Headache Education for General Public by Leaflets Distribution During COVID-19 Vaccination and School-Based On-demand E-learning in Japanese One City -Itoigawa Geopark Headache Awareness Campaign-

doi:10.21203/rs.3.rs-1822180/v1

Objective

Headache is a common public health problem, but its burden could be avoided by raising headache awareness and the appropriate use of acute medication and prophylactic medication. Few reports on raising headache awareness in the general public have been reported, and there are no reports on headache awareness campaigns in Japan. We prospectively performed Itoigawa Headache Awareness Campaign from August 2021 to June 2022 and evaluated its effectiveness to the general public.

Methods

The main target group was the general public, especially those aged 15–64 y.o. We performed 2 projects; Project 1; Leaflet and paper-based headache awareness during COVID-19 vaccination, and Project 2; On-demand e-learning and online survey through schools. In these projects, we emphasize the 6 important topics for the general public, which were described in the Clinical Practice Guideline for Headache Disorders 2021. The awareness of the 6 topics among the 2 main projects’ cohorts before and after the campaign was evaluated.

Results

We obtained 4016 valid responses in project 1 and 2577 in project 2; thus, 32.23% of the working-age population of Itoigawa city experienced these projects. The ratios of individuals who know the 6 topics significantly increased after the 2 projects from 7–40% to 64–92% (p < 0.001, all).

Conclusions

We conducted this Itoigawa Headache Awareness Campaign through 2 main projects with improved ratios of individuals who know about the headache. The 2 methods of community-based awareness projects could raise headache awareness less costly and effectively.

education

medication-overuse headache (MOH)

migraine

online

prevention

rational analgesic-use for headache

Headache is a common public health problem [1, 2]. The 2 representative headaches are migraine and tension-type headache (TTH), and they are described in the International Classification of Headache Disorders 3rd edition (ICHD-3) [3]. Migraine impacts the quality of life, familial relationships, and work productivity [4]. In Japan, the total prevalence of migraine is 4.3–8.6% [4–8]. The economic and social impacts of migraine on productivity are starting to be recognized [9, 10]. Still, there was also a substantial unmet need for migraine care: 36.5% of respondents had hesitated to seek medical care for their headaches, and 89.8% had never used preventive medication [4]. Additionally, about 15–20% of Japanese individuals have TTH, and 22.4–29.2% complained that TTH disturbed their performances [11–13]. However, 59.4% of patients with primary headaches had never consulted a physician about their headaches [11]. Therefore, most headache sufferers presumably manage the pains by taking over-the-counter (OTC) medicines [13]. In addition, only neuroimaging is performed when headache sufferers visit a doctor to exclude emergent or organic diseases, and the diagnosis for detailed primary headache and its treatment is insufficient. Even when the doctors diagnose primary headaches, their treatment knowledge is insufficient, leading to patient dissatisfaction [13]. These inadequate headache medical resources and OTC medicine use may lead to medication-overuse headache (MOH) and chronic migraine development [14].

This major public health problem could, in large part, be avoided by raising headache awareness and appropriate use of acute medication and prophylactic medication because many headache patients are not being adequately treated by headache practitioners. The simple advice [15, 16], cognitive-behavioral minimal contact program [17], and mobile phone application [18] for headache sufferers who consult headache practitioners in clinics or hospitals can prevent MOH development. However, many headache sufferers never consulted doctors, called non-doctor headaches [19], so they may not be able to get the right information about headaches in such ways. Therefore, raising headache awareness not only among headache sufferers who routinely consult doctors but also among the general public, including headache sufferers who never come to the hospital and non-headache sufferers, is important.

The Global Campaign against Headache, as a collaborative activity with the World Health Organization (WHO), was formally launched in Copenhagen in March 2004 [20]. This campaign has been leading efforts to increase awareness about headache disorders. However, although the campaign has revealed the huge socioeconomic burden of headaches [21], few reports on raising headache awareness in the general public have been reported [14, 22, 23]. Also, there are no reports on headache awareness campaigns in Japan. In this context, we prospectively performed Itoigawa Headache Awareness Campaign from August 2021 to June 2022 and evaluated its effectiveness to the general public.

