Awareness of Stroke Risk Factors and Warning Signs and Attitude to Acute Stroke
Keywords:stroke, knowledge, risk factors, signs and symptoms, attitude, behaviour, medical patients
Background: Stroke is a leading cause of death and disability worldwide. Knowledge of stroke risk factors and warning signs might improve its prevention and ensure prompt activation of emergency medical services and access to thrombolysis. Educational campaigns have been held in Portugal though its impact on knowledge of medical patients has not been assessed.
Methods: A cross-sectional observational study was performed to medical outpatients, through an interview. Main objectives were to assess the extent of knowledge on risk factors and warning signs and the attitude to stroke and to identify predictive factors of stroke-related knowledge. Two subgroups were studied: hypertensive and elderly.
Results: Two hundred and forty eight patients were randomly selected. Two hundred and nine patients (84,3 %) spontaneously recalled at least one risk factor, most frequently hypertension, dyslipidemia and stress. One hundred and eighty four patients (74,2%) spontaneously named at least one warning sign, most frequently hemiparesis, speech impairment and facial palsy, but few (6,5%) spontaneously recalled the three together. One hundred and sixty nine patients would activate emergency medical service (69,5%). Hypertensive patients revealed a better stroke-related knowledge while no significant difference was found in elderly. Educational level was a predictor of better knowledge. Failure to activate emergency medical service was inversely associated to knowledge of risk factors, but not to warning signs.
Conclusion: Despite reasonable stroke-related knowledge, it is insufficient particularly concerning awareness of three main warning signs and behavior to acute stroke. Further investigation is necessary to identify barriers to activation of emergency medical service.Â
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57.
Shiber JR, Fontane E, Adewale A. Stroke registry: hemorrhagic vs ischemic strokes. The American journal of emergency medicine 2010; 28:331-3.
Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP. Hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors. Stroke; a journal of cerebral circulation 2009; 40:2068-72.
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England journal of medicine 2008; 359:1317-29.
Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet 2008; 372:1303-9.
Wardlaw JM, Murray V, Berge E, Del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane database of systematic reviews 2009:CD000213.
Harraf F, Sharma AK, Brown MM, Lees KR, Vass RI, Kalra L. A multicentre observational study of presentation and early assessment of acute stroke. BMJ 2002; 325:17.
Salisbury HR, Banks BJ, Footitt DR, Winner SJ, Reynolds DJ. Delay in presentation of patients with acute stroke to hospital in Oxford. QJM : monthly journal of the Association of Physicians 1998; 91:635-40.
Johnston F, Wardlaw J, Dennis MS, et al. Delays in stroke referrals. Lancet 1999; 354:47-8.
Keskin O, Kalemoglu M, Ulusoy RE. A clinic investigation into prehospital and emergency department delays in acute stroke care. Medical principles and practice : international journal of the Kuwait University, Health Science Centre 2005; 14:408-12.
Chang KC, Tseng MC, Tan TY. Prehospital delay after acute stroke in Kaohsiung, Taiwan. Stroke; a journal of cerebral circulation 2004; 35:700-4.
Wein TH, Staub L, Felberg R, et al. Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project. Stroke; a journal of cerebral circulation 2000; 31:1925-8.
Carroll C, Hobart J, Fox C, Teare L, Gibson J. Stroke in Devon: knowledge was good, but action was poor. Journal of neurology, neurosurgery, and psychiatry 2004; 75:567-71.
Lecouturier J, Murtagh MJ, Thomson RG, et al. Response to symptoms of stroke in the UK: a systematic review. BMC health services research 2010; 10:157.
Jones SP, Jenkinson AJ, Leathley MJ, Watkins CL. Stroke knowledge and awareness: an integrative review of the evidence. Age and ageing 2010; 39:11-22.
Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA : the journal of the American Medical Association 1998; 279:1288-92.
Reeves MJ, Hogan JG, Rafferty AP. Knowledge of stroke risk factors and warning signs among Michigan adults. Neurology 2002; 59:1547-52.
Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledge of the warning signs and risk factors for stroke. JAMA : the journal of the American Medical Association 2003; 289:343-6.
Stroebele N, Muller-Riemenschneider F, Nolte CH, Muller-Nordhorn J, Bockelbrink A, Willich SN. Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective. International journal of stroke : official journal of the International Stroke Society 2011; 6:60-6.
