Critical Analysis of a Health Promotion Campaign

Introduction:

This essay is a detailed critical analysis of the health promotion activity namely the ``F.A.S.T stroke campaign” It will be based on aspect of the campaign rationale, the scientific evidence behind the campaign, theories related to the campaign and the impact of the campaign based on perceived stroke recognition and response behaviour. Finally, few recommendation will be addressed which could increase the effectiveness of the campaign based on scientific evidences.

Campaign Overview

F.A.S.T is a shortened word for Face, Arm, Speech and Time which has been used as a mnemonic for the identification of situation of a person who is having the risk of stroke and need further interventions and responsiveness of an individual to such situation. F.A.S.T was initially introduced by a group of ambulance personnel along with the stroke physician in the United Kingdom in the year, 1998 and then it was included within an integral part of the training program of the ambulance staff (Flynn, et al, 2014). In 2009 the Department of Health England launched the “FAST campaign” as a media campaign to raised awareness of stroke and the need to response appropriately in such emergency situation. Again, in 2018 the campaign was relaunched by Public Health England along with the Stroke Association in the name of “ACT F.A.S.T. stroke campaign” to raised awareness among the people regarding the signs and symptoms of stroke so that an individual can recognize them among themselves and can call the emergency helpline number 999 for treatment. The rationale of choosing this particular programme is that stroke has been considered as one of the major significant impact on the rate of mortality throughout the world. Although, several people reported that there was no impact observed from the campaign conducted, on the other hand few other studies have reported that the campaign was successful in terms of raising awareness among the target audience although a much more effort was needed to improve the symptoms concerning the reluctance attitude towards calling the helpline number 999. (Dobrowski, et al, 2013; Public Health England, 2008).

The reason behind the conduction of the campaign was to make the public aware of the increasing incidence rate of stroke within society. About 113000 are suffering from stroke every year in the United Kingdom and approximately 1 million survivors of stroke. However, these numbers are increasing day by day due to the ageing of the population and improvement of the medical treatment facilities eventually resulting in the better survival rates (Feigin, et al, 2003). A review study conducted by a group of authors highlighted that the mean age of the first stroke was 68.6 years among men and 72.9 years among women. The incidence rate and the prevalence rate of stroke among males were found to be approximately 33% and 48% higher in comparison to females respectively (Appelros, et al, 2009). However huge variation was observed because of the age bands within the populations. It also stated that the severity observed due to the stroke was more in women showing 1-month fatality cases of 24.7% when compared to 19.7% of men (Keir, et al, 2002). In contrast to the previous study, another cohort study conducted by another group of authors between the period 1999 to 2008 including 32 151 patients who reported the first incidence of stroke highlighted that there was a need for better risk stratification among women because of the underutilisation of anticoagulation among the patients suffering from atrial fibrillation and overall poorer use of the preventive measures of stroke in comparison to males. The study highlighted the mortality rate among women up to 18.6% and within the male population of 11.3% (Coco, et al, 2016).

Fig: 1&2 Stroke associated mortality and ratio according to age bands for both genders

The target audience for this programme was people age 50 years and above as these people are more at risk of suffering from stroke due to the fact that their arteries become more thinner and harder as they grow older (Stroke Associate 2018).

Also, the lower level of education was significantly associated with the rising incidence of stroke within the age span of 60 -74 (Coco, et al, 2016).

Act FAST is a public taught that worked at both national and local level to make their resources available to all by using mass media such as social medial, TV advertisement, and distribution of posters, pamphlets and handmade bills to the local hospital and General practise surgery. The ACT FAST along with the stroke association also, created an awareness website that are actively participated in the fundraising programmes and charitable events and also conducted group discussion on cardiovascular disease and the risk factor associated with it (Lecounturier et al, 2010).

It also stated that the severity observed due to the stroke was more in women showing 1-month fatality cases of 24.7% when compared to 19.7% of men (Keir, et al, 2002). In contrast to the previous study, another cohort study conducted by another group of authors between the period 1999 to 2008 including 32 151 patients who reported the first incidence of stroke highlighted that there was a need for better risk stratification among women because of the underutilisation of anticoagulation among the patients suffering from atrial fibrillation and overall poorer use of the preventive measures of stroke in comparison to males. The study highlighted the mortality rate among women up to 18.6% and within the male population of 11.3% (Coco, et al, 2016).

