JMIR FORMATIVE RESEARCH

Denny et al

Original Paper

An Intervention Mapping Approach to Developing a Stroke Literacy
Video for Recent Stroke Survivors: Development and Usability
Study
Mary Carter Denny1, MPH, MD; Andrea Ancer Leal2, BSN, MSW; Tahani Casameni Montiel2, MBA; Keona J
Wynne3, MBE; Gabrielle Edquilang4, BSN, RN, SCRN; Kim Yen Thi Vu4, MBA, MSW; Farhaan Vahidy5,6,7, MBBS,
MPH, PhD; Sean I Savitz8,9, MD; Jennifer ES Beauchamp2,9, PhD, RN; Anjail Sharrief8,9, MPH, MD
1

Department of Neurology, Georgetown University Medical Center, MedStar Health, Washington, DC, DC, United States

2

Department of Research, Cizik School of Nursing at UTHealth, Houston, TX, United States

3

Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States

4

Memorial Hermann – Texas Medical Center, Houston, TX, United States

5

Center for Outcomes Research, Houston Methodist, Houston, TX, United States

6

Department of Population Health Sciences, Weill Cornell Medical School, New York, NY, United States

7

Houston Methodist Neurological Institute, Houston Methodist, Houston, TX, United States

8

Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, United States

9

UTHealth Institute for Stroke and Cerebrovascular Disease, Houston, TX, United States

Corresponding Author:
Mary Carter Denny, MPH, MD
Department of Neurology
Georgetown University Medical Center
MedStar Health3800 Reservoir Road NW, PHC 7
Washington, DC, DC, 20007
United States
Phone: 1 202 444 8532
Fax: 1 877 245 1499
Email: MaryCarter.Denny@medstar.net

Abstract
Background: Most vascular events after stroke may be prevented by modifying vascular risk factors through medical andbehavioral interventions. Stroke literacy—an understanding of stroke symptoms, risk factors, and treatment—likely contributes
to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racialand ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke
survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy
interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides aframework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions.
Objective: We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients withacute stroke.
Methods: The 6-step iterative process of IM was used to develop a video-based educational intervention and related
implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change
objectives, the selection of theory- and video-based intervention methods and practical applications, the development of avideo-based stroke educational intervention, plans for implementation, and evaluation strategies.
Results: A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention
development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planningphase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed.
Conclusions: An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke
literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support
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widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke.
Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care
optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based
stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy.
International Registered Report Identifier (IRRID): RR2-10.1371/journal.pone.0171952(JMIR Form Res 2023;7:e31903) doi: 10.2196/31903
KEYWORDS
stroke; stroke prevention; health literacy; stroke literacy; patient education; transition of care; risk factors; cardiac; digital health

Introduction
There are more than 7 million stroke survivors in the UnitedStates and 80 million worldwide [1]. Mortality from stroke has
steadily declined over the past 10 years, which is due in part toadvances in acute stroke treatments and the establishment ofcomprehensive stroke centers [2]. However, the incidence ofstroke continues to rise, which is driven primarily by an aging
population [3]. The total annual cost of stroke in the UnitedStates, including direct medical costs and indirectly lost
productivity, is estimated to be US $120 billion currently, and
it is projected to double to US $240.7 billion by 2030 [4]. Given
the large public health impact of stroke, Healthy People 2030
[5] includes goals for increasing the proportion of people who
receive acute stroke treatment and decreasing stroke-related
mortality rates. In the 2017 National Health Interview Survey,
only 67.5% of adults over 20 years old were aware of thecommon signs and symptoms of stroke and the necessity ofactivating emergency medical services (EMS) [6]. Among young
adults, 28.9% were unable to name 5 stroke symptoms [7].
Acute stroke treatments are time-dependent; therefore, the earlyrecognition of the common stroke symptoms and activation of
EMS are crucial to decreasing disability and mortality fromstroke.
Of the 795,000 strokes that occur in the United States annually,
185,000, or nearly 25%, occur in patients with a history of priorstroke [8]. Up to 80% of vascular events after stroke may be
prevented by modifying vascular risk factors through medical
and behavioral interventions; however, up to 40% of patients
experience a second stroke within 10 years [9,10]. Multiple
variables, including stroke literacy, likely contribute to vascularrisk factor control and stroke recurrence risk in turn. Stroke
literacy, which is an understanding of stroke signs andsymptoms, risk factors, and treatment, is vital for secondary
stroke prevention campaigns [11]. Stroke survivors and theirfamily members reported unmet educational needs, including
an understanding of the causes of strokes and how to prevent
future strokes [12,13]. The Joint Commission, the principal
accreditation organization that certifies hospital stroke services
in the United States, has recognized the importance ofaddressing this stroke literacy gap and requires that all stroke
survivors and their families receive stroke education [14].
However, the format, language, and content of this mandatory
stroke education is not defined clearly. Studies suggest that
Hispanic groups are less aware of stroke signs and symptoms,
opportunities for acute stroke treatment, and the crucial timefrom stroke onset to treatment [6,7,15-17]. Data from the 2019https://formative.jmir.org/2023/1/e31903