Campaign procedure

We performed this headache awareness campaign prospectively from August 2021. This campaign was held by Itoigawa General Hospital in cooperation with Nou National Health Insurance Clinic, Itoigawa City, 3 high schools in Itoigawa City, SMS Corporation, and Regnition. The leading target group was the general public, especially those aged 15–64 y.o., for whom MOH prevalence is highest [5]. The time course is shown in Fig. 1. The components were designed for both the general public and health professionals. Surveys on headache, leaflet distribution, on-demand e-learning through schools, news media, and articles in technical journals are used for this campaign (Table 1). To aware the public more efficiently and to measure the effects, we performed 2 main projects and 1 additional small project under this campaign described later. To reinforce the campaign’s effectiveness, we also raised awareness in 2 local newspapers, 7 technical journals, 1 local television, and their websites. The 2 local publishers published 19000 and 400000 newspapers daily. The local broadcast was provided to 860000 households with 2.22 million population in Niigata prefecture.

Campaign messages

This campaign emphasizes 6 important messages from the Clinical Practice Guideline for Headache Disorders 2021 [24] (Table 2). Topic 1; The economic loss caused by headaches, including interference with work, schoolwork, and household chores, has become a social problem. Topic 2; The economic loss due to reduced performance in studies and work caused by headaches (presenteeism) is greater than the economic loss due to missed school or work caused by headaches (absenteeism). Topic 3; Headache is a treatable disease. Topic 4; If you have migraine attacks more than twice a month, if you have strong headaches more than three days a month, or if you take painkillers more than 10 days a month, you should consult doctors. Topic 5; There are two important treatments for headaches: (1) acute and (2) prophylactic medications. Topic 6; There is a “medication-overuse headache,” in which the headache returns and worsens by taking painkillers for more than 10 days a month. The 6 topics were stated in all the components (Table 1).

Project 1; Leaflet and paper-based headache awareness during COVID-19 vaccination.

We performed the MOH prevalence survey at the first-time COVID-19 vaccination from August to October 2021, called Itoigawa Study [5]. In the survey, we also handed out leaflets and survey sheets (Table 2) for this campaign in which the 6 topics were described. We collected the questionnaire response in the first-time vaccination as the baseline. Then, the third-time vaccination started in March 2022 and was completed in June 2022. We again handed the same survey sheet and collected the answers as results of the headache awareness campaign in Project 1 at the third-time vaccination. We also asked the respondents to fill in their age, sex, and whether they answered the survey sheet in the first vaccination. Valid responses were those that filled in all the items on the survey sheet, as well as who answered in both first- and third-time vaccination. People who could not understand the questionnaire due to dementia, psychiatric disorder, mental retardation, and who indicated that they did not want to participate in this study, were excluded. The survey sheets with one or more blank answers were also excluded from this study. People aged 15–64 y.o. were analyzed.

Project 2; On-demand e-learning and online survey through schools.

During the COVID-19 pandemic, elementary, junior high, and high schools in Itoigawa city were sometimes forced to close. Since 2021, one tablet terminal has been loaned to each student, and interactive remote learning has been conducted in Itoigawa city [24]. As part of the online lectures, an e-learning video by a headache physician was delivered. The video was 10 minutes long, produced by one of the authors. The students and their parents were asked to watch the movie together any time they wanted on-demand in April 2022. The high school student and the one parents of elementary, junior high, and high school students were also asked to answer an online survey sheet (Table 2) through google form, which was the same as in Project 1. Then, we performed a post-educational survey in June 2022; We again asked the high school students and the one parents to fill out the online survey as results of the headache awareness campaign in Project 2. Valid responses were those that filled in all the items on the survey sheet and who answered in both the first and second online survey. The individuals who had already participated in project 1 were excluded. We also asked “why most headache sufferers do NOT consult doctors?” as choice questions.