Al Shafaee MA, Ganguly SS, Al Asmi AR. Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke. BMC neurology 2006; 6:38.
Samsa GP, Cohen SJ, Goldstein LB, et al. Knowledge of risk among patients at increased risk for stroke. Stroke; a journal of cerebral circulation 1997; 28:916-21.
Gupta A, Thomas P. Knowledge of stroke symptoms and risk factors among at-risk elderly patients in the UK. International journal of clinical practice 2002; 56:634-7.
Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular diseases 2008; 25:457-507.
Lecouturier J, Rodgers H, Murtagh MJ, White M, Ford GA, Thomson RG. Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment. BMC public health 2010; 10:784.
Marx JJ, Nedelmann M, Haertle B, Dieterich M, Eicke BM. An educational multimedia campaign has differential effects on public stroke knowledge and care-seeking behavior. Journal of neurology 2008; 255:378-84.
Guidelines on Emergency Pathways of Myocardial Infarction and Cerebral Vascular Accident - Portuguese Office of the High Commissioner for Health - National Coordinating Body for Cardiovascular Disease. Vol. 2011, 2007.
Branco MJ, Nunes, B. Warning signs of myocardial infarction and stroke: A note on knowledge and attitudes. Portuguese National Health Institute Doutor Ricardo Jorge. Lisbon, 2007.
Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke; a journal of cerebral circulation 2007; 38:2115-22.
Pontes-Neto OM, Silva GS, Feitosa MR, et al. Stroke awareness in Brazil: alarming results in a community-based study. Stroke; a journal of cerebral circulation 2008; 39:292-6.
Wahab KW, Okokhere PO, Ugheoke AJ, Oziegbe O, Asalu AF, Salami TA. Awareness of warning signs among suburban Nigerians at high risk for stroke is poor: a cross-sectional study. BMC neurology 2008; 8:18.
Nicol MB, Thrift AG. Knowledge of risk factors and warning signs of stroke. Vascular health and risk management 2005; 1:137-47.
Pandian JD, Jaison A, Deepak SS, et al. Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India. Stroke; a journal of cerebral circulation 2005; 36:644-8.
Muller-Nordhorn J, Nolte CH, Rossnagel K, et al. Knowledge about risk factors for stroke: a population-based survey with 28,090 participants. Stroke; a journal of cerebral circulation 2006; 37:946-50.
Segura T, Vega G, Lopez S, Rubio F, Castillo J. Public perception of stroke in Spain. Cerebrovascular diseases 2003; 16:21-6.
Sug Yoon S, Heller RF, Levi C, Wiggers J, Fitzgerald PE.
Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population. Stroke; a journal of cerebral circulation 2001; 32:1926-30.
Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T. Community-based education improves stroke knowledge. Cerebrovascular diseases 2001; 11:34-43.
Gongora-Rivera F, Gutierrez-Jimenez E, Zenteno MA. Knowledge of ischemic stroke among a Mexico City population. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2009; 18:208-13.
Gutierrez-Jimenez E, Gongora-Rivera F, Martinez HR, Escamilla-Garza JM, Villarreal HJ. Knowledge of ischemic stroke risk factors and warning signs after a health education program by medical students. Stroke; a journal of cerebral circulation 2011; 42:897-901.
Kothari R, Sauerbeck L, Jauch E, et al. Patients' awareness of stroke signs, symptoms, and risk factors. Stroke; a journal of cerebral circulation 1997; 28:1871-5.
Hickey A, O'Hanlon A, McGee H, et al. Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults. BMC geriatrics 2009; 9:35.
Mikulik R, Bunt L, Hrdlicka D, Dusek L, Vaclavik D, Kryza J. Calling 911 in response to stroke: a nationwide study assessing definitive individual behavior. Stroke; a journal of cerebral circulation 2008; 39:1844-9.
Truelsen T, Krarup LH. Stroke awareness in Denmark. Neuroepidemiology 2010; 35:165-70.
Falavigna A, Teles AR, Vedana VM, et al. Awareness of stroke risk factors and warning signs in southern Brazil. Arquivos de neuro-psiquiatria 2009; 67:1076-81.
Novak EM, Zetola Vde H, Muzzio JA, Puppi M, Carraro Junior H, Werneck LC. [Lay knowledge about stroke]. Arquivos de neuro-psiquiatria 2003; 61:772-6.