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census in the United States showed that 18.4% of the country’s
population identified as Hispanic [18]. Despite the large numberof Hispanic adults at risk for a stroke, there are limited stroke
literacy educational interventions tailored for Spanish-speaking
populations [19].
Video-based educational interventions have demonstrated higher
efficacy in increasing knowledge and modifying healthbehaviors than written educational materials for other chronic
diseases [20]. Video-based interventions targeting stroke literacy
may help stroke survivors understand stroke and lead to a
reduction in stroke recurrence. However, many prior stroke
literacy interventions have been unsuccessful in achieving
sustained knowledge acquisition and stroke-related behavior
change [21]. The failure of these stroke literacy interventions
may be in part because although they were pragmatic“commonsense interventions,” they were neither theory-driven
interventions nor evidence-based interventions [22,23]. Being
explicit in the theory used to develop health interventions
mitigates the unintended consequence of differential uptake ofthe intervention, whereby more educated individuals will gain
more from the intervention than less educated individuals, who
often carry a larger disease burden [24]. The 2021 secondary
stroke prevention guidelines from the American Heart
Association/American Stroke Association emphasize that
“Changing patient behaviors such as diet, exercise, andmedication compliance requires more than just simple advice
or a brochure from their physician. Programs that use theoreticalmodels of behavior change, proven techniques, andmultidisciplinary support are needed” [25].
Intervention mapping (IM) is “a planning approach that is basedon the importance of developing theory- and evidence-informed
programs, taking an ecological approach and intervening in
health problems and community participation” [22]. IM provides
a framework for health promoters to use in the development,
implementation, and evaluation of health-related interventions.
An IM approach is an iterative process comprising the following
six steps: (1) needs assessment, (2) identification of outcomes
and change objectives, (3) selection of theory-based intervention
methods and practical applications, (4) development of theintervention program, (5) implementation, and (6) evaluation.
Therefore, the primary aim of this study was to develop avideo-based educational intervention, using an IM approach,for stroke survivors in the acute hospital setting.

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Methods

as the implementation and evaluation of the video-based
educational intervention.

Ethics ApprovalIntervention Developed Using the IM ApproachThis study was approved by the university’s institutional review
board (HSC-MS-14-0931). All study participants or their legallyauthorized representatives provided written informed consent
prior to the initiation of participant-related study activities, such

Overview of the IM Approach
The video-based educational intervention was developed using
the 6-step IM approach, which is outlined in Textbox 1.

Textbox 1. Intervention mapping steps and descriptions (reprinted with permission from Bartholomew et al [26]).
Step 1: Needs assessment•

Create a planning committee•

Determine needs•

Assess community knowledge and attitude

Step 2: Change objectives•

Determine outcomes for behavioral and environmental change

Step 3: Theoretical methods and practical applications•

Develop program intervention ideas with the aid of a planning committee•

Verify that applications are aligned with previously identified change objectives

