Title: The impact of the UK 'Act FAST' stroke awareness campaign: content analysis of patients, witness and primary care clinicians' perceptions

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1 Author's response to reviews Title: The impact of the UK 'Act FAST' stroke awareness campaign: content analysis of patients, witness and primary care clinicians' perceptions Authors: Stephan U Dombrowski (stephan.dombrowski@ncl.ac.uk) Joan E Mackintosh (joan.mackintosh@ncl.ac.uk) Falko F Sniehotta (falko.sniehotta@ncl.ac.uk) Vera Araujo-Soares (vera.araujo-soares@ncl.ac.uk) Helen Rodgers (helen.rodgers@ncl.ac.uk) Richard G Thomson (richard.thomson@ncl.ac.uk) Madeleine J Murtagh (mm399@le.ac.uk) Gary A Ford (gary.ford@ncl.ac.uk) Martin P Eccles (martin.eccles@ncl.ac.uk) Martin White (martin.white@ncl.ac.uk) Version: 2 Date: 30 August 2013 Author's response to reviews: see over

2 University of Stirling School of Natural Sciences, Division of Psychology, Cottrell Building, Room 3A107 FK9 4LA Tel.: +44(0) Dear Editor, RE: MS: We would like to re-submit our manuscript now entitled The impact of the UK Act FAST stroke awareness campaign: content analysis of patients, witness and primary care clinicians perceptions for publication in BMC Public Health. We wish to thank the reviewers for their positive and insightful comments on our manuscript and the editor for giving us the opportunity to incorporate the reviewers comments and resubmit a revised version of the manuscript. We have amended the manuscript accordingly and answered each reviewer comment separately in the tables below. All authors have made intellectual contributions to this manuscript warranting authorship and have approved the resubmission of this manuscript. All authors declare no conflict of interest. On behalf of the co-authors, thank you for reconsidering this manuscript for publication in BMC Public Health. With kind wishes, Stephan Dombrowski, PhD 1

3 Reviewer 1 # Comment Response Thank-you for the opportunity to review this paper. This topic is important given the large numbers of individuals who experience a stroke and don t treat it as an emergency. I have outlined my feedback as follows: 1 I suggest you change the title to more accurately reflect your study design. For example The impact of a stroke awareness campaign: content analysis of patients, witness and primary care clinicians perceptions 2 Background - Sloppy working: promote or raise? 3 Results The results here do not clearly match the results section 4 Paragraph 2, sentence 3 please provide a reference for e few studies 5 Paragraph 3, sentence 1 please expand on what you mean by suboptimal effects 6 Paragraph 3, sentence 2- be clear up front re who the qualitative investigation was conducted with. I would refrain from using the terminology in-depth investigation as I don t believe Content analysis lends itself to a true in-depth and iterative approach. Thank you very much for the comments to our paper which we found extremely helpful in the revision process. We believe that the changes made as a result of the feedback have improved the manuscript. We have changed the title in line with this suggestion to The impact of the UK Act FAST stroke awareness campaign: content analysis of patients, witness and primary care clinicians perceptions Redundant word deleted We have now re-written the results and conclusion section to bring it further in line with the findings of the study. We now provide two references which illustrate our point. p.3 We have rephrased this sentence now to increase clarity. It now reads Limited effects of mass media campaigns for stroke on sustaining public awareness of the need for urgent assessment and emergency response behaviour suggest a need to further optimise and develop intervention components., p.3 We have now added details on the participant groups to this sentence to increase clarity. Please also note that the target groups were also mentioned in the title of the paper as well as the abstract. Regarding terminology, we agree with the reviewer and have removed the reference to in-depth from the sentence. The sentence now reads To inform efforts to improve such campaigns, we undertook a qualitative investigation of the awareness, perceived impact of, and views on, the recent English mass media stroke campaign Act FAST in stroke patients, stroke witnesses and primary care clinicians. 7 Methods We have re-written the method section in 2

