By Maricela Wilson, RN, BSN; Remle Crowe, PhD, NREMT; and Paul Banerjee, DO
More than 20 years of stroke research has shown that Hispanic Americans have strokes at younger ages and are more likely to experience poorer outcomes across the board compared to non-Hispanic white Americans [1]. Patient delay in seeking medical attention is a major barrier for timely access to life-saving medical interventions like thrombolysis, thrombectomy, coiling and clipping. A primary factor influencing these delays likely relates to lack of awareness regarding stroke signs and symptoms.
Stroke survivors who speak Spanish have shown lower stroke literacy than their English-speaking counterparts. In a recent study, fewer than 1-in-5 Spanish-speaking stroke survivors correctly identified three stroke symptoms compared to 1-in-3 English-speaking stroke survivors [2]. Collectively, these findings highlight a pressing need to break down language barriers to reduce disparities.
Public educational campaigns lead to increased community awareness of warning signs for stroke and the need to activate emergency services. In English, the FAST mnemonic (Face, Arm, Speech, Time to Call 911) has been used in many campaigns since its introduction over a decade ago. FAST has since been extended to BE-FAST to include additional symptoms related to Balance and Eyes. The addition of these two symptoms increases recognition of strokes involving the vertebrobasilar circulation, which are often missed with FAST alone [3]. Both FAST and BE-FAST are easy-to-remember mnemonics that can help the public remember stroke symptoms and encourage early activation of EMS. Nevertheless, this same benefit has not yet been achieved for Spanish-speaking populations as no corresponding mnemonic exists in wide use.
Three amigos and the creation of AHORA
The absence of a simple Spanish mnemonic for stroke recognition represents an important public health education gap. Determined to help fill this gap, three friends with backgrounds in stroke education, public health and EMS came together. Maricela “Marcie” Wilson, RN, BSN, a community outreach coordinator at Seton Healthcare in Austin, Texas; Remle Crowe, PhD, NREMT, a research scientist at ESO in Austin Texas and Paul Banerjee, DO, medical director at Polk County EMS in Florida, set out to create a Spanish translation of the BE-FAST tool.
It was important that the translated tool demonstrate the same desirable characteristics of the BE-FAST in that each letter of the mnemonic represents common signs and symptoms of stroke and the mnemonic spells a word that inspires action. After many iterations, the AHORA tool was born. AHORA, meaning “NOW” in Spanish, contains all of the elements of the BEFAST and adds the symptom of a terrible headache unlike past headaches. Sudden, severe headache is an important predictor of hemorrhagic stroke, a particularly debilitating type of stroke experienced more frequently among Hispanic populations [4]. After completion of the translation, in true grassroots spirit, Marcie’s cousin, Aracely Gomez, volunteered to create the first AHORA infographic similar to images available for the English tools. This image is free to use and may be reproduced.
English Translation of the AHORA Stroke Tool:
| How to recognize a stroke NOW! | |
|---|---|
| A | Walking Does the patient have trouble walking? Is the patient experiencing balance problems? |
| H | Speech Does the patient have trouble speaking or understanding? |
| O | Eyes Has the patient had any vision changes? Double vision? Trouble seeing with both eyes? |
| R | Face and Head Does the patient have facial droop? Does the patient have a terrible headache unlike any previous headache? |
| A | Both Arms and Legs Does the patient have weakness or difficulty lifting one arm or leg on the same side of the body? |
| If the answer is “yes” to any of these questions, call 911 NOW (even if the symptoms have gone away) |
EMS and community stroke outreach
As the familiar adage goes: during a stroke, time lost is brain lost. EMS clinicians have a meaningful influence on helping patients reach timely care, often serving as the first medical contact for patients experiencing stroke. While rapid EMS assessment and immediate transport to a stroke center are important, studies have found that the biggest delay in receiving life-saving care is the time it takes patients or bystanders to recognize stroke symptoms and decide to seek medical care. Community education and outreach can work to reduce these delays.
EMS can also play an important role in educating the public on the signs and symptoms of stroke and the need to activate emergency services. There are many activities EMS agencies can do to provide important information to communities about stroke. Here are some ideas to get started:
- Distribute AHORA stroke recognition materials at community centers in areas with Spanish-speaking populations
- Partner with local Spanish-language publications to include AHORA in upcoming editions
- Host blood pressure screenings at your agency or department and distribute AHORA materials
- Host a stroke education event in May for stroke awareness month and distribute AHORA materials
Outreach efforts by EMS agencies may improve stroke literacy in the community and empower individuals to activate EMS immediately upon recognizing the signs and symptoms of stroke. Consider partnering with local hospitals, government, or local businesses and organizations to get the word out, AHORA.
Read next: How does the Cincinnati prehospital stroke scale compare to other tools?
References
- Laura Williamson. How 20 years of stroke research revealed disparities among Mexican Americans. October 2020. https://www.heart.org/en/news/2020/10/02/how-20-years-of-stroke-research-revealed-disparities-among-mexican-americans
- Pamela Cheng, Barbara Vickrey, Frances Barry et al. Unraveling Disparities: Stroke Literacy, Self-Efficacy, and Perceptions of Care Among Spanish-Speaking Stroke Survivors. Feb 2020. https://www.ahajournals.org/doi/10.1161/str.51.suppl_1.184
- Sushanth Aroor, Rajpreet Singh, Larry B. Goldstein. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time). Stroke, 2017; 48 (2): 479. DOI: 10.1161/STROKEAHA.116.015169
- Axana Rodriguez-Torres, Meredeth Murphy, Christina Kourkoulis, et al. Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals. Neurology, 2018; 91 (1): e37-e44. DOI: 10.1212/WNL.0000000000005729.