Step 4: Intervention program•

Create the program•

Pretest the program

Step 5: Adoption and implementation•

Determine the procedures and protocols necessary for adoption

Step 6: Evaluation•

Assess program concept and design•

Review logic model•

Write evaluation questions

Step 1: Literature Review and Needs Assessment
Involving Major Stakeholders
A literature review on the educational needs of stroke survivors
and previous in-hospital and posthospitalization stroke
educational interventions was conducted. Moreover, publishedstudies on stroke educational interventions and health behavior
change theories that would be most suitable for the developmentof a video-based educational intervention for recent stroke
survivors were identified. The literature review was conductedusing PubMed and other available library resources, using thesearch terms “educational video,” “health literacy,” “stroke
education,” “stroke literacy,” “stroke prevention, “educational
intervention,” and “transitions of care.” The search was
restricted to publications in English only.
An interview-based needs assessment was conducted at a large
academic medical center in Southeast Texas, involving
approximately 50 acute stroke survivors and their family
members. Our multidisciplinary stroke care team, including
rehabilitation therapists, a social worker trained as a transitionsof care coordinator, case managers, stroke-trained nurses, andhttps://formative.jmir.org/2023/1/e31903

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stroke physicians, was also interviewed to identify common
concerns and stroke knowledge gaps. The educational needs ofstroke survivors and their family members were based on themost frequently asked questions and topics during the monthly
hospital-based stroke support group. Medical and nursing staff
directly involved in the care of stroke survivors were asked
about the perceived educational needs of the patients and theirfamily members in terms of the educational gaps they commonly
encountered. Additionally, the study team reviewed call logs
compiled by the nurse in charge of the stroke unit to identify
7-day postdischarge telephone calls to stroke survivors and theircaregivers and common stroke knowledge needs. Finally, 2
stroke physicians identified common questions raised by stroke
survivors and their caregivers at outpatient follow-up visits.

Step 2: Identification of Outcomes, Determinants, andChange Objectives
Using the information gathered in the literature review andneeds assessment, several prominent gaps in stroke knowledge
and outcomes in the population with stroke were identified.
Short-, medium-, and long-term outcomes were identified, using
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Denny et ala logic model, to develop a structure for determining how avideo-based educational intervention would fit into the larger
goal of stroke sign and symptom recognition as well as
secondary stroke prevention.

they were nearing hospital discharge. All potential study
participants had already received standard verbal and written
stroke education from their bedside nurses, physicians, andrehabilitation therapists, as appropriate.

Step 3: Selection of Theory-Based Intervention Methods
and Practical Applications

Step 6: Generation of an Evaluation Plan

The McGuire communication persuasion matrix (CPM) theory[26-28] was selected to identify theoretical methods, as it was
the most relevant one for this population of adult learners. The
McGuire CPM theory uses 7 principles to identify theoreticalmethods and anticipate how differences in the character,personality, and rationale of individuals will affect their adoptionof a health promotion campaign [26-29]. The McGuire CPM
has been adapted and updated by public health experts to include
elements from the Bandura social cognitive theory (attitude,
social influences, and self-efficacy) [26].

Step 4: Development of the Video Intervention andQuestionnaire
The most complex steps were the following: (1) developing thevideo-based educational intervention with a video script at asixth-grade reading level, (2) creating a novel pre- andpostintervention questionnaire, (3) engaging multiple healthcare team members in filming the video, and (4) obtaining
hospital administrative approvals.
Members of the stroke care team were engaged to film the video
in a question-and-answer format, followed by the editing of thevideo. The overall development of the video-based educational
intervention and questionnaire involved iterative processes thattook place over a 6-month period. A novel 10-item questionnaire
was developed by the principal investigator, with inputs fromthe multidisciplinary stroke team based on the major gaps
identified in step 1. Items 1 to 8 assess stroke knowledge, item
9 evaluates self-efficacy in identifying stroke symptoms, anditem 10 measures satisfaction with stroke education (Multimedia
Appendix 1).
Although not a part of the original study, in 2020, a team ofdiverse Spanish-speaking research team members collectivelytranslated the video content into Spanish. The initial draft of
the Spanish transcript was created by 1 member, and the other2 members reviewed it independently for accuracy. Any
disagreements in word choice were reviewed and resolved,
using Spanish grammar resources. The final translation of thetranscript was added in the video as Spanish subtitles.

Step 5: Generation of the Adoption and Implementation
Plan
An implementation plan was developed by using the IM
approach. Key stakeholders, including stroke nurses, social
workers, and stroke physicians, came together to develop a plan
to implement the video intervention for stroke survivors once
they were medically stable. We tried showing the video on
hospital room televisions, computers on wheels, and a bedside
laptop. Study team members developed a plan to screen patientsfor participation in the educational video intervention study
during daily multidisciplinary rounds and identify them once

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An evaluation plan was generated with the stroke care team.