Additional small project; On-demand e-learning and online survey through social networking services

Headache is common in nurses [25] and wind instrumental musicians [26]. There are major social networking services (SNS) for nurses and wind instrumental musicians in Japan. The former one is called “nurse-senka” (https://knowledge.nurse-senka.jp/) with 1 million nurse users and 4 million page views per month. The latter one is called “CreatOne” (https://www.creatone.jp/), on which users can communicate with professional musicians, and they can learn and be taught by professionals online or by e-learning videos. We distributed the same leaflets in projects 1 by online. After a month, we then asked the users answer an online survey sheet same as in project 2. The users did not acquire any honorarium and responded on a voluntary basis.

Measuring effectiveness

The awareness of the 6 topics among the 2 main projects’ cohorts was evaluated. A Chi-square test was performed to compare the ratio of the individuals who knew the 6 topics before and after the projects. A two-tailed p < 0.050 was defined as statistically significant. We used SPSS software version 28.0.0. (IBM, New York, USA) for statistical analysis.

Ethical aspects

The study was approved by Itoigawa General Hospital Ethics Committee (approval number 2021-16, 2022-2, 2022-3). The questionnaire was anonymous and did not contain any personally identifiable information. The purpose of the study was explained to the subjects in writing and handed to them or shown in the online survey form. They were asked to complete the survey sheet if they could participate in the study. If they were unable or did not want to participate, they were asked to submit a blank sheet, thus providing an opportunity for non-participation. All methods were carried out under relevant guidelines and regulations (Declaration of Helsinki). This study deleted all personal patient information from the database to protect patient privacy.

We obtained 4016 valid responses with 864 invalid responses in project 1. The mean age was 46.56 ± 13.66 y.o. and 49.39% were women. Apart from project 1, We acquired 594 valid and 66 invalid responses from high school students and 1983 valid and 304 invalid responses from one parents in project 2. In August 2021, the overall population of Itoigawa city was 40822, and the working-age population is 20458 (50.11%). Therefore, project 1 reached 19.63%, and project 2 reached 12.60% of the target citizens; thus, 32.23% of the working-age population of Itoigawa city experienced these projects with valid responses.

Results are summarized in Fig. 2. The ratios of individuals who knew the 6 topics significantly increased after the 2 projects (p < 0.001, all). The awareness-raising effect by project 1 did not seem so high as that of project 2. The effect seemed lower with high school students compared to the parents. Supplementary Table 1 shows the results of the additional projects via SNS.

The questionnaire results of “why most headache sufferers do NOT consult doctors?” are shown in Table 3. The ratio of “Because people around me tell me to be patient” was significantly higher in high school students (p = 0.001). In contrast, those of “Because taking time off from work or school to see a doctor would cause inconvenience to others” (p = 0.022), “Because I cannot take time to visit a hospital during the daytime on weekdays” (p < 0.001), “Because doctors and co-medical staffs will not be kind to me even if I go to the hospital.” (p = 0.025), “Because I do not know that there are prophylactic medicines to prevent headaches” (p = 0.015), and “Because I feel that my headache does not interfere with my daily life” (p = 0.005) were significantly higher in parents compared to high school students. Supplementary Table 2 shows the results of the additional projects.

We conducted this Itoigawa Headache Awareness Campaign through 2 main projects and 1 additional project, together with several other media. Project 1 was performed paper-based and during COVID-19 vaccination. Project 2 was performed online and on-demand through schools. The ratios of individuals who knew the 6 topics significantly increased after the 2 projects (p < 0.001, all). Our results suggest that 2 methods of community-based awareness projects could raise headache awareness effectively.

Needs of migraine and MOH education

The Global Campaign against Headache collaborated with the WHO started in March 2004 [20]. Strategically, it was conceptualized in 3 stages, each of these aligned with strategic objectives; 1) Knowledge for awareness to adduce and collate evidence of the scope and scale of the global burden of headache, 2) Awareness for action to promote awareness, among politicians, healthcare providers, employers, schools and the general public, of headache disorders as remediable causes of public ill health and disability, and high financial cost, 3) Action for change to develop evidence-based, adaptable recommendations for intervention, justified by cost-effectiveness analysis. About 1), a series of population-based burden-of-headache studies have been performed in not only developing countries [20] but also in developed countries [8, 10]. As a result, the objective needs of clinical headache practice have been proven. About 2), the campaign has used the knowledge it gathered in 1) to raise awareness among people with headaches [17], healthcare providers, and health policymakers [20]. With the introduction of new drugs such as calcitonin gene-related peptide blocker [27, 28], its receptor blocker [29], ditan [30], and gepant [31], pharmaceutical companies are actively engaged in educational activities for medical professionals and patients. Online or onsite intensive educational courses [23, 32] for general clinicians have also been held. The awareness campaigns for the general public were also performed [14, 22, 23]. Regarding 3), the first and foremost requirement of a putative solution is to dismantle the barriers to care, and public education is required to dismantle other barriers: banishing stigma and promoting self-efficacy, in which people understand their headache disorders and seek and utilize care appropriately [20].

