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J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-231
10.4103/jehp.jehp_917_23
Original Article
The effectiveness of the stroke sign by sticker: Enhancing stroke knowledge among village health volunteers in community care
Satsarn Rodsawan
Sarakshetrin Atiya 1
Sujimongkol Chinakorn 2
Sriyasak Atcharawadee 3
Ninkhan Phattharalapha 4
Phra Chom Klao Hospital, Thailand
1 Faculty of Nursing, Praboromarajchanok Institute, Thailand
2 Scientific Research Services Subdivision, Loei Provincial Public Health Office, Thailand
3 Boromarajonani College of Nursing, Yala Province, Thailand
4 Aranyaprathet Hospital, Thailand
Address for correspondence: Dr. Atiya Sarakshetrin, 60 Building 7 Floor 1, Faculty of Nursing, Praboromarajchanok Institute, Nonthaburi Province, 11000, Thailand. E-mail: chinaks@umich.edu
2024
11 7 2024
13 23128 6 2023
03 11 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Stroke is a global and Thai concern. Village Health Volunteers (VHVs) are vital in community healthcare but lack stroke knowledge. Prior efforts to improve their knowledge were ineffective. The “Stroke Sign by Sticker” application was created to enhance VHV literacy. To evaluate the effectiveness of the “Stroke Sign by Sticker” line application in enhancing stroke awareness among VHVs.

METHODS AND MATERIAL:

The study was conducted in a health community setting using a quasi-experimental design. The study was conducted within a healthcare community in Thailand. The “Stroke Sign by Sticker” mobile application was developed specifically for the LINE platform. The knowledge scores were measured using a tool that demonstrated a high validity coefficient of. 93. The intervention itself lasted for 3 weeks. The entire process, from the development of the mobile application to the assessment of its effectiveness, took place during the period of 2021-2022. The R program was used to implement the analysis of covariance method for adjusting pretest scores as a covariate.

RESULTS:

A total of 60 participants were included, with half assigned to the experimental group and the other half to the control group. The post-test knowledge scores were the main outcome measure of interest. The results showed a significant effect of the independent variable, with the experimental group exhibiting a higher mean knowledge score compared to the control group (F = 24.26, P < .001).

CONCLUSIONS:

The “Stroke Sign by Sticker” line application demonstrated its effectiveness in promoting stroke knowledge among VHVs, underscoring its potential as a valuable tool for health promotion and education within healthcare settings.

Health community
knowledge assessment
mobile application
stroke
village health volunteers
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pmcIntroduction