Results
Step 1: Literature Review and Needs Assessment
Involving Major Stakeholders
The literature review yielded 10 studies [11,21,30-37] focusing
on stroke literacy. The need for theory-based interventions
designed with materials that are culturally tailored and are at
the appropriate health literacy level was emphasized [21,24].
Prior stroke education studies had primarily used writtenmaterials as a teaching modality, and few had focused on recent
stroke survivors in their transition of care as they left the acutehospital setting [11,31-33].
We identified stroke knowledge gaps from our stroke support
group, which were raised by recent stroke survivors and theircaregivers, including common questions like “what is a stroke”
and “what happens after I leave the hospital?” Using theinformation gathered from multiple stakeholders, we identified
the most common stroke knowledge gaps—the definition of
stroke, warning signs and symptoms of stroke, risk factors forstroke, the activation of EMS, and follow-up after discharge.
These stroke knowledge gaps were in line with the stroke
education mandate set forth by the Joint Commission as part ofstroke center certification [14,38].

Step 2: Identification of Outcomes and Change
Objectives
Several prominent gaps in stroke knowledge among the
population with stroke were identified, including the definitionof stroke, the recognition of stroke signs and symptoms, theimportance of activating EMS if stroke is suspected, themanagement of risk factors for stroke prevention, and theimportance of follow-up care. Additionally, stroke survivor
satisfaction with stroke education was identified as an important
topic for formative outcome data to the major stakeholders.
Short-term outcomes were identified that assessed the impactof the educational video intervention on stroke knowledge
acquisition, self-efficacy in identifying stroke symptoms, andsatisfaction among recent stroke survivors prior to hospitaldischarge. The medium-term outcomes of self-efficacy inidentifying stroke symptoms and activating 911 (EMS) wereassessed. Additionally, the keeping of outpatient follow-up
appointments, home blood pressure monitoring, and adherence
to medications were also identified. These identified short-term
outcomes may be necessary, although not sufficient alone, toaffect the identified medium-term outcomes of attending
follow-up appointments and monitoring blood pressure at home.
Long-term outcomes were not measured in this pilot study(Textbox 2).

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Textbox 2. Logic model details from step 2.
Input•

Staff: 1 to 2 program staff members to deliver video and answer questions•

Materials: 5-minute educational video shown on bedside laptop

Activities••

One 5-minute video covering the following:•

Recognition of stroke symptoms•

Importance of calling 911 for suspected stroke•

Control of stroke risk factors•

Importance of outpatient follow-up visits

Facilitators will answer any questions and clarify information for participants

Outputs•

Number of staff members trained to provide video to patients and family members•

Number of patients and family members who participate in the video session

Short-term outcomes•••

Increase at-risk participants’ knowledge of the following:•

Stroke symptoms•

Importance of calling 911•

Control of stroke risk factors•

Importance of outpatient follow-up visits

Improve stroke knowledge in participants, so that they better understand the following:•

Basic physiology of stroke•

Medical interventions that took place in the acute stroke setting•

How to prevent another stroke in the future

Increase previous stroke survivors’ and their caregivers’ knowledge of stroke risk factors (ie, high blood pressure, high cholesterol, diabetes, andtobacco use)

Intermediate outcomes•

Increase participants’ abilities to recognize stroke symptoms in themselves and others and to take appropriate action (ie, calling 911)•

Improve previous stroke survivors’ ability to modify stroke risk factors, such as the following:•

Keeping 75% of outpatient follow-up visits•

Monitoring blood pressure daily at home•

Adhering to chronic disease medications for at least 80% of the timeLong-term outcomes•

Decrease the incidence of stroke (including recurrent stroke) and the morbidity and mortality from stroke in previous stroke survivors

Step 3: Selection of Theory-Based Methods andPractical Strategies
An IM approach was selected because it uses health behavior
theory to plan and develop health promotion interventions andhas been successful in prior stroke education interventions[22,39,40]. A video modality for the practical delivery of theeducational intervention was chosen, as it has proved morehttps://formative.jmir.org/2023/1/e31903

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effective than written material in promoting knowledge
acquisition and behavior change in several health conditions[20].