The survival rate of stroke has also increased over the past 10 years but the women should be considered more in comparison to male in terms of risk factors so the funding was done by the UK government and it was conducted by the Health Department. Initially, for spreading the messages of the FAST campaign, as a leading charity concern for stroke in the UK, the Stroke Association funded the research process for the campaign. It is the responsibility of the association to provide fund to basic research on formulating novel treatment or any measures to prevent stroke (ACT FAST, PHE, 2018). Though the overall cost expenditure of the campaign was not clear, it was estimated to be of £105 million for total period of three years as quoted by the Welcome Trust article. However, Department of Health stated that it costs up to £740,000 for advertising for a period of 3 months in the phase 4 (Flynn, et al, 2014).

The Krippendorff, et al, 2004 and Wolters, et al, 2015 stated that the maximum number of stroke patients were aware of the campaign when they were experiencing stroke. Majority of the patients recalled that they had seen the advertisement on the television while the other reported that they had seen the posters within the primary care. According to Dombrowski, et al, 2013 few people had reported that the campaign was successful in terms of raising awareness against stroke by the identification of symptoms. On the contrary, few people also reported that symptoms reported on the advertisement concerning stroke were extremely severe and mismatched with the actual stroke experience. Therefore, this can be considered to be a vital point for the evaluation of the campaign that there was a potential mismatch between the expected and the experienced symptoms which also hindered the identification of stroke.

Context of the campaign

The campaign was initiated to reduce the presenting time of patients experiencing stroke which will eventually enhance the chances of thrombolysis and quick initiation of secondary prevention. The potential tools of the FAST campaign were Face, Arm, Speech, and Time (FAST). One potential limitation of the ACT FAST campaign can be stated that the acronym did not include the symptoms of the sudden loss of vision as the manifestation of disease in the anterior or posterior circulation. The solution to this particular issue is the modification of the acronym to “Act VFAST” (which denotes act very fast) to include the vision. However, Brandt, et al, (2000) stated that the diagnostic sensitivity of the FAST was considered to be good (>75%) when it is applied by the ambulance staff. Another major point of consideration was the study designs that were included allowed the inclusion of patients who were already consulted with the hospital, therefore, no scope for the determination of the rate of false negatives (Harbison, et al, 2003). The other point that must be considered is that it did not include the number of patients with embolic visual change who could not make to acute services for review purpose. Therefore those patients who did not have any idea that sudden loss in vision can be due to stroke will not present in the first time. Therefore, to improve the situation, recognition within the overall community has to be increased as addressed by the authors of the articles. The mismatching of symptoms of expected and experienced stroke symptoms such as the sudden loss in vision or decrease in the vision had to be considered as early diagnosis can diminish the chances of progressing to carotid endarterectomy (CEA) (Freischlag, et al, 1991). Moreover, the stroke awareness services have to differentiate between the actual stroke and their mimics such as Bell's palsy, dysphasic migraine and the associated functional weakness. Therefore differentiating between the embolic and non-embolic conditions of visions should be considered as a natural extension (Lawlor, et al, 2015). On the contrary in the findings of the previous study, the concept of primary care clinicians about perceived impact was based on the public awareness and the patients reported that the impact of the campaign was decisive in terms of recognising the symptoms of a stroke. They also shared that most of them tried the EMS within 1 hour of the event (Dombrowski, et al, 2013). On the contrary, they also stated that they got confused that during stroke concerning the prevalence of all symptoms which had to be observed to confirm the event though it was mentioned that presence of only one symptom could be also considered (Dombrowski, et al, 2013).