Stroke, a classical manifestation of cerebrovascular diseases (CVDs), is a major public health challenge both in Thailand and globally. In 2019 alone, CVDs, including strokes, accounted for an estimated 17.9 million deaths, making it the second-leading cause of mortality worldwide. Stroke is typically triggered by the blockage or rupture of a blood vessel in the brain, resulting in significant brain damage and the subsequent impairment of critical bodily functions. Speech, movement, memory, and even life itself can be profoundly affected by this condition. It is closely intertwined with prevalent risk factors such as obesity, hypertension, and smoking, further emphasizing the urgency of addressing stroke prevention and management.[1] The rising trend of stroke in Thailand mirrors the global situation, affecting communities across the country. From 2016 to 2020, the occurrence and mortality rates of stroke increased, highlighting the urgent need for effective stroke management strategies and education.[2] The magnitude of the stroke is reflected in these numbers. Numerous countries and organizations have developed strategies and measures to address this significant health issue. These measures encompass screening initiatives and educational campaigns aimed at promoting symptom recognition and facilitating early diagnosis. Notably, a study conducted in the United States highlighted the effectiveness of using prehospital personnel to accurately identify individuals with acute cerebral ischemia and intracerebral hemorrhage.[3] Therefore, implementing these measures holds the potential to greatly enhance stroke care within communities, enabling early detection and the implementation of effective preventive strategies. The effectiveness demonstrated by the utilization of prehospital personnel in the USA study can be paralleled in the context of the Thai healthcare system. In Thailand, Village Health Volunteers (VHVs) hold a crucial position in fostering community involvement and bolstering healthcare delivery. With their vast network of 1.04 million individuals, VHVs actively contribute to disease surveillance, health management services, and the collection of daily information. Their widespread presence and dedicated efforts greatly enhance the comprehensive and impactful approach to healthcare in Thailand. Numerous studies have highlighted the significant contributions of health volunteers in implementing diverse health programs across various countries, each with their specific roles and responsibilities.[45] These invaluable volunteers are at the forefront, delivering essential primary and community health services, while also actively combating both communicable and noncommunicable diseases. Their pivotal role has been particularly evident during the ongoing COVID-19 pandemic in Thailand. However, health volunteers require additional support in fundamental aspects of disease knowledge and management. Strengthening their knowledge in these domains is imperative to maximize their impact and effectiveness within the healthcare system, ultimately leading to improved health outcomes for the communities they serve. Health volunteers, particularly those who are older, may encounter barriers associated with a lack of knowledge.[6] Overcoming these barriers is crucial to ensure their effectiveness in delivering healthcare services. Additional support and resources should be provided to enhance their knowledge and address any gaps, enabling them to fulfill their roles more effectively. By addressing these challenges, health volunteers can continue to make valuable contributions to the well-being of the communities they serve. Previous efforts to improve the knowledge of health volunteers, particularly those who are older or have limited educational backgrounds, have proven ineffective. Traditional methods such as classroom lectures have not adequately addressed their specific needs. Therefore, developing new, easily accessible learning methods that can be integrated into their daily lives presents a significant challenge. Overcoming this challenge is crucial, especially when it comes to complex topics like stroke disease. Tailored and practical approaches are necessary to ensure effective knowledge transfer and empower health volunteers in Thailand to effectively handle such critical information. The present study introduced a new and innovative mobile learning tool called “Stroke Sign by Sticker,” which used illustrations and stickers specifically designed for the popular LINE platform. The widespread use of this platform in Thailand and other Asian countries, including among older individuals, enhanced its accessibility. A key feature of the tool was the utilization of stickers, which served as visual representations of emotions and body language. Recognizing the potential of the LINE platform, the researchers developed animations and stickers that depicted stroke signs and symptoms, creating a user-friendly tool. This study was carried out to address the existing research gap by introducing an innovative mobile learning tool called “Stroke Sign by Sticker.” Specifically designed for VHVs, the tool aimed to enhance their understanding of stroke signs and symptoms. By assessing the effectiveness and satisfaction of using this tool, the study aimed to contribute valuable insights to the literature, offering a novel approach to improving VHV knowledge in stroke management. The ultimate goal of this study was that this method of learning would provide sustainable knowledge enhancement and skill development for VHVs, who could easily access and use the tool in the field and within the community. It was expected that VHVs would be able to recall and employ this tool whenever they encountered potential stroke cases.

General aim

The general aim of this study was to evaluate the effectiveness and satisfaction of using the “Stroke sign by sticker” on the line application in enhancing the knowledge of village health volunteers in stroke management.

Specific aims

To assess the knowledge improvement among village health volunteers in a primary care setting after using the “Stroke sign by sticker” on the line application.

To compare the knowledge levels of village health volunteers in a primary care setting who used the “Stroke sign by sticker” on the line application between controlled and experimental groups.

Materials and Methods

Study design and setting

The methodology of this study involved a quasi-experimental research design. It included both controlled and experimental groups and used pretest and post-test measurements to assess the effectiveness of implementing the “Stroke sign by sticker” on the line application in enhancing the knowledge of stroke disease among VHVs in primary healthcare or community healthcare settings in Thailand. The study was conducted in a local primary care setting within one province in Thailand, which served as the study site and target population.