Step 4: Development of the Intervention Program(Making the Video)
A 5-minute educational video with high emphasis on
incorporating diagrams and visual materials was created.
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Specifically, a full-screen animation module simulated bothischemic and hemorrhagic strokes occurring in the brain. The
animations were shown after the physicians defined anddiscussed each type of stroke separately to avoid confusion.
Visuals were also used to illustrate the acronym FAST (face,arm, speech, and time) with regard to calling 911. Each visualcorresponded with each letter of the acronym and appeared one
at a time on the screen until the entire acronym was present. A
voice-recording explaining this acronym was used to supplement
the visual material presented.
The video intervention (Multimedia Appendix 2) also used
words and visuals to demonstrate stroke risk factors (eg, eating
a greasy hamburger for high cholesterol). The video used visuals
to illustrate specific ways to control risk factors (eg, blood sugar
monitoring for diabetes). Special emphasis was placed on
hypertension—the most major stroke risk factor—with ademonstration of how to monitor blood pressure at home.
Finally, the use of imagery and modeling allowed for visualand physical cues to be created. As an example of modeling,
the use of a blood pressure cuff (video modeling) by a stroke
survivor was shown when hypertension was discussed, creating
a visual cue. Care was taken to ensure that a diverse cast(patients and health care professionals alike) was included in
the video, as it has been proven that the effectiveness of video
modeling increases when the cast is ethnically consistent withthe target population [20]. The stroke literacy topics covered in
the video included what is a stroke, the recognition of stroke
symptoms, the activating of EMS by calling 911, stroke risk
factors, stroke prevention, transition to rehabilitation, and theimportance of outpatient follow-up.
In 2020, based on our initial results, epidemiologic data, andthe geographic location of our institution in Southeast Texas,
we decided to translate the contents of the video into Spanish,
checking for linguistic accuracy. We are currently investigating
if our results hold when applied to a broader Spanish-speaking
population.
The questionnaire included 8 questions related to the knowledgeof stroke, stroke sign and symptom recognition, risk factors forstroke, and stroke prevention; 1 question regarding self-efficacy
in recognizing stroke symptoms; and 1 question about patientsatisfaction with stroke education (Multimedia Appendix 1).

Step 5: Generation of the Adoption and
Implementation Plan
Hospital computers on wheels were found to often be in use byproviders and would not be consistently accessible to study
staff. The logistical challenge of having a large video file to
upload onto a hospital-networked computer was also identified.
As such, we considered showing the video on the television in
the stroke survivor’s hospital room, but we soon realized that
if the video was uploaded onto the hospital content channel, we
would not have control over how many times patients withstroke viewed the video during their hospital stay, which could
alter the study results. Therefore, we found it most feasible toshow the video to stroke survivors on a bedside laptop that we
could adjust according to their bed position and line of sight.
We found that, owing to the ambient hospital noise (ie, monitors
beeping and staff going in and out of the room), several patients
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Denny et al
required external speakers with the laptop to provide adequate
audio volume.
Prior to enrolling the first study participant, each member ofthe study team would be trained on performing the proceduresof obtaining informed consent, administering the 10-item
questionnaire in person and by telephone, showing the 5-minuteeducational video, and answering common questions fromparticipants and their informal caregivers (eg, spouses andfamily members).
The 5-minute stroke educational video was implemented foruse in the hospital before the discharge of recent stroke survivors
at the Memorial Hermann Hospital - Texas Medical Center(MHH-TMC). The MHH-TMC is a high-volume,
comprehensive stroke center located in Houston. The enrollment
period for the study was from March to June 2015.
All of the participants had the opportunity to complete the10-item questionnaire by using a pen and paper, per theirconvenience. For study participants with visual impairment,
illiteracy, neglect, or reading impairment due to stroke, the study
personnel read the questionnaire aloud. For participants withdominant hand weakness or impaired dexterity, study personnel
could circle the answer choice they provided verbally. In cases
where the participants could not complete any items on thequestionnaire due to somnolence, cognitive impairment, aphasia,
or other reasons, the study personnel checked this box on thequestionnaire accordingly. As noted above, the study participants
completed the 10-item questionnaire before, immediately after,and 30 days following the viewing of the stroke video.

Step 6: Generation of an Evaluation Plan
The novel 10-item questionnaire was used to evaluate strokeknowledge before, immediately after, and at 30 days following
the viewing of the stroke educational video, and the results were
published in a peer-reviewed journal [41].
The external review of the video-based stroke educationintervention study was conducted by public health professionals
with expertise in health promotion. The review included anevaluation and critique of the study design, implementation,and outcomes. A logic model generated in the initial program
description was used as a guide in the external review (Textbox
2).