Despite so much effort being put into headache awareness and headache medical resources enrichment around the world, our survey showed very low retention of headache knowledge among the general public; there is still a stigma for headaches. About the 6 topics we asked the participants in our study, the awareness rate was only 7–40% before performing the 2 projects. While awareness-raising seems to be progressing in other countries, there still seems to be a lack of awareness of headaches in Japan.

Awareness campaign for the general public

Although the education program for doctors and headache sufferers has been widely performed, only 3 campaigns were performed to inform the general public about headaches.

James educated MOH to undergraduate students at the University of Birmingham through social networking sites. The 485 respondents, about half of them in healthcare training, completed the questionnaire. Of the respondents, 77% were unaware of the possibility of MOH resulting from regular analgesic use for a headache. Following education on MOH, 80% stated they would reduce analgesic consumption or seek medical advice. In addition, 83% indicated that over-the-counter analgesia should carry a warning of MOH [22].

In Yekaterinburg, Russia, the education system for the general public, headache sufferers, and medical staffs was developed. In this context, public education through the media, organized by the Russian Headache Research Society, was done, focusing on the recognition of different headache types, their causation and steps that might be taken to prevent them, appropriate and inappropriate use of medication, and when to seek professional advice [23]. The article does not describe the effect of education on the general public, but we speculate it was a large campaign because mass media collaborated, and its population is over 1.3 million.

The most extensive awareness campaign for MOH was performed in Denmark in 2016 with about 6 million population. Online videos on YouTube, posters and leaflets in pharmacies, radio interviews, television broadcasts, articles in print media, and headache lectures for general practitioners were all performed. As a result, the survey showed an increase in the percentage of the public who knew about MOH from 31–38%, unfortunately not statistically significant [14].

The results of the awareness-raising activities at the university were beneficial, whereas the large-scale awareness-raising in Denmark had only a marginal effect. Under the complex media environment, consumer-generated media such as weblogs and social networking services have been used rather than mass media [33, 34]. Therefore, we assume that passively informing users, including non-headache sufferers, about headaches via media was not influential because non-headache sufferers may not be interested in the headache burden. The “education” program like James’s practice at the university may be better. Our methods for 2 projects may have been effective maybe because they had some of the requests for respondents to participate. Handing out the leaflets by nurses during the 15 minutes rest after COVID-19 vaccination let the individuals read them carefully. Participation in the on-demand e-learning and e-survey was initially low, and several calls were made for participation for students and their parents. After that, the field of school education may have improved the participation rate.

Future perspective

Our results showed 5 suggestions. 1) The cost was very low. Only distributing leaflets [35] or online e-learning costs less than mass media use. 2) Education through schools, such as compulsory education, is effective in aware the general public. Similar practice regarding stroke treatment was reported [35]. 3) With limited educational resources under COVID-19, leaflet distribution and online e-learning were available, and medical staffs could raise awareness sufficiently without directly teaching the general public. It is possible to minimize people’s movement and equalize educational opportunities. 4) Online and on-demand learning systems can be installed into headache applications [36] or promoted in SNS [37]. Further influence can be expected. 5) The lack of medical resources for headaches was proven. The high answer ratio of “Because taking time off from work or school to see a doctor would cause inconvenience to others,” “Because I cannot take time to visit a hospital during the daytime on weekdays,” and “Because doctors and co-medical staffs will not be kind to me even if I go to the hospital” suggested the needs of the system in which patients can consult doctors outside of the weekday hours and general physicians appropriately diagnose and treat patients. In January 2022, online medical care officially started in Japan [38], and an artificial intelligence-supported diagnosis system has been studied [39]. Our results should further encourage improving the efficiency and availability of headache care through this digitalization.