Study participants and sampling

The sample for this study comprised VHVs from a specific district, selected as the study site. These criteria included having communication devices compatible with Wi-Fi and 4G internet and the line application installed for sticker-based communication. Proficiency in the Thai language and the absence of significant intellectual disabilities were also necessary. Age, gender, and educational level were not limiting factors for participation. The willingness to take part in the research was crucial. Exclusion criteria encompassed individuals who declined participation or were unable to meet the required research activities within the designated timeframe. Furthermore, participants who were nonmobile phone users or individuals who were not ready to engage in the learning process due to personal reasons, such as health or socioeconomic factors, were allowed to withdraw from the study at any time. Given practical constraints, a specific subgroup of 92 VHVs was purposefully selected to participate in the research. This purposive sampling approach aimed to ensure that the chosen participants possessed the required knowledge and experience relevant to the study’s objectives. By including individuals who were likely to contribute valuable insights and information, the research sought to enhance its validity and obtain meaningful findings.

The VHVs were randomly assigned to either the control or experimental group using simple random sampling. The random allocation method resulted in 30 participants in the experimental group and 30 participants in the control group.

Data collection tool and technique

The development of the “Stroke sign by sticker” learning tool was guided by Knowles, M. S. (1984)[7] learning theory for adults, which encompasses four key areas: Self-learning, learning experience, readiness to learn, and orientation to learn. These principles were systematically incorporated into the design and structure of the tool. The creation and design of stickers within the line application were performed using programs such as ibis Paint Ver. 9.1.1 and Procreate. Additionally, the utilization of the LINE Official Account was reviewed, and the necessary application registration was completed. The final features of the tool included a selection of line stickers that provided knowledge about stroke across seven important aspects: risk factors, warning signs, proper diet, appropriate exercise, emergency management, and stroke prevention. These stickers were designed to be visually clear and dynamic, accompanied by concise messages and sound effects, ensuring their effectiveness and suitability for practical use.

The evaluation form on knowledge about stroke was developed by adapting previous work[8] and conducting a comprehensive review of relevant literature. The form comprised various questionnaires aimed at gathering general information, such as participants’ gender, age, training experience in stroke care, and their knowledge of multiple aspects of stroke. The form consisted of 15 items, covering topics such as the causes and risk factors of stroke, identification of warning signs, proper exercise and diet practices, emergency management, and stroke prevention. Additionally, the evaluation form included 16 items related to the satisfaction of using the “Stroke sign by sticker” tool. To ensure the content validity of the evaluation form, a panel of five experts from the fields of nursing, stroke, and assessment thoroughly examined the questions and objectives. The assessment resulted in a high content validity score of. 93, indicating the robustness and relevance of the evaluation form for measuring stroke knowledge and satisfaction with the learning tool.

The research was conducted over a 3-week period, in 2022. In the initial week, the researchers established rapport with the village health volunteers, providing a clear understanding of the objectives and addressing any inquiries. Data collection commenced with a pretest, using an evaluation form that assessed knowledge about stroke. This form encompassed general information and inquiries pertaining to mobile device usage and internet accessibility. Eligible participants from both the controlled and experimental groups were then invited to join a chat group through the line application.

During the second and third weeks, line stickers, specifically the “Stroke sign by sticker” tool, were used exclusively for educational purposes in the experimental group, while the control group received instruction through conventional chat methods. For the experimental group, each day was dedicated to a specific topic, and Line Official Account was used to send clear motion illustrations, concise messages, and accompanying sounds to the participants’ chat group three times daily. Upon completion of the experiment, both the controlled and experimental groups underwent a post-test evaluation focusing on the domain of stroke knowledge. Additionally, the experimental group provided feedback on their satisfaction with the intervention. One important rule outlined in the study protocol was to inform participants in the experimental group that they should refrain from sharing the stickers with individuals outside of the designated LINE group and the research team members. This measure was implemented to minimize the potential for study contamination, such as issues related to intention to treat or protocol adherence.