4 Overall this section is difficult to follow. I suggest you present the design and the recruitment more clearly Eg: This was a qualitative study involving individual semi-structured interviews with stroke survivors, witness and stroke clinicians. Participants were identified from two separate studies. Introduction Participants in Study one outline sampling, inclusion and exclusion criteria etc. Participants in Study two 8 Was time the only factor in purposively sampling? 9 It is not clear how clinicians were contacted, how they responded to contact and how they were purposively selected. 10 The demographics could be more reflective of purposive sampling eg time to Ed and rural/ubran mix. I am not sure if you truly did purposive sampling or if it was more convenience? 11 Overall I find the analysis section simplistic and lacking depth of analysis. I believe you need to re-work you analysis line with the suggested structure (see p.4-6). We also purposively sampled type of health service contact, which we now make more explicit in the method section (see p. 4). Participants in Study one [8] were stroke patients and witnesses who were purposively selected from three stroke units in north-east England to include a range of health service contacts and response times. Health service contacts were: telephoning EMS (i.e. dialling 999), telephoning the primary care physician office (i.e. general practice surgery) and presenting to the emergency department (ED). Response times to health service contact included longer or short than 1hour following the onset of stroke symptoms. We provide more detail on clinician contact and purposive selection (see p.5). Participants in Study two were primary care clinicians who were recruited through the local primary care research network supported by NHS North of Tyne who contacted primary care practices and passed details of interested practices on to JM. Practices were purposively selected with the aim to generate diversity regarding geographical location of general practices (urban vs. rural) and profession of primary care clinicians (general practitioner, practice nurse, health care assistant). We have now added more information to the demographics section, which includes participant gender, health care response behaviour and timing, and location of the primary care practice, p.7 The reviewer suggests two types of changes: 1. a re-work of the analysis and 2. a different style of presentation of 3

5 and coding. A decision matrix (as used in most content analysis papers) would have been helpful rather than simply listing quotes in the boxes. I believe that a matrix would help you develop and outline subcategories rather than simply list quotes and expecting the reader to decipher meanings. findings. Regarding 1, it should be noted that the data analysed in this paper was generated as part of two studies which investigated broader issues in relation to stroke and not only the campaign. Although these interviews all included questions on Act FAST, they were not centred on this campaign (we mentioned this in the abstract, methods and limitations section of the paper). As a result the paper focuses on three key question that can be answered using the collected data and present the findings in relation to these. In order to not over-interpret data we have refrained from in-depth analyses which would be possible had the interviews solely focused on the Act FAST campaign. Regarding 2, We agree with the reviewer that presentation of results can be improved to increase clarity. We have now re-written the results section to make our interpretation of the data more explicit. 12 Stroke patients Awareness Be consistent with counting in your presentation of result e.g count tv versus posters. Any stand out features or the campaign? 13 Impact What does generally did not influence responses mean? If it didn t influence We have integrated the quotes into the text to provide explicit explanations of our interpretations and have added further quotes where additional evidence was perceived to be beneficial. We now consistently report numbers for how participants report having become aware of the campaign. The stand out feature of the campaign is that most participants report having become aware of the campaign through the TV advertisements, which we briefly highlight in the results section and comment on in the discussion. It should be noted that we keep this section deliberately brief as it is not central to the paper. Campaign awareness is mainly interesting to validate subsequent findings. Discussions of impact and views on the campaign would be meaningless if participants had not heard of it. We meant to say that most reported no influence and have re-worded the section in the re-write. It is now stated positively 4

6 their response, then what was the behaviour seen? 14 You expect the reader to decipher the meaning of the quotes which are simply listed in a box 1 and not categorised. The presentation of results is brief and lack. An in-depth analysis is warranted. 15 The Box 2 title is simplified whereas a matrix would explore learning s from the campaign? Eg confusion concerning different symptoms etc 16 Specify what was the appropriate response? It is not clear- did they call the ambulance or present to hospital? Indeed, apart from knowledge gains and the ability to identify symptoms of symptoms - what was the actail response? 17 View This paragraph is brief and vague. What do you mean by spontaneous views. Can you give more more details? Can you provide a more detailed analysis eg Why did they pay little attention? What about the style- spell this out. You elude to deeper coding in the box re using negative, positive (as the box suggests). Present this is the text. Can you identity gap in the campaign? 18 Witness Awareness Sentence one- do you mean the reported REFELCTING on campaign awareness and reads: 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<1h) and response to stroke symptoms ( I think it made me realise that I had to get help quick, W17, 999<1h). p.10 We now provide information on response behaviour and speed alongside quotes (see also response to comment 16) As suggested, we now provide quotes alongside the text which outlines the results of the analysis. Box 2 has been omitted and quotes integrated into the text. Please note that we provide interpretation of these findings in the discussion section, but not in the results section where we limit ourselves to presenting the findings based on the collected data. We now provide additional information by adding the type of health care contact and time to contact alongside the quotes to illustrate the actual response time and behaviour. The patient group did not provide many views regarding the campaign, so these cannot be analysed in depth. Note that campaign views were not explicitly prompted and thus spontaneously voiced. This is highlighted in the limitation section of the discussion which reads: Second, although patients and witnesses were directly prompted on campaign awareness and perceived impact on decisions/action, no specific prompts on their views on the campaign were included in the topic guide p.15 We mean that witnesses reported having been aware of the existence of the campaign at the time of witnessing the stroke. Whether they reflected on the 5

