Nineteen patients (11 women, 8 men), 26 witnesses (21 women, 5 men) and 30 primary care clinicians (24 women, 6 men) were interviewed. The patients were aged 41 to 86 years. Witnesses’ relationships to the patients were: wife/husband (n = 14), son/daughter (n = 9), nephew (n = 1), formal care-giver (n = 1) and acquaintance (n = 1).
Patient health service contacts within 1 hour of symptom onset were all made to EMS (n = 5), whereas those made after 1 hour included primary care surgery (n = 8), ED (n = 3) and EMS (n = 3). Ten patients were able to make health service contacts themselves, the remaining contacts (n = 9) were made by other individuals on behalf of the patient.
Most witness contacts with EMS (n = 13) and some to primary care physician offices (n = 2) were made within 1 hour of symptom onset. For those who responded after 1 hour, contact included EMS calls (n = 7), primary care physician (n = 3) and ED visits (n = 1).
Primary care clinicians were recruited from 13 different practices (7 urban, 6 rural) and included 14 general practitioners, 10 practice nurses and 6 health care assistants. All male clinicians were GPs. Job experience ranged from 3 weeks (GP) to 33 years (practice nurse). Ages of witnesses and primary care clinicians were not recorded.
Stroke patients
Awareness of ‘Act FAST’
The majority of stroke patients reported being aware of the campaign overall (n = 14/19) at the time of experiencing the stroke. Most recalled having seen the television advertisements (n = 11; “I’ve seen this latest thing on the television where the mouth droops and they can’t smile and the speech is affected”, P02, GP > 1 h). Other channels through which the campaign reached patients were posters in primary care (n = 2; “It’s up in our doctors on the side of the wall, ring 999 if you’re worried”, P04, GP > 1 h) or the radio (n = 1; “I had heard about it on the radio”, P12; 999 > 1 h).
Perceived impact on stroke recognition and response behaviour
Two patients reported being influenced by the campaign. One patient described how the campaign helped to recognise symptoms as stroke.
“Were it not for the benefit of having seen that on the television, it would have taken me an awful lot longer…to realise that [I had a stroke], so I do think that I benefitted a lot from actually seeing those adverts”, P10, 999 < 1 h
Another patient outlined how the campaign influenced recognition as well as response to stroke symptoms.
“I knew I was having a stroke […] because of what I’d seen on the television, the way my mouth went. I was drinking coffee and it came all the way out the side […] that’s why I says to [witness]: ‘You’d better call the paramedics’ and then they were here within minutes”, P11, 999 < 1 h
One patient was unsure whether the campaign had any impact in relation to the stroke episode, but reported an impact on general awareness of health issues.
“It might have done a little bit but, it just made me more conscious that you’ve got to watch one’s health when you get a bit older”, P12, 999 > 1 h
The majority of patients who were aware of the Act FAST campaign reported that the campaign had no impact on stroke recognition or response (n = 11/14). Some patients commented on the mismatch between the severity of advertised stroke symptoms and the stroke experience.
“You just think of somebody sitting there and they can’t move their arm. My arm was numb but it wasn’t where I couldn’t move it”, P05, GP > 1 h
Some patients commented on the campaign’s visual image of a flame within the head as an analogy for stroke, and might have consequently identified the head as the main location for symptoms (“My head wasn’t bad or anything, it was just my lip and the fingers”, P17, GP > 1 h). A mismatch between expected and experienced symptoms was reported to prevent the recognition of stroke.
“It didn’t [fit my experience] because it wasn’t a very bad headache, it was just sort of disorientated at first, you know. And I think you know that’s why I just thought it wasn’t a stroke”, P04, GP > 1 h
One patient reported relating the television advertisement to other peoples’ past experience rather than the possibility of experiencing a stroke oneself.