The ACT FAST campaign in accordance with the policy of the stroke workforce as mentioned in the Stroke Association. The policy states that each and every person who had a person that had previous exposure of stroke should be cared by people having the right skills and knowledge so that they can meet the need of overall stroke pathway. But unfortunately, shortage of skilled person is responsible for creating a vulnerable situation for the person who are experiencing stroke and also post stroke survivors. Therefore, with ACT FAST stroke campaign a large number of target audience had been addressed and it increase the awareness about the sign and symptoms of stroke among them. It encourage the target audience who were at more risk to learn the right skill which will help them to identify their or other situation in their vicinity. However, more attention should be given on the response related behaviour after the identification of condition. The campaign was in line with the intent of the policy but it failed to address the issues of care for the post stroke survivor and the immediate responsive behaviour. The overall vision of the policy is to create a world with an environment that will enhance the conduciveness to healthy living as with the support of NHS, schools, retailers, charities, mass media and other trust organisations (French, et al, 2019). The other recent health policies in the United Kingdom are enhancement of primary care service, improvement of acute care, increasing survivor rate for the cancer patients, prevention of the spread of obesity tackling of harmful use of alcohol and providing financial security to long term care. Among all these existing health policies in the UK, the improvement of acute care service is concerned with the 24 hours multidisciplinary care service to the stroke patients and includes the stroke-specific rehabilitation (Ham, et al, 2009). Based on the evidence it could be stated that the performance level of the UK was poor in comparison to other peer countries due to the so-called “weekend effect”. The risk of death of patients admitted to hospitals in the acute care setting is more during the weekend (Metcalfe, et al, 2016).

Theoretical underpinnings of the campaign:

The two theories in association with the campaign were the health belief model and social marketing scheme. The health belief model (HBM) is considered to be social-psychological health-associated behavioural change model that was developed to provide explanation and predict other related behaviour concerning the uptake of healthcare services. It should be associated with a trigger to enhance health-promoting behaviour. To reduce the risk of stroke among individuals with the application of HBM were based on the parameters such as undertaking the health promotion activity due to the perceived benefits and the self-efficacy while implementation. Thus HBM addressed the health situation (stroke) and the necessary measures that can be taken to tackle the emergency (behavioural change). Social marketing theory of mass communication comprises the promotion of valuable social information and the other socially accepted behaviours. It works on the principle of integration of marketing ideas, tools and principles to provide effective communication for the benefit of society (Maiman, et al, 1974; Dann, et al, 2010). ACT FAST campaign involved the mass media and the advertisement strategies for the promotion of measures to identify signs and responsive behaviour that should be taken after identification. Such as recognising the signs of stroke based on the symptoms shown in the advertisement and television and calling up EMS for quick measures was related to the two theories in practice. The behavioural change of acting fast in response to the signs of stroke is in accordance with HBM and its success was dependent on the perceived benefits. With the help of the social marketing strategy, the theory was able to target a large volume of individuals via the campaign and helped in creating a memory among the audience as perceived by the clinicians by the questions of patient in relation to the campaign (Dombrowski, et al, 2013). It can be further explained with the study conducted by several authors in the UK to investigate about the perceived impact of the campaign in terms of raising awareness about the stroke and the responsive behaviour it included 19 stroke patients and 26 stroke witnesses. Evaluations of semi structured interviews were conducted by content analysis. The data findings highlighted that most of them were aware about the campaign and it helped them to identify the signs and symptoms but majority of them reported no such impact. As evidenced by the meta analysis study on effectiveness of variables of HBM on predicting behaviour stated that a behaviour will only be up taken if the benefits of outcome is high and perceived barrier is low (Carpenter, et al, 2010). Clinicians especially the primary care clinicians responded positively about raising awareness factor but expressed critical views against responsive behaviour (Dombrowski, et al, 2013).

Evaluation of the campaign

Perceived impact on stroke recognition and response behaviour:

According to source ACT FAST, PHE, 2018, the campaign was a huge success as because it highlighted about the vital symptoms of stroke and also mini strokes and therefore people would show the same urgency to treat mini strokes which would save approximately 10,000 strokes annually by calling the helpline number 999. Deputy Director of Stroke Associations said that it was really devastating that people still missed the signs of initial stroke and failed to call the emergency number, but they hope that they would be successful in spreading the awareness of acting fast during stroke can save many lives annually. The campaign was also supported by author and designer named Jools Oliver and former Bond Girl Jenny Hanley to raise the awareness (ACT FAST, PHE, 2018). Some patients reported that the campaign had influenced both the recognition and responsive behaviour to stroke. On the contrary few patients had also stated that the campaign had contributed to the general knowledge about health issues but did not have any impact upon the stroke episodes. Majority of the patients reported about the mismatch of symptoms of actual stroke with the ones that were shown in the advertisement. Some people had also critically commented on the contents of the campaign stating that the delivery style was too dramatic. However, Dombrowski, et al, contradicted that the analogy used in the campaign was much more effective in addressing the targets via television. Many people voiced positive comments about the campaign as it included mass media to target a large audience instead of the prototypical stroke cases. According to primary care clinicians, the impact on public awareness about stroke was visible as many patients mentioned about the campaign. But they also highlighted that many patients still delay in the responsible service and also present it to the wrong service. Overall the campaign was found to be helpful, clear, informative and also powerful. The clinicians also reported on the simplicity and visibility of the campaign. They expressed both critical and positive comments on the content and suggested the frequent change of the materials to attract attention (Dombrowski, et al, 2013).