The collected data underwent analysis using the R program. Descriptive statistics were employed to examine general information and satisfaction, involving calculations of percentages, frequencies, mean scores, and standard deviation. The present study also employed inferential statistics to examine the main outcome using the method of analysis of covariance (ANCOVA) within a pretest–post-test comparison group design. This statistical approach involved incorporating the pretest scores as a covariate and adjusting the post-test scores based on a significant linear relationship identified between the pretest scores (covariate) and post-test scores (variate). By integrating the pretest as a covariate and implementing the necessary adjustments, the analysis focused exclusively on the post-test scores, thus accounting for any potential influence of the pretest scores. This analytical strategy enabled the researcher to estimate the effects of interest in the comparison between the groups while effectively controlling for the covariate.[9] Additionally, dependent t-tests or Fisher’s exact tests were considered as appropriate for the data, if indicated, to further explore the relationships and provide robust statistical inferences. Statistical significance was determined with a predetermined alpha level of P < .05.

Ethical consideration

In compliance with ethical standards and regulations, this study obtained formal approval from the local Institutional Review Board under reference number PCKCN REC No. 10/2022. The ethical clearance ensured that the research adhered to rigorous ethical principles and guidelines, thus facilitating the responsible conduct of the study. Following the receipt of institutional review board approval, the research proceeded with the data collection process, prioritizing the welfare and rights of all participants involved.

Results

Participants demographic

A total of 92 eligible VHVs were identified during the enrollment process [Figure 1]. Of these, 60 VHVs met the study criteria and consented to participate in the study, with an equal allocation to the experimental and control groups (n = 30 each). Importantly, there were no dropouts or loss to follow-up throughout the program. These findings indicate that the randomization process successfully allocated VHVs with comparable demographic characteristics to both groups.

Figure 1 Flow diagram of study

The demographic characteristics of the VHVs in the controlled and experimental groups are shown in Table 1. The study included a total of 60 VHVs, with an equal number of participants in each group. The distribution of gender, age, and prior stroke care training was assessed for both groups. The majority of participants in the study had completed basic education up to grade 9.

Table 1 Demographic characteristics of VHVs in controlled and experimental groups

Demographic Variable	Controlled Group (n=30)*	Experimental Group (n=30)†	P‡	
Gender				
   Male	11 (36.67%)	6 (20.00%)	0.25	
   Female	19 (63.33%)	24 (80.00%)		
Age (years)				
   <60	12 (40.00%)	9 (30.00%)	0.58	
   ≤60	18 (80.00%)	21 (70.00%)		
Experiences on training on stroke				
   Ever	10 (33.33%)	-	0.0008	
   Never	20 (66.67%)	30 (100%)		
Prior experience with Line stickers				
   Yes	30 (100%)	30 (100%)	N/A§	
Proficiency in Line application				
   1 year	30 (100%)	30 (100%)	N/A§	
*†The values are expressed as numbers and percentages. ‡Fisher’s exact test. §N/A, Not Applicable

In terms of gender, the control group had a higher proportion of female VHVs compared to the experimental group. The age distribution revealed that the majority of participants in both groups were aged between 40 and 59 years. Additionally, the control group had a higher percentage of VHVs with prior stroke care training compared to the experimental group.

Statistical analyses, including Chi-square tests, were conducted to examine the differences in demographic characteristics between the two groups. The analysis showed that there was no statistically significant difference in gender between the controlled and experimental groups (P = .251). However, the analysis of the age distribution in both groups revealed that approximately two-thirds of the participants were aged 60 years or more. The Fisher’s exact test did not indicate a significant association between age and group assignment (P = .58), suggesting that age was not a determining factor in the allocation of participants to the control and intervention groups. Furthermore, a significant difference was observed in the prior stroke care training variable (P < .001), with a higher percentage of VHVs in the controlled group reporting prior training. All participants (100%) demonstrated a high level of proficiency in using the line application without the need for instructional support. This proficiency was evident as they had prior experience using other stickers in the line application, which had a similar format to the learning materials used in the study.