“…when I saw that flame for a start [I thought]: ‘ooh that’s what must have happened to [husband who previously had a stroke]’, I wasn’t thinking about myself”, P17, GP > 1 h
Views on ‘Act FAST’
Patients voiced few views on the campaign. Some stated that they paid little attention to the advertisement (“I never really paid it that much attention to be quite honest”, P06, ED > 1 h), with others commenting negatively on the style of the campaign (“I think is very dramatic”, P05, GP > 1 h; “They [the television advertisements] were brilliant”, P10, 999 < 1 h) and length of campaign delivery (“… [the television advertisements] had been on quite a long time”, P18, 999 < 1 h).
Stroke witnesses
Awareness of ‘Act FAST’
All witnesses except two (n = 24/26) reported having heard of the campaign prior to the time of witnessing the stroke. Out of the witnesses who were aware of the campaign all but one (n = 23/24) mentioned having seen the televised advertisement, with the one remaining reporting having seen it on posters in the GP practice (n = 1).
Perceived impact on stroke recognition and response behaviour
Some witnesses stating campaign awareness (n = 9/24) reported having been influenced by it in terms of stroke recognition (“I had a vague idea of what happened plus the advertisement on the television that I have seen quite a few times and I did think that’s what it was”, W09, 999 < 1 h) and response to stroke symptoms (“I think it made me realise that I had to get help quick”, W17, 999 < 1 h). One witness reported a negative impact of the campaign due to misdiagnosis leading to delay (“I recognised the TV [advertised symptoms and] said: ‘Can you put your arms up?’ He says: ‘I’m putting my arms up’. I’m thinking: ‘Well it cannot be a stroke’”, W04, GP > 1 h). Some witnesses reported that the severity and pattern of symptoms advertised by the campaign were not in line with the experienced stroke episode.
“It wasn’t following the pattern that you see on television advert which you take notice of, it wasn’t following that pattern her speech hadn’t gone, it was delayed, but hadn’t gone and she was still able to move her arms”, W06, GP > 1 h
Three witnesses stating campaign awareness (n = 3/24) reported being unsure whether it impacted on their recognition or response (“I don’t know if I would have been alert as much of the stroke if I hadn’t have seen the adverts”, W03, 999 < 1 h) with the remaining witnesses (n = 12/24) reporting to not have been influenced in recognition or response by the campaign (“I don’t think so, I think I would have done it anyway”, W13, 999 > 1 h).
Views on ‘Act FAST’
Several witnesses voiced positive views towards the campaign, including comments on the execution of the television advertisement,as well as the targeting of a broad audience not only including prototypical stroke cases.
“I think it’s a good advert … puts a point across doesn’t it, you know, like fire we’ve got to get it put out right straight away, that’s it, obviously the subconscious sort of thing like, isn’t it?”, W10, 999 > 1 h
“I think it’s good that it isn’t just [focusing on] residential homes, [or] nursing homes so people are targeted - it’s everybody - so even if say [witnesses’ nephew] was at home with his grandmother and it happened to her he would know what to do”, W01, 999 < 1 h
One witness commented positively on the memorability of the television advertisements (“I don’t usually watch advertisements on the television but that one sort of stuck in my mind”, P09, 999 < 1 h), whereas another witness reported the opposite effect (“…it just goes straight over my head to tell you the truth”, W19, 999 > 1 h). Although the majority of opinions were positive, a few critical comments were voiced during interviews. A further witness found the television advertisements misleading, highlighting that these might create false expectations of stroke
“It’s a misleading advert. For people who’ve never had […] to deal with strokes before I think that it’s a real bells ringing, you know, shit this is going to happen. That’s very misleading”, W25, 999 < 1 h
Primary care clinicians
Awareness of ‘Act FAST’
All primary care clinicians were aware of the campaign through campaign engagement with primary care (“Yes we got the information through the post”, PCC22, PN), as well as through the media (“I’ve seen two adverts the one with the male and the one with the female”, PCC13, GP).
