Stroke is the second leading cause of death worldwide and the leading cause of acquired disability in Europe (1). The number of persons aged 60 or above is expected to more than double from 2017 to 2050 (2). Consequently, this will lead to an approximate 34% increase in stroke incidence from 2015 to 2035 (3). Early treatment for ischemic stroke decreases the likelihood of disability within three months by at least 30% (4, 5). Successful medical treatment is time-dependent and should preferably be administered within a 4.5-h window (6–8). Research shows that as few as 15% of stroke patients arrive at the hospital within this timeframe (9). Late hospital arrival from stroke onset has been associated with certain social determinants like higher age and race. Some ethnic groups have lower stroke awareness than others (10). On the other hand, existing comorbidities, such as stroke history and related risk factors (e.g., hypertension, atrial fibrillation) play an important role in earlier response (7, 10–13). Consequently, it is not just the knowledge of stroke symptoms that prompt timely hospital arrival but also the response to symptoms (12, 14). It is thus crucial that people correctly identify symptoms pointing toward a stroke that they or their loved ones encounter (15). Furthermore, the perceived danger of symptoms is a motivating factor for persons with a suspected stroke to seek immediate help. Unfortunately, only 11% of stroke patients call an ambulance instantly after symptom onset, 67% opt to call a relative or family member as their first response, while 70% of the people from whom advice is solicited do not recommend calling an ambulance “now” (11). These striking results emphasize an urgent need for launching effective national and international educational campaigns to improve symptom-to-treatment times.

To understand how to educate the public about stroke, one first needs to understand whom to educate. The median adjusted age at which the first stroke occurs is 70.3 years in Europe (with an interquartile range of 14.1 years) (16, 17). Concurrently, the Eurostat Ageing Europe report shows that as many as 54.1% of people aged 50–64, the “Baby Boomers,” spend several days a week caring for their grandchildren (18, 19). On that account, the Health Promoting Schools approach (20) suggested that a significant advantage of using schools and children for health promotion has the potential to reach a large part of the community, such as grandparents, through a single channel because more than 90% of children worldwide are in school (21).

Over the last two decades, several health-related campaigns targeting children have shown impressive results (22–27). The Head Start program in the US concluded that children embracing healthy behaviors transfer this knowledge to their extended family. They advocate for a healthy diet, encourage parents to stop smoking, and favor face-to-face activities over more screen time. The family unit with young children can become an important pylon for adopting more healthy living habits. They showed that ambulance visits declined by 58%, and school attendance was reduced by 29%. Days absent from work for parents were decreased by 42% (28). Another study showed that only 3% of parents in the intervention group identified all four letters of the stroke FAST (Facial droop, Arm weakness, Speech disturbance, Time to call 911) acronym before their training. Knowledge of FAST increased to 20% at immediate post-training and 17% at 3-month delayed post-training (29).

The FAST acronym was developed in the UK in 1998 and has been culturally adapted worldwide. Studies using FAST have demonstrated high accuracy in diagnosing strokes by paramedics and emergency medical technicians with positive predictive values between 61 and 77% (30). The “Grand Mission” FAST Heroes project is a global school-based stroke educational campaign that educates children and their extended family (i.e., parents/guardians, grandparents) about stroke symptomatology and the necessary actions in response to stroke. FAST Heroes program differs significantly from other programs because it targets kindergarten children from the age of 4 years old, and it aims to educate the extended family, outside the nuclear family, about stroke symptom recognition and appropriate course of action. In this way, stroke knowledge can be delivered to the broader community (31, 32). The element that is added in this study is the transference of stroke knowledge from children to their parents within an international setting. Despite regional variations, we look at the compiled effects of the Grand mission FAST Heroes' program across multiple countries.

The primary aim of this descriptive cross-country study is to disseminate the first results of the global “Grand Mission” FAST Heroes program and its effectiveness on knowledge transfer to parents of participating children worldwide. Researchers have recently referred to “stroke knowledge” as knowledge of stroke warning signs, and appropriate behavioral response to stroke symptoms (33, 34). In addition to our primary aim, we also examine the program's impact 6 months after implementation to evaluate trends regarding long-term knowledge attrition. The secondary aim of the study is to report parents' and teachers' perceptions about the global campaign.

The FAST Heroes campaign includes a comprehensive set of educational resources that was designed and developed in 2018 by a multidisciplinary team consisting of kindergarten teachers, health care professionals, school psychologists etc. A series of pilot studies were used to assess children's baseline stroke knowledge and fine-tune the educational approach for 5- to 9-year-old children so they carry their stroke-related knowledge onwards to their parents For further details please see (31, 32, 35). Among other teaching aids, a website¹ was created in order to involve parents in the educational process. We used the relevant local emergency number as a mental peg and linked the stroke symptoms to this number (36, 37). We adapted learning theories, e.g., spacing, repetition, and pegging techniques, to refresh knowledge, overcome the forgetting curve, and assisting children in systematically internalizing the knowledge (38). We also created a direct communication channel to the Grandparents by using principle learning strategies such as incidental learning through their grandchildren (39, 40). These studies yielded promising results regarding increased knowledge and stroke preparedness for children and their families.