7 at the time of witnessing the stroke? If the one person didn t see the tv then where did they lean? 19 Impact Spell out the difference between no impact and being unsure these have different implications for ongoing campaigns. Can you provide details on why people were unsure it is not clear and I suggest you could provide subcategories in the Box 2. As you elude to eg severity and patterns 20 You discuss the appropriateness of response re the patient section. What can you say re the Witnesses? The tile of Box 2 refers to potential reasons but you require the reader to do the analysis. 21 Views I suggest that the BX 3 should have subcategories to show deeper analysis as you have begun re broad target audience and memorability -can you subcategorise and outline potential reasons eg emotion reaction, visual 22 Clinicians Impact I have real concern with the sweeping statements in this section eg many basing this judgement of interaction with campaign during the stroke episode is covered in the impact section. We have now re-worded the sentence to make this distinction more explicit, which now reads All witnesses except two (n=24/26) reported having heard of the campaign prior to the time of witnessing the stroke, p.10 We have now added the awareness information regarding the one remaining witness. We prefer to not speculate as to why individuals were unsure as this would go beyond the available data. It is not uncommon for health messages to influence health care seeking behaviour through non-reflective processes which people would be unaware of and thus not able to report. In addition, witnessing stroke is a stressful event which might influence how memories are stored and retrieved. The appropriateness of responses is now discussed in the re-written results section for the witnesses to make this more explicit. We have also added response and timing information to the presented quotes. Box 2 has been deleted and the quotes are integrated into the text to make the analysis more explicit. Box 3 has been deleted in the re-write of the results section. The subcategories have now been integrated in the text of the analysis section and are evidenced by participant quotes. Interpretations of these findings in terms of potential reasons are not outlined in the results section as this would go beyond the available data. We do however discuss some reasons in the discussion section. See also reply to comment 17 for regarding interpretation of data on views. The interpretation of health care clinicians basing their judgement on patient interaction has now been further evidenced through quotes (e.g. Yes, it does [raise awareness], because we ve got patients 6

8 patients. Where is the evidence in quotes? What do they mean by unsure or no impact? Are there any quotes re impact on the clinical workload 23 Views Are views mostly based on tv advertisements? Any difference between the GPs, nurses and assistants? 24 Conclusion Don t refer to the Boxes. You data presentation and evidence stays in the Results section. You shouldn t be putting forward new evidence in the Conclusion. often... people would often mention it, HCP04, GP). P.12 When clinicians reported not being sure whether the campaign impacted on patient behaviour, or when they reported no impact we took these opinions at face value and report these as such, rather than attempting to interpret what clinicians mean by these statements. Views would be based on advertisements and GP practice involvement in the campaign, this would be difficult to disentangle. There were no obvious differences between health care professional groups. We now indicate the profession alongside quotes for further information. We have deleted the boxes and do not refer to these anymore. 7

9 Reviewer 2 Minor Essential Revisions: # Comment Response The authors conducted qualitative evaluation of stroke awareness campaign in UK. This paper provides important information for better future campaign of stroke awareness in other areas of the world. There are a couple of comments. 1 Medthods: Please provide more detailed information on the methods used for selection of participants. Thank you very much for this positive comment and for the valuable feedback. We are delighted that the reviewer thinks this paper contains important information. We have re-written the methods section now to provide further details on the selection of participants. 2 Results: How many patients/witnesses/primary physicians were invited and how many people refused the interview? See also response to Reviewer 1, comment 7 for further details. We now provide information why it was not possible to estimate the number of patients and witnesses who were invited to participate. Potential participants were approached by stroke research nurses and the names of interested individuals were passed to JM. It was not possible to ascertain how many people declined to participate, p.5 We now provide information on the number of GP practices that were invited and the number that took up this invitation. 3 Results: Please provide basic characteristics such as age and gender of patients/witnesses/primary physicians. Altogether 19 practices were invited to participate and 13 accepted participated., p.5 We have added information to the demographics section. We provide the age of patients and range of years of job experience for clinicians. We have now included the gender of participants. We also include further information on practice locations, and health care response behaviour and time for patients and witnesses. We state that age of witnesses and clinicins was not recorded. Ages of witnesses and primary care clinicians were not recorded., p.7 8

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