Limitation

First, this study was performed in a rural city in Japan, and the respondents covered about 32.23% of the working-age population of Itoigawa city. Our study can have responder bias due to the collection method employed. Therefore, the results did not necessarily reflect those of the general population. Second, the collection rate in project 2 was about 60%. It was suggested that a certain number of people who were not interested in headaches did not participate in the on-demand survey, even if it was a school initiative. Third, we did not evaluate the patients’ number, patients’ satisfaction or burden, or the social-economic effect of our campaign. We should investigate them next. Nevertheless, our projects seemed less costly and effective. A further large awareness campaign is expected.

We conducted this Itoigawa Headache Awareness Campaign through 2 main projects together with several other media. Project 1 was performed paper-based and during COVID-19 vaccination. Project 2 was performed online and on-demand through schools. The ratios of individuals who knew the 6 topics significantly increased after the 2 projects (p < 0.001, all). Our results suggest that 2 methods of community-based awareness projects could raise headache awareness effectively.

Competing Interests: The authors report no conflicts of interest concerning the materials or methods used in this study or the findings presented in this paper. No sources of financial or material supported were given. This article and contents of this study were not published nor presented previously.

Acknowledgments

We are thankful for the medical staff and servant services to support our work and data acquisition. Michio Sakate, Joetsu Times and Itoigawa Times, Nami Ikarashi, Niigata Nippo Corporation, made very nice article on our medication-overuse headache prevalence survey in local newspapers. Mariko Nakamura, Yukari Masuko, Teny, Television Niigata, and Medica Staff Promotion promoted the study on the local broadcast.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Table 1 Overview of campaign components

Form	Interventions	Target group
Survey	MOH prevalence survey at the first COVID-19 vaccination	General public
Leaflets about headache and MOH	Handed out at vaccination cites, hospitals, pharmacies, schools	General public Health care provider
On-demand e-learning	E-learning about headache for students and parents through schools	Students Parents
News media	Hospital website 2 local newspapers 1 local television broadcast	General public
Articles	7 technical journals and their websites	Office workers Teachers Other medical doctors Nurses Pharmacists Rehabilitation therapists

MOH; medication-overuse headache

Table 2 Survey sheet

These are the medical facts as stated in the Clinical Practice Guideline for Headache Disorders 2021. Please read and respond to the following question.
Topic number	Statement	Question (choose the answers)
Topic 1	The economic loss caused by headaches, including interference with work, schoolwork, and household chores, has become a social problem.	I know / I do NOT know
Topic 2	The economic loss due to reduced performance in studies and work caused by headaches (presenteeism) is greater than the economic loss due to missed school or work caused by headaches (absenteeism).	I know / I do NOT know
Topic 3	Headache is a treatable disease.	I know / I do NOT know
Topic 4	If you have migraine attacks more than twice a month, if you have strong headaches more than three days a month, or if you take painkillers more than 10 days a month, you should consult doctors.	I know / I do NOT know
Topic 5	There are two important treatments for headaches: (1) acute and (2) prophylactic medications.	I know / I do NOT know
Topic 6	There is a "medication-overuse headache," in which the headache returns and worsens by taking painkillers for more than 10 days a month.	I know / I do NOT know

Valid responses were those that filled in all the items in the survey sheet. People who could not understand the questionnaire due to dementia, psychiatric disorder, mental retardation, and who indicated that they did not want to participate in this study, were excluded. The questionnaire sheets with one or more blank answers were also excluded from this study. In project 1, respondents answered by sheet and pen and filled in their age and sex. In project 2, respondents answered through an online survey form, without filling in their age and sex. We let respondents who answered in project 1 not answer in project 2.

Table 3 The questionnaire results of “why most headache sufferers do NOT consult doctors?”

