Factors Related to Knowledge of Stroke Symptoms and Risk Factors in a Norwegian Stroke Population Antje Sundseth, MD,*† Kashif Waqar Faiz, MD,*† Ole Morten Rønning, MD, PhD,*† and Bente Thommessen, MD, PhD*
Background: Previous studies have identified insufficient knowledge of stroke symptoms and risk factors both among survivors of stroke and in the general population. The purpose of this study was to investigate knowledge of stroke symptoms and risk factors in a Norwegian stroke population and to identify factors associated with good knowledge. Methods: This prospective study included patients with acute transient ischemic attack, ischemic stroke, and intracerebral hemorrhage. Knowledge of stroke symptoms and risk factors was explored by asking open-ended questions. Bivariate and multivariate regression analyses were performed to identify factors related to good knowledge. Results: In total, 287 patients (mean age 6 standard deviation, 70.0 6 12.9 years) answered the open-ended questionnaire of which 71% knew at least 1 symptom of stroke whereas 43% knew at least 1 risk factor. Knowledge of both numbness/weakness and speech difficulties as symptoms of stroke (43% of the patients) was associated with lower age (odds ratio [OR], .96; 95% confidence interval [CI], .94-.99), higher education (OR, 2.25; 95% CI, 1.17-4.30), and having previously received information regarding stroke (OR, 7.74; 95% CI, 3.82-15.67). Knowing at least 2 of the 3 risk factors of stroke ‘‘smoking’’, ‘‘hypertension’’, and ‘‘diabetes’’ (14% of the patients) was associated with lower age (OR, .94; 95% CI, .92-.97). Conclusions: Knowledge of stroke symptoms and risk factors in patients with acute cerebrovascular disease seems to be insufficient. Further educational efforts are needed, as better knowledge may improve prevention of stroke and increase the number of patients who can receive thrombolysis. Key Words: Stroke patients—knowledge—stroke symptoms—stroke risk factors—predictors. Ó 2014 by National Stroke Association
The burden of cerebrovascular disease can be reduced by providing optimal acute care in stroke units,1 including time-dependent reperfusion therapy. Intrave-
From the *Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog; and †Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Received November 26, 2013; revision received February 26, 2014; accepted February 27, 2014. Supported by the South-Eastern Norway Regional Health Authority (project number 2007039). Address correspondence to Antje Sundseth, MD, Department of Neurology, Medical Division, Akershus University Hospital, N-1478 Lørenskog, Norway. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.02.026
nous thrombolytic therapy within the time window of 4.5 hours after stroke offers beneficial effect in selected patients with acute ischemic stroke.2 Admission to hospital within this narrow time window presupposes the patients’ recognition of stroke symptoms and knowledge of the necessity of rapid hospitalization. However, the lack of stroke awareness often results in delayed admission, making thrombolysis accessible only for a small proportion of patients.3 Furthermore, knowledge of risk factors of cerebrovascular disease in the population is essential to improve risk profiles and thus prevent stroke. A number of studies regarding knowledge of stroke symptoms and risk factors, both in the general population and in stroke patients, were conducted in the 1990s and early 2000s, at the beginning of the thrombolysis era. A weakness of many of these studies is the use of
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-7
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close-ended questions instead of open-ended questions that may have resulted in better performance regarding knowledge compared with what patients might actually recall when experiencing a stroke. The respondents’ knowledge of stroke in most of the previous studies was generally poor,4-11 especially among those at highest risk.4,6,7,12 One would expect that increased media focus on public health, people’s increased awareness of their own health, and widespread access to health information would have improved knowledge and awareness of stroke. Recent studies, however, indicate that knowledge of stroke is still inadequate.13-16 The aims of the present study were to explore the current knowledge of stroke symptoms and risk factors, using open-ended questions in a Norwegian population with acute cerebrovascular disease, and to identify factors associated with good knowledge.
Methods The present study is part of a prospective trial on prehospital delay in patients with acute transient ischemic attack (TIA), or stroke, admitted to the stroke unit of the Department of Neurology, Akershus University Hospital, during a 1-year period.17 No public campaigns regarding stroke were conducted before or during the study period. Patients 18 years of age or older with a suspected TIA or stroke (acute ischemic stroke or intracerebral hemorrhage, first-ever or recurrent), were included. Stroke was defined, according to the World Health Organization definition, as ‘‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin’’.18 Patients with subarachnoid hemorrhage, in-hospital TIA/stroke, and those