for reaching economically disadvantaged ethnic minorities with critical stroke information,” Williams and colleagues wrote. “[Hip-Hop Stroke] may represent an effective intergenerational alternative to mass media campaigns and may be used to support annual public stroke education requirements for stroke center certification in the United States.” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.

Children who underwent a stroke literacy intervention that incorporated hip-hop music had improved stroke preparedness compared with those who took nutrition classes, according to a study published in Stroke.

“The program’s culturally tailored multimedia presentation is particularly effective among minority youth or other groups among whom hip-hop music is popular,” Olajide Williams, MD, MS, associate professor of neurology at Columbia University Medical Center at New York Presbyterian Hospital, said in a press release. “One unique aspect of the program is that the children who receive the program in school are used as ‘transmission vectors’ of stroke information to their parents and grandparents at home. Our trial showed that this is an effective strategy.”

Researchers analyzed data from 3,070 children in fourth to sixth grade and 1,144 parents from 22 New York City public schools. Schools were assigned a stroke preparedness intervention or nutritional classes.

The stroke preparedness intervention — called Hip-Hop Stroke — was culturally tailored to target urban minority children and incorporated hip-hop music with stroke lyrics, a clotbuster stroke video game, animated narrative cartoons and a comic book. Children shared the information they learned with their parents through homework activities. Nutritional classes involved the United States Department of Agriculture My Pyramid nutritional program.

Primary outcomes included child and parental stroke knowledge and preparedness. Parents were assessed using in-person surveys at baseline and telephone interviews at follow-up. Children were assessed in the classroom. A secondary and exploratory outcome was the occurrence of and response to stroke-like symptoms after classes, including whether 911 was called and how the child participated in recognizing stroke.

Children who underwent a stroke literacy intervention that incorporated hip-hop music showed an increase in stroke preparedness
Photo credit: Shutterstock.com

At baseline, 1% of children in the control group (95% CI, 0-1) and 2% in the intervention group (95% CI, 1-4; P = .09) had optimal stroke preparedness. This increased to 57% in the intervention group (95% CI, 44-69) but was only 1% in the control group (95% CI, 0-1; P < .001) after the interventions. The intervention group better retained optimal preparedness at 3 months (24%; 95% CI, 15-33) vs. the control group (2%; 95% CI, 0-3; P < .001).

Parents in the intervention group improved their ability to identify all letters of the FAST acronym from baseline (3%; 95% CI, 2-4) to after completion of the intervention (20%; 95% CI, 16-24). This continued at 3 months (17%; 95% CI, 13-21; P = .0062). Parents in the control group had no significant changes between baseline and 3 months.

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Four children in the intervention group called 911 for stroke events after completion of the program. One of those children overruled a parent’s suggestion to proceed with the wait-and-see approach.

“Children may be underused conduits for reaching economically disadvantaged ethnic minorities with critical stroke information,” Williams and colleagues wrote. “[Hip-Hop Stroke] may represent an effective intergenerational alternative to mass media campaigns and may be used to support annual public stroke education requirements for stroke center certification in the United States.” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Bruce I. Ovbiagele

    Bruce I. Ovbiagele

    These findings show us that it is possible to use a relatively cheap, broadly disseminable and culturally tailored approach with potentially sustained effects to target stroke education in populations with higher risk. We know that previously, lots of high-cost mass media campaigns have really not been very effective, and more importantly, were not sustainable and certainly not culturally tailored to higher-risk populations. This advance is a relatively cheap intervention that can be implemented very broadly, probably very easily and has shown some modest sustainability at 3 months after the intervention was delivered. We haven’t had that before.

    This has implications on how to educate people on stroke recognition. The people we’re targeting are the high-risk parents who will potentially have these symptoms.

    It’s clear that there was some uptake in children and there was definitely uptake in the parents as well. It was sustained in both populations. It translated into improved awareness and sustained improved awareness.

    The intervention seemed to work. Immediately after, 57% of children remembered what they were taught. They were stroke-prepared, so to speak. The first question I would ask is, while it is very impressive that half were able to remember, how can we get those numbers even higher to make sure that immediately after, more people remember? We saw that at 3 months, about 24% remembered. This is still impressive, as we haven’t had those kinds of numbers in the past. Having said that, the issue is how do we get more children to remember immediately after and of course for it to be sustained at a higher rate at 3 months?

    When you look at the parents, about 20% were able to recognize one of the key symptoms of the FAST acronym immediately after. About 17% were able to remember after 3 months. With the parents, about the same proportion still remembered at 3 months, while you saw a drop-off in the kids from about one in two remembering immediately after to one in four remembering after 3 months. The issue again is how do we get those numbers up if only one out of five parents or grandparents immediately after intervention were able to recognize at least one of the key symptoms of the acronym? If we can somehow impart this knowledge in a way that more parents upfront are able to recollect the information, maybe that might translate to even more impressive recollection and action rates down the road. Still, it’s very impressive that even the proportion that remembered were able to remember.

    More research is needed to see if we can increase the numbers of people who remember immediately, because I suspect that would help to increase the number of people who have a sustained recollection of this knowledge. I’d love to see how long this knowledge is sustained. Three months is very helpful, but stroke can obviously strike at any time, so could we see if this knowledge is retained at 6 months or even 1 year later? How long from the time that they were taught can both parents and children can retain this? When and how many ‘booster’ training sessions are needed? It’s very important.

    Another aspect of this would be prevention. I always tell my patients the best stroke is the stroke you never had. We know that 80% of strokes are imminently preventable. That’s why I wonder if this same, very novel approach, ie, using children as transmission vectors for important health knowledge can be used to improve stroke risk factor control and prevent strokes from happening in the first place? Recognizing stroke symptoms promptly and getting treatment early is a high priority, but it may not get us to where we ideally want to be, which is substantially reducing the overall burden of stroke on society through prevention. Maybe the future focus could be to create hip-hop videos for preadolescents that confer knowledge about physical activity, diet, major risk factors for stroke like hypertension, hyperlipidemia, diabetes, obesity, etc. If these kids retained this knowledge and shared it with their parents, it could have an impact on lifestyle choices in the home/household. Besides, given challenges with rising preadolescent and adolescent obesity rates in the country, beyond possibly positively influencing their parents and grandparents to reduce their stroke risk, such knowledge may also be of benefit to these children now and in the future, so they are able to ward off metabolic syndrome, diabetes, strokes, MIs, etc.

    This is very promising work. It has really moved the field forward in many ways. I’d love to see durability, more uptick immediately after the intervention and to see this also applied to stroke risk factor control.

    • Bruce I. Ovbiagele, MD, MSc, MAS, MBA
    • Professor, Chairman of Neurology Medical University of South Carolina, Charleston

    Disclosures: Ovbiagele reports no relevant financial disclosures.