Reasons	Response rate by high school students (n=594)	Response rate by parents (n=1983)	p-value
Because I don't think headaches are sick enough to go to the hospital.	66.00%	68.94%	0.192
Because taking time off from work or school to see a doctor would cause inconvenience to others.	47.81%	53.25%	0.022*
Because I cannot take time to visit a hospital during the daytime on weekdays.	47.48%	58.45%	<0.001
Because my headache will go away if I just persevere.	38.72%	38.58%	1.000
Because people around me tell me to be patient.	8.41%	4.19%	0.001*
Because doctors and co-medical staffs will not be kind to me even if I go to the hospital.	16.16%	20.32%	0.025*
Because over-the-counter medicines are sufficient.	61.95%	62.88%	0.664
Because I do not know that there are prophylactic medicines to prevent headaches.	35.52%	41.20%	0.015*
Because I feel that my headache does not interfere with my daily life.	30.98%	37.32%	0.005*

Supplementary Table 1 Survey results through social networking services for nurses and professional musicians

These are the medical facts as stated in the Clinical Practice Guideline for Headache Disorders 2021. Please read and respond to the following question.
Users		SNS for nurses		SNS for professional musicians
Topic number	Statement	Ratio of “I know” before e-learning through SNS	Post 1 month	Ratio of “I know” before e-learning through SNS	Post 1 month
Topic 1	The economic loss caused by headaches, including interference with work, schoolwork, and household chores, has become a social problem.	27.87%	93.61%	18.2%	84.8%
Topic 2	The economic loss due to reduced performance in studies and work caused by headaches (presenteeism) is greater than the economic loss due to missed school or work caused by headaches (absenteeism).	21.99%	94.78%	15.2%	88.9%
Topic 3	Headache is a treatable disease.	30.31%	98.65%	21.2%	84.8%
Topic 4	If you have migraine attacks more than twice a month, if you have strong headaches more than three days a month, or if you take painkillers more than 10 days a month, you should consult doctors.	40.97%	97.14%	47.0%	80.4%
Topic 5	There are two important treatments for headaches: (1) acute and (2) prophylactic medications.	40.13%	95.79%	21.2%	91.8%
Topic 6	There is a "medication-overuse headache," in which the headache returns and worsens by taking painkillers for more than 10 days a month.	36.77%	92.18%	39.4%	90.9%

SNS; social networking services.

Nurses: The sample number was 1191. Women comprised of 94.37%. Headache sufferers were 63.76%, but only 35.12% of them consult doctors.

Professional musicians: The sample number was 134. Women comprised of 77.3%. Headache sufferers were 87.9%. Of them, 36.4% of them consult doctors and 24.2% were medication-overuse headache, and 75.9% experienced disturbance of music performance due to their headaches.

Supplementary Table 2 The questionnaire results of “why most headache sufferers do NOT consult doctors?”

Reasons	Response rate by users in SNS for nurses (n=1191)	Response rate users in SNS for wind instrumental musicians (n=134)
Because I don't think headaches are sick enough to go to the hospital.	38.37%	77.3%
Because taking time off from work or school to see a doctor would cause inconvenience to others.	68.84%	45.5%
Because I cannot take time to visit a hospital during the daytime on weekdays.	62.30%	48.5%
Because my headache will go away if I just persevere.	24.43%	50.0%
Because people around me tell me to be patient.	8.14%	12.1%
Because doctors and co-medical staffs will not be kind to me even if I go to the hospital.	17.29%	15.2%
Because over-the-counter medicines are sufficient.	41.22%	62.1%
Because I do not know that there are prophylactic medicines to prevent headaches.	25.77%	40.9%
Because I feel that my headache does not interfere with my daily life.	17.71%	19.7%

SNS; social networking service

Headache Education for General Public by Leaflets Distribution During COVID-19 Vaccination and School-Based On-demand E-learning in Japanese One City -Itoigawa Geopark Headache Awareness Campaign-

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusions

Figures

Introduction

Materials And Methods

Campaign procedure

Campaign messages

Additional small project; On-demand e-learning and online survey through social networking services

Measuring effectiveness

Ethical aspects

Results

Discussion

Needs of migraine and MOH education

Awareness campaign for the general public

Future perspective

Limitation

Conclusions

Declarations

References

tables

Supplementary Tables

Status:

Version 1