Rau R, Mensing M, Brand H. [Community knowledge about stroke. A survey in the District of Wesel, Germany (2002)]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 2006; 49:450-8.
Derex L, Adeleine P, Nighoghossian N, Honnorat J, Trouillas P. [Knowledge about stroke in patients admitted in a French Stroke Unit]. Revue neurologique 2004; 160:331-7.
Sug Yoon S, Heller RF, Levi C, Wiggers J. Knowledge and perception about stroke among an Australian urban population. BMC public health 2001; 1:14.
Kim JS, Yoon SS. Perspectives of stroke in persons living in Seoul, South Korea. A survey of 1000 subjects. Stroke; a journal of cerebral circulation 1997; 28:1165-9.
Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement. Southern medical journal 2001; 94:613-8.
Alkadry MG, Wilson C, Nicholson D. Stroke awareness among rural residents: the case of West Virginia. Social work in health care 2005; 42:73-92.
Blades LL, Oser CS, Dietrich DW, et al. Rural community knowledge of stroke warning signs and risk factors. Preventing chronic disease 2005; 2:A14.
Neau JP, Ingrand P, Godeneche G. Awareness within the French population concerning stroke signs, symptoms, and risk factors. Clinical neurology and neurosurgery 2009; 111:659-64.
De Dominicis L, Cardinali P, Pucci E, et al. What do Italians at high risk of stroke know about ischaemic stroke? A survey among a group of subjects undergoing neuro-sonographic examination. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2006; 27:7-13.
Hux K, Rogers T, Mongar K. Common perceptions about strokes. Journal of community health 2000; 25:47-65.
Park MH, Jo SA, Jo I, et al. No difference in stroke knowledge between Korean adherents to traditional and western medicine - the AGE study: an epidemiological study. BMC public health 2006; 6:153.
Evci ED, Memis S, Ergin F, Beser E. A population-based study on awareness of stroke in Turkey. European journal of neurology : the official journal of the European Federation of Neurological Societies 2007; 14:517-22.
Kamran S, Bener AB, Deleu D, et al. The level of awareness of stroke risk factors and symptoms in the Gulf Cooperation Council countries: Gulf Cooperation Council stroke awareness study. Neuroepidemiology 2007; 29:235-42.
Miller JE. Knowledge of stroke risk factors, symptoms, and treatment among New Jersey adults. New Jersey medicine : the journal of the Medical Society of New Jersey 2001; 98:47-53.
Parahoo K, Thompson K, Cooper M, Stringer M, Ennis E, McCollam P. Stroke: awareness of the signs, symptoms and risk factors--a population-based survey. Cerebrovascular diseases 2003; 16:134-40.
Oro M, Sanahuja-Montesinos J, Hernandez L, Seto E, Purroy F. [The extent of knowledge about strokes among the population of a rural area in the province of Lleida]. Revista de neurologia 2009; 48:515-9.
Nedeltchev K, Fischer U, Arnold M, Kappeler L, Mattle HP. Low awareness of transient ischemic attacks and risk factors of stroke in a Swiss urban community. Journal of neurology 2007; 254:179-84.
Greenlund KJ, Neff LJ, Zheng ZJ, et al. Low public recognition of major stroke symptoms. American journal of preventive medicine 2003; 25:315-9.
Fogle CC, Oser CS, Troutman TP, et al. Public education strategies to increase awareness of stroke warning signs and the need to call 911. Journal of public health management and practice : JPHMP 2008; 14:e17-22.
Jurkowski JM, Maniccia DM, Dennison BA, Samuels SJ, Spicer DA. Awareness of necessity to call 9-1-1 for stroke symptoms, upstate New York. Preventing chronic disease 2008; 5:A41.
Fussman C, Rafferty AP, Lyon-Callo S, Morgenstern LB, Reeves MJ. Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey. Stroke; a journal of cerebral circulation 2010; 41:1501-7.
Schroeder EB, Rosamond WD, Morris DL, Evenson KR, Hinn AR. Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study. Stroke; a journal of cerebral circulation 2000; 31:2591-6.
Chaturvedi S, Femino L. A pilot study regarding knowledge of stroke risk factors in an urban community. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 1997; 6:426-9.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under aÂ Creative Commons Attribution LicenseÂ that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (SeeÂ The Effect of Open AccessÂ and Benefits of Publishing Open Access).