Impact of the intervention

As depicted in Table 2, the presented findings showcase the outcomes of the analysis conducted using a pretest–post-test comparison within-group design for both the controlled group and experimental group. The aim of this analysis was to examine the change from baseline to 3 weeks on the Knowledge Score Questionnaire within each group. The table presents the results of the dependent t-test conducted to compare the pretest and post-test scores within each group, along with the resulting mean difference, 95% confidence interval (CI), and P value. The dependent t-test was used because it accounts for the paired nature of the observations. The findings suggest that both the controlled and experimental groups showed significant improvements in knowledge scores from pretest to post-test. The mean differences in scores for both groups were positive, indicating a gain in knowledge. The 95% CIs for the mean differences did not include zero, further supporting the significance of the observed changes.

Table 2 Change in knowledge score questionnaire from baseline to 3 weeks within groups

	Baseline Score (T0)	Change from Baseline to 3 weeks (T1)	P	
		
n	Mean±S.D	n	Mean±S.D	
Controlled Group	30	11.60±1.78	30	11.96±1.35	0.003	
   Mean difference	0.58	
   95% CI	(0.19-0.96)	
Experimental Group	30	12.00±1.68	30	13.63±1.37	0.001	
   Mean difference	1.97	
   95% CI	(1.34-2.62)	
Cl, confidence interval

We also calculated the effect size using Cohen’s d, which yielded an estimate of -1.48 (95% CI: -2.07 to -0.90). These results suggest a significant and substantial difference between the two groups in terms of the outcome variable. The observed effect size and the confidence interval provide strong evidence of the effectiveness of the intervention using the line application in improving stroke knowledge among VHVs.

The gain in knowledge is affected by categorical predictors, specifically the new mobile tool and conventional learning technique. To gain a better understanding of the impact of these predictors, a side-by-side comparison of the group means is plotted. This visual representation, as depicted in Figure 2, takes the form of a boxplot and also includes the ANCOVA F-test. The boxplot allows for a visual assessment of the differences between the groups, while the F-test provides statistical evidence of the significance of these differences. In Figure 2: Boxplot illustrating the distribution of post-test knowledge scores for the experimental and control groups. The boxplot provides a visual comparison of the central tendency of each group, represented by the median line within the box. Notably, the median line of the experimental group is located outside the box of the control group, indicating a potential difference in knowledge scores between the two groups.

Figure 2 Boxplot illustrating the distribution of post-test knowledge scores for the experimental and control groups

Additionally, the analysis used the ANCOVA, which transformed the design from a mixed design to a single-factor design. The analysis revealed a clinically significant impact of the independent variable, the innovative mobile learning tool called “Stroke Sign by Sticker.” The F-statistic of 24.26 with 2 and 57 degrees of freedom and a P value < .001 indicated a highly significant and clinically meaningful effect. Furthermore, after adjusting for the covariate and the pretest score, the significance of the effect remained. The observed significance level (Sig <.05) suggests that there are substantial and clinically meaningful differences in knowledge gain between the experimental group using the innovative tool and the control group.

Discussion

Health volunteers play a crucial role in numerous countries across different continents, including America, Africa, and Asia, with a specific emphasis on low-income and middle-income countries.[101112] Although health volunteers come from diverse backgrounds and may have varying levels of education, including basic educational qualifications, systematic reviews have provided evidence that the services delivered by community or VHVs are on par with, and sometimes even surpass, those provided by other healthcare professionals. This finding underscores the potential effectiveness and value of well-trained VHVs in addressing the healthcare needs of their communities.[13] Furthermore, despite the availability of various traditional methods for training community health volunteers, such as books, classes, and lectures, these approaches may not always be effective, particularly in challenging circumstances like the COVID-19 pandemic. The limitations of in-person training have become evident, necessitating the exploration of alternative approaches that can guarantee successful training outcomes for community health volunteers.