Clinicians also referred to the COPD campaign, United Kingdom as more efficient than ACT FAST in terms of creating a memory in patients. The campaign should also address the health status of women and educating them about the associated risk factors as it mostly based on knowledge related to male counterparts (Flynn, et al, 2014; Hickey, et al, 2018).

Conclusion

Therefore, it can be concluded that the ACT FAST campaigned aimed to reduce the presenting time of patients experiencing stroke and act fast to save their life or others if they are in the risk of suffering from a stroke by encouraging and training them with right skills. Overall the campaign was thought to be informative and powerful for the target audiences and was also considered to be successful in terms of raising awareness among population.

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Recommendations

However, the campaign needs to address the women by the inclusion of more effective ways which would increase their health awareness as approximately 7% of the women in the UK die because of stroke. Moreover, the post-stroke symptoms should be considered as patients find it difficult to recognize due to lack of awareness and it is evident that the greatest risk of recurrent strokes is within the first 30 days (ACT FAST, PHE, 2018). Apart from these, the campaign should address the self-recovery aspect of the patient so that the patient may understand the significance of it. It should also include all the embolic symptoms of stroke. To improve the effectiveness of the campaign, it must modify the acronym to “Act VFAST” which denotes “act very fast”. The mismatch between the experienced and expected symptoms should be solved to reduce the confusion of patients and it should also incorporate frequent changes in the context to continue with the attention. According to the ACT FAST Hero campaign statistics, PHE, 2018 released by press there were around 40,000 deaths due to stroke every year, 1.2 million stroke survivors among which two third of them leave the hospital with disability and 93% of the population called 999 if they witness any symptoms of stroke whereas only 24% of them think incorrectly that they need to wait for more number of symptoms in the UK (ACT FAST, PHE, 2018). Thereafter another spin-off campaign should be conducted after addressing all the issues (Dombrowski, et al, 2013; Flynn, et al, 2014; Wolters, et al, 2015; Hickey, et al, 2018).

References:

Appelros, P., Stegmayr, B. and Terént, A., 2009. Sex differences in stroke epidemiology: a systematic review. Stroke, 40(4), pp.1082-1090.

Brandt, T., Steinke, W., Thie, A., Pessin, M.S. and Caplan, L.R., 2000. Posterior Cerebral Artery Territory Infarcts: Clinical Features, Infarct Topography, Causes and Outcome1. Cerebrovascular Diseases, 10(3), pp.170-182.

Carpenter, C.J., 2010. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health communication, 25(8), pp.661-669.

Coco, D.L., Lopez, G. and Corrao, S., 2016. Cognitive impairment and stroke in elderly patients. Vascular health and risk management, 12, p.105.

Dann, S., 2010. Redefining social marketing with contemporary commercial marketing definitions. Journal of Business research, 63(2), pp.147-153.

Dombrowski, S.U., Mackintosh, J.E., Sniehotta, F.F., Araujo-Soares, V., Rodgers, H., Thomson, R.G., Murtagh, M.J., Ford, G.A., Eccles, M.P. and White, M., 2013. The impact of the UK ‘Act FAST’stroke awareness campaign: content analysis of patients, witness and primary care clinicians’ perceptions. BMC public health, 13(1), p.915.

Feigin, V.L., Lawes, C.M., Bennett, D.A. and Anderson, C.S., 2003. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. The Lancet Neurology, 2(1), pp.43-53.