Perceived impact on patient recognition and response behaviour
The majority of primary care clinicians (n = 13/22) perceived the campaign to have impacted on patient awareness, many basing this judgement on interactions with patients about stroke (“Yes, it does [raise awareness], because we’ve got patients often … people would often mention it”, PCC04, GP). The remaining primary care clinicians were either unsure (n = 7/22; “I hope it has, but I’m not sure”, PCC05, HCA) or did not perceive the campaign to have made an impact on awareness (n = 2/22). One primary care clinician compared ‘Stroke - Act F.A.S.T.’ with another recent campaign that was perceived as prompting more dialogue between patients and health care professionals, which was often seen as a proxy measure of patient awareness.
“Maybe it wasn’t the right campaign I’m afraid. Because what I do know is at the moment the COPD campaign, I’ve got people mentioning it to me all the time”, PCC18, GP
Despite many primary care clinicians perceiving increased awareness, only a few (n = 3/22) perceived the campaign to have impacted on patient responses to stroke symptoms (“I think people are more aware and call for help sooner”, PCC04, GP). The majority (n = 14/22) remained unsure of campaign impact on response behaviour (“I don’t know how much a success it’s seen as”, PCC01, GP). Some primary care clinicians commented on their inability to judge campaign impact due to the difficulty of detecting a lack of patient contact in case of campaign effect on response behaviour.
“I suppose in some ways we might not [know if the campaign affects stroke response] because what would happen is they would actually bypass us so we wouldn’t, you know we would only find out when they came out of hospital”, PCC16, GP
Some primary care clinicians assumed that the campaign impacted on the speed of response, but not on the health service that people contact.
“It has made a difference to their responses because I think they do phone, they probably do phone more quickly, but they probably still phone us”, PCC03, GP
One primary care clinician attributed changes in response to stroke to a general trend and noted that many patients still delay and present to the wrong service.
“I think not necessarily that programme but I think people in general are more keen to present with those symptoms. But I still get people ringing up on a Monday saying their leg went weak on a Saturday, you know, they don’t necessarily present quickly”, PCC15, GP
Some primary care clinicians (n = 5/22) remained unconvinced that the campaign affected patient response behaviours in the event of stroke.
“Certainly over the last few months the people I have seen who have had those symptoms haven’t changed their behaviour, […] there’s no obvious sign of them going very quickly into 999 rather than coming to see us”, PCC14, GP
One primary care clinician noted a lack of appropriate response despite correct recognition symptoms as stroke.
“Some people, yes they know all about it and then you still get them ringing in and saying: ‘I think my mother’s had a stroke’ and you just think ‘Why haven’t you just dialled 999 like they tell you on the television’”, PCC20, PN
Views on ‘Act FAST’
The vast majority of primary care clinicians held positive views about the campaign itself (“I thought it was good”, PCC11, GP) and/or the principle of raising awareness (“Anything that makes people aware is good”, PCC18, GP). Other adjectives used to describe the campaign were ‘helpful’, ‘informative’, ‘clear’, and ‘powerful’. One primary care clinician was complementary about the ‘fire in the brain’ analogy for stroke.
“I liked where they described it as a fire in the brain that was quite a visual [image]. Yes you can talk to people about ‘Did you see that advert and the fire destroys your brain and that’s what a stroke would do’, kind of thing”, PCC20, PN
Primary care clinicians also commented on the campaign’s visibility (“It’s probably one of the most visual campaigns”, PCC01, GP) and simplicity (“They’ve kind of kept it quite simply and compact”, PCC05, HCA). Some primary care clinicians expressed both critical and positive comments regarding the content (“It’s alright. It’s like all health campaigns which means that it’s massively over inclusive”, PCC14, GP) and style of the campaign (“…possibly over dramatic, but they did kind of bring the point across”, PCC13, GP). One primary care clinician suggested a frequent change of campaign materials to continue attracting attention.
“I think it’s like anything else that, if it’s there too often you ignore it, […] you get familiar with the poster that has the FAST on, and so you don’t see it. So I think campaigns need to be changed regularly to then catch somebody’s attention”, PCC02, PN
Some more critical remarks were voiced regarding the potential impact on individuals (“Distressing I think for some people”, PCC21, PN) as well as the limited coverage of all relevant stroke symptoms (“It only covers some symptoms of stroke, it doesn’t cover everything”, PCC07, GP).