The primary objective of this study was to create a digital innovative learning tool that would enhance the stroke prevention, early detection, and rehabilitation skills of VHVs who do not have formal education or training in healthcare professions. They may come from various educational backgrounds, such as nonmedical fields, and have limited knowledge or experience in healthcare-related topics. The tool was specifically designed to improve their literacy in basic stroke management and facilitate informed decision-making. To ensure usability and integration into the VHV’s existing workflow, the tool was developed with robust information and presented in a user-friendly format. The features of knowledge management tools commonly used in community healthcare settings were incorporated to maximize their effectiveness. Based on these considerations, the researchers decided to develop the learning tool using the line application. LINE OpenChat is a widely popular mobile messenger application in Asia, with a significant user base in countries such as Japan, Taiwan, Indonesia, and Thailand.[1415] It functions as a “chat community” and is known for its accessibility and user-friendly features. The familiarity and experience that VHVs have with LINE OpenChat make it a convenient and effective platform for communication and information sharing. VHVs are likely to be well-versed in navigating the application’s features, further enhancing their accessibility and usability in the context of healthcare interventions. Consequently, the study aimed to assess the effectiveness of the “Stroke sign by sticker” line application in enhancing stroke knowledge among VHVs in Thailand’s community healthcare system. The focus was on evaluating the impact of the application on VHVs’ knowledge levels, both before and after its use.

The study findings demonstrated the effectiveness of the “Stroke sign by sticker” line application in enhancing stroke knowledge among VHVs. This digital learning tool yielded positive outcomes and had a significant impact on the participants’ knowledge acquisition and comprehension. The results shed valuable light on the application’s efficacy in improving stroke knowledge specifically among VHVs. Regarding the intergroup comparison analysis, the results indicated that there was no significant difference in the mean scores of knowledge about stroke between the controlled and experimental VHV groups before the experiment. This suggests that the two groups were comparable in terms of their baseline knowledge levels. However, after the experiment, a significant difference was observed, with the experimental group demonstrating a higher mean score in knowledge about stroke compared to the control group. These findings highlight the effectiveness of the “Stroke sign by sticker” line application in improving VHVs’ knowledge about stroke. Research on using line chat as a learning platform is relatively limited, with only a few studies available. One notable study conducted in Japan explored the use of line chat for language learning and reported positive outcomes and impacts. This study highlighted the potential of line chat as an effective tool for facilitating language learning.[16] Acknowledging the scarcity of research in the field, this study can be considered pioneering as it explores the integration of mobile technology, specifically the line chat application, with learning materials in the form of illustrations and stickers to address the topic of stroke disease. The unique combination of mobile technology, interactive chat, and visual aids in the form of stickers makes this study innovative and distinct from previous research. By leveraging these features, the study aims to enhance the knowledge and understanding of stroke disease among participants, particularly village health volunteers. This study contributes to the existing literature by presenting a novel approach to mobile-based learning and its potential impact on knowledge acquisition and retention. The study findings reveal the positive impact of incorporating animation as a learning tool, particularly in the context of knowledge acquisition. These findings align with existing evidence that highlights the effectiveness of animation in simplifying complex information and processes, leading to improved comprehension and engagement among learners. Notably, visuals have been found to enhance learning by up to 400%.[17] In today’s digital age, learners have become accustomed to consuming shorter videos, as evidenced by the popularity of platforms like TikTok. Additionally, a recent study conducted by Microsoft emphasizes the superior effectiveness of visual learning,[18] indicating an 83% improvement compared to text-only materials. These collective findings emphasize the importance of leveraging animation as a valuable strategy to optimize learning outcomes. By visually conveying information, animation captures learners’ attention, facilitating better retention and understanding of the subject matter. According to the survey conducted by Harris Poll, commissioned by GIF platform Tenor, as reported in Katy Steinmetz’s article on the Time website, it was found that 36% of millennials aged 18 to 34 years prefer “visual expressions” like emojis and stickers over traditional words. This preference underscores the benefits of using tools that incorporate animated stickers as a more effective means of imparting knowledge, as they enhance recognition and engagement compared to traditional training methods.[19]

To ensure the robustness of the results, the study design took into consideration potential variations between the control and experimental groups, enabling a rigorous assessment of the line application’s influence on stroke knowledge among VHVs. The analysis comparing the two groups indicated that there was no significant difference in the average knowledge scores related to stroke before the experiment. This finding suggests that both groups began with a similar baseline level of knowledge, establishing a fair and unbiased basis for comparison. As a result, any observed disparities in knowledge improvement can confidently be attributed to the impact of the line application. This aspect of the study design strengthens the validity of the results by eliminating the possibility of pre-existing disparities in knowledge between the groups. It provides a solid foundation for assessing the true effect of the line application in enhancing stroke knowledge among VHVs. With comparable starting points, any improvements in knowledge can be confidently attributed to the intervention itself rather than pre-existing differences.