Primary Pilot Results
A full account of the pilot findings can be found in the authors’previously published primary results [41]. In summary, 250
inpatient stroke survivors were screened for participation, 102
were enrolled in the study, and 93 completed the videointervention. The short-term outcomes were stroke literacy andself-efficacy in identifying stroke symptoms. Stroke literacy
was measured before, immediately after, and 30 days following
the viewing of the stroke educational video, using a 10-item
questionnaire. The median stroke knowledge score on thequestionnaire before viewing the video was 6 (IQR 4-7) out of
8 and increased to a median score of 7 (IQR 6-8; P<.001) after
viewing the video. The proportion of participants who were“very satisfied” with their education increased from 49.5%
before viewing the video to 74.2% after viewing the video
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JMIR FORMATIVE RESEARCH(P<.01), and this was also maintained at 30 days (75.4%; P<.01).
A median stroke knowledge score of 7 (IQR 5-8; P=.04) was
maintained at 30 days. The proportion of participants who were“very certain” in recognizing stroke symptoms increased from
35.5% before viewing the video to 53.5% after viewing thevideo, and this was maintained at 30 days (35.5% vs 53.5%,
P=.01; 35.5% vs 54.4%, P=.02) [41].

Discussion
Primary Findings
To our knowledge, this remains the first theory-driven study ofa video-based stroke literacy intervention, which was developedby using IM, for recent stroke survivors and their families in
the acute hospital setting. The development and implementationof this stroke literacy video required input from amultidisciplinary team that included nurses, physicians, social
workers, and rehabilitation therapists alongside stroke survivors
and their families. The individuals portrayed in the video are
diverse in terms of race, ethnicity, sex, and age, which is anotable strength. The stroke education video was designed tobe compatible with a wide range of literacy levels and address
the most common concerns of stroke survivors and their families
in the transition of care from the acute care hospital torehabilitation centers or homes [42-45]. The clinical team at
our hospital continues to receive positive feedback on the video
not only from patients but also from their families andcaregivers, who often watch the video with them as they prepare
for hospital discharge. However, we learned that it takes
cooperation from the hospital administration, bedside nurses,
and physicians to ensure that the video continues to be shownas part of the services provided in a busy inpatient stroke unit.
As an educational tool, the video format allows stroke survivors
and their families to rewind, pause, and rewatch the video while
watching it at a speed that is comfortable for them in the privacyof their hospital room. The ability to ask questions after viewing
the video along with a health care provider may remove someof the stigma and potential shame of not understanding healthinformation when it is presented initially. The use of the video
allowed imagery to be incorporated, which can aid visual
learners and solidify concepts for auditory learners. Visualmaterials have been used in multiple behavior change strategies,
but there is a lack of literature focusing on stroke survivors.
Unlike text, visuals can be perceived and understood
immediately upon their view [28]. It is necessary for the visualmaterials to incorporate elements that are familiar andpersonable to the target population [26,28]. Furthermore, visuals
should strive to be realistic as opposed to being symbolic, simple
with few distracters, illustrate health-promoting activities withvisuals, and be used to stimulate interaction [26]. The video
also includes text, which is accompanied by images that candemystify some of the hard-to-understand medical language
and help patients begin to build a recognition system, as theyencounter the same terms in their follow-up care.

Comparison With Prior Work
Previous studies on stroke messaging via television advertisinghave shown significant increases in correct responses to warning
signs of stroke [46-48]. When 2173 participants in Ohio werehttps://formative.jmir.org/2023/1/e31903

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Denny et al
asked to report their sources of knowledge, television made up
32% of the cited sources [49]. One study even suggested thatthe population-level distribution of television campaigns was
associated with a significant increase in emergency department
visits related to stroke [48]. If media advertising, specifically
television or video advertising, can increase the number ofpeople who take emergency action when experiencing stroke
symptoms, our video-based educational intervention has
important consequences. Informal video presentation platforms,
such as YouTube, have been shown to reach over 1 billion users,with many videos related to medical information [50]. Studies
have reported that social media and general search engines aresome of the most common avenues used to find health-related
information [51]. Although misinformation or a lack of scientific
relevance is an issue in these informal settings, the outreach
could be beneficial and increase the amount of accurate
information on such sites [52]. In waiting rooms or physician
offices, educational interventions have been shown to increase
patient satisfaction, and one television-based healthadvertisement intervention resulted in a significant increase inknowledge and the intention to seek medical help among patients
after they viewed the video in a general practice waiting room
[53,54]. This evidence suggests that partnering with careproviders in various health care settings to promote the use of
our video in waiting rooms could offer a streamlined avenue tostroke survivors and their families, as well as those at risk forstroke.