The successful implementation of the program on a national level in Greece justified its expansion globally. To date, the campaign has been adapted to 11 local emergency numbers, i.e., 103, 106, 107, 112, 123, 131, 192, 911, 995, 998, 999. It has also been translated into the local language for a still growing list of more than 37 communities, including Argentina, Belarus, Brazil, Bulgaria, Canada, Catalonia, Chile, Colombia, Croatia, Czech Republic, Ecuador, Egypt, Georgia, Germany, Greece, Hungary, Iceland, Italy, Iran, Kazakhstan, Lithuania, Malaysia, Moldova, Peru, Poland, Portugal, Romania, Russia, Singapore, Slovakia, South Africa, Spain, Ukraine, United Arab Emirates, United Kingdom, and Uzbekistan. From March to June 2021, a global initiative called “Grand Mission” was launched, through which we aim to enroll one million children and their families worldwide in the next 5 years (41). Public Relations (PR) agencies were recruited in every participating country to assist with the Grand Mission project implementation as well as recruit local, national and international celebrities and social media influencers for promotional activities.

The project received endorsement of the World Stroke Organization (July 20, 2019), Stroke Alliance for Europe (February 11, 2019), and the Schools for Health in Europe Network Foundation (June 23, 2020). This study received clearance from the Committee for Research Ethics of the University of Macedonia (Thessaloniki, Greece) (14/15.06.2020), where the program's educational content was developed. The ethical permission is in accordance with the 1964 Declaration of Helsinki.

Process and outcome evaluations of the global FAST Heroes campaign were explored in this study in conjunction with the effectiveness of strategies used for its development and implementation. We examined the extent to which the campaign succeeded to meet its primary objective, that was evaluating the program's impact on knowledge delivery from children to their parents, as well as its secondary objectives, which included reporting parents' and teachers' perceptions about the campaign.

Results from parental group 1 who completed the SPQ in t1 and t2 of the study showed that they chose “Call an ambulance” for all three stroke symptoms in t2 which was a significant increase. Marto et al. (43) had similar results with parents more correctly regarding calling an ambulance if someone presented with stroke symptoms (43). Our findings confirm what is reported in the literature insofar as they show that school-based educational programs can be an effective, intergenerational model to enhance parental stroke literacy (34, 43–48). Parallel to previous studies the school-based educational programs appear to be both feasible and effective and the intergenerational model excellent for enhancing parental stroke literacy (49). A statistically significant improvement was found in parents' correct answers for the emergency number. Interestingly, a considerable cross-country variation existed among parents who indicated that they would choose the correct course of action in relation to all three stroke symptoms after the campaign ended from 54 to 77%. Regional differences within countries in terms of socioeconomic as well as educational levels could partly explain this finding. However, this issue merits attention in future studies.

Stroke literacy of parents has been examined up to 3 months post-intervention (49). Knowledge retention through the FAST Heroes educational program extended even further, or until 6 months after program completion. Importantly, parents found it harder to choose the correct action (call an ambulance) when presented with stroke symptoms mixed with non-stroke symptoms vs. being asked to select stroke symptoms from a preselected symptom list. This finding explains the unbridged gap between recognizing stroke symptoms or considering stroke a medical emergency and the lack of an appropriate response, i.e., seeking help. According to Mackintosh et al. (50), while the general public support that they would call an ambulance in case of a stroke, in reality both patients and bystanders often contact a general practitioner at first, which significantly delays medical care administration.

Teachers from 5 European countries (Poland, Slovakia, Romania, Greece, and Ukraine) participated in the current study. Nearly all teachers (98.1%) would recommend the campaign to others. Almost half of the teachers delivered parts of the program remotely. Due to local lockdown restrictions during the COVID-19 pandemic, almost half of the teachers delivered parts of the program remotely using online learning tools. This suggests that the program can be implemented both in class and digitally and may thus be viable to implement even in remote areas. Most teachers (90%) also recognized that children had fun while participating and that the educational material contained entertaining ways of transferring knowledge between children and their families.

Altogether, results concur with the primary goal of the FAST Heroes campaign, which is to educate young children and their extended families to recognize the main stroke symptoms and act urgently in the event of a stroke.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Committee for Research Ethics of the University of Macedonia (Thessaloniki, Greece) (14/15.06.2020). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

This study received funding from Boehringer Ingelheim (Grant Number 395479, 2019). The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article, or the decision to submit it for publication.

KT, JM, CW, and HP are employed by Boehringer Ingelheim. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.