Moreover, the choice of ANCOVA as the preferred method for comparing the main outcome adds further strength to the study. ANCOVA has demonstrated superior performance compared to alternative methods, offering treatment effect estimators with smaller variances. This reliability makes ANCOVA an optimal choice for analyzing the data and drawing robust conclusions.[20] Additionally, the “Stroke sign by sticker” line application proves to be particularly suitable for use during the COVID-19 pandemic, considering the need for remote and contactless educational interventions. The application allows VHVs to access stroke education materials and resources without the requirement for face-to-face interactions or physical materials. This aspect is of great significance, as it ensures the safety and wellbeing of both the VHVs and the individuals they serve, minimizing the risk of viral transmission. Moreover, even beyond the pandemic, the application’s adaptability and accessibility make it a valuable tool for stroke education, as it can continue to be used effectively to raise awareness and enhance knowledge about stroke signs and symptoms. Its versatility allows for seamless integration into future healthcare initiatives, ensuring that its benefits can extend well beyond the current health crisis. Moreover, the effect size calculation, specifically Cohen’s d, further supports the findings of the study, revealing a significant and substantial difference between the two groups in terms of the outcome variable. The calculated Cohen’s d estimates of -1.486 indicates a large effect size, indicating a notable impact of the intervention using the line application on the participants’ scores. Additionally, the 95% CI for Cohen’s d, ranging from -2.07 to -0.90, provides additional strength to the study. This interval represents a plausible range of values for the true effect size in the population. The fact that the CI does not include zero reinforces the statistical significance of the observed effect. These findings further support the argument that the line application has a meaningful impact on improving stroke knowledge among VHVs.

Limitation and recommendation

It is important to acknowledge certain limitations of the study. First, the study did not include a subgroup analysis based on specific educational statuses or age ranges, which could have provided valuable insights into how these factors may influence the main outcome. Second, it is important to acknowledge that the study employed a quasi-experimental study design, which means that the allocation of participants to the control and experimental groups was not fully randomized. This introduces potential limitations and may impact the internal validity of the study. The nature of the design itself may have inherent biases that could affect the interpretation of the results. Future studies should consider implementing randomized controlled trials or community trials to ensure a more rigorous study design, minimize bias, and enhance the overall validity of the findings.

Conclusion

In conclusion, the findings of this study demonstrate the significant impact of using the “Stroke sign by sticker” line application in improving stroke knowledge among VHVs. The analysis revealed a large effect size, with a Cohen’s d estimate of -1.48, indicating a substantial difference in the scores of knowledge between the two groups. Furthermore, the F test (F = 24.26) showed a statistically significant difference, further supporting the effectiveness of the line application in enhancing stroke knowledge among VHVs. These results underscore the potential of the line application as a valuable tool for knowledge acquisition and highlight the need for its integration into healthcare training and education, promoting health awareness. By incorporating such innovative tools into their training and education, health volunteers can strengthen their knowledge base, leading to better management and care for stroke patients in the community. This, in turn, can contribute to improved patient outcomes and overall healthcare quality, advancing health promotion efforts. Further research and evaluation are warranted to assess its long-term impact and benefits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

We would like to express our sincere gratitude to all the participants who took part in this study. Their valuable contribution and commitment to advancing knowledge in the field of healthcare are greatly appreciated. We would also like to acknowledge the support and assistance provided by the healthcare professionals and organizations involved in the recruitment and coordination of participants. Their collaboration and dedication were instrumental in the successful completion of this research.
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