Limitations
A key limitation was that the audio of our stroke literacy video
was only available in English. Although our team added Spanish
subtitles to the English audio in 2020, Spanish-speaking stroke
survivors may miss important content if they are slow readersand cannot watch the video at normal play speed. Furthermore,
the video may exclude those with no reading ability. Although
the inclusion of Spanish subtitles is a step toward providing
language-competent video-based stroke education to
Spanish-speaking stroke survivors and their families, translating
the script and recording the video in various languages,
including Spanish, will be important for future studies. The pilot
study excluded 23 potential participants because they were not
English speakers, and the study inclusion criteria required
English fluency [41]. If translated into multiple languages, thevideo could be further tailored to different cultural groups. For
example, healthy food choices from various cuisines could beincorporated.

Conclusions
We received feedback from patients and families stating thatthey wanted access to the video to view it again after they wenthome. A future aim is to make the video easily accessible tostroke survivors and their families after hospital discharge toreinforce key messages and promote behavior changes
associated with stroke risk reduction.
We plan to pair the video with a skill-building activity for risk
factor self-management, along with subsequent viewings at
patients’ follow-up visits in the stroke clinic. One suchskill-building activity would be training stroke survivors andtheir families to perform home blood pressure monitoring.
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Moreover, in our pilot study, we collected longitudinal data toassess the impact of the video on stroke literacy, self-efficacy,
and patient satisfaction at longer-term time points [40]. In a
future study, we will assess the impact of the video on both

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stroke literacy and behavior change outcomes at short- andlonger-term time points. A future multicenter study with thevideo translated into Spanish and other languages has beenplanned.

Acknowledgments
The authors would like to acknowledge the contributions of Melissa Peskin, PhD, and Danika Brodak, MD, MPH, for their criticalappraisal of this project from the health promotion perspective. The authors would also like to thank Abhishek Kadiyala andAlejandra Castro for their work in translating the video content into Spanish. Lastly, the authors would like to recognize EliseSiders and Sophie Clayton for their assistance in reviewing and revising the manuscript. MCD received support for this workfrom the National Institutes of Health T32 training grant awarded to The University of Texas Health Science Center Houston(principal investigator: SIS) from July 2014 to June 2016 (grants 2T32NS007412-16 and 5T32NS007412-17).

Conflicts of Interest
None declared.

Multimedia Appendix 1
Stroke knowledge questionnaire.
[DOCX File , 16 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Stroke video.
[MP4 File (MP4 Video), 108602 KB-Multimedia Appendix 2]

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Abbreviations
CPM: communication persuasion matrix
EMS: emergency medical services
FAST: face, arm, speech, and time
IM: intervention mapping
MHH-TMC: Memorial Hermann Hospital-Texas Medical Center
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Denny et al

Edited by A Mavragani; submitted 28.12.21; peer-reviewed by P Aslani, E Scruth; comments to author 11.07.22; revised version
received 05.08.22; accepted 05.08.22; published 04.01.23
Please cite as:
Denny MC, Ancer Leal A, Montiel TC, Wynne KJ, Edquilang G, Vu KYT, Vahidy F, Savitz SI, Beauchamp JES, Sharrief A
An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability
Study
JMIR Form Res 2023;7:e31903
URL: https://formative.jmir.org/2023/1/e31903
doi: 10.2196/31903
PMID: 35972729©Mary Carter Denny, Andrea Ancer Leal, Tahani Casameni Montiel, Keona J Wynne, Gabrielle Edquilang, Kim Yen Thi Vu,
Farhaan Vahidy, Sean I Savitz, Jennifer ES Beauchamp, Anjail Sharrief. Originally published in JMIR Formative Research(https://formative.jmir.org), 04.01.2023. This is an open-access article distributed under the terms of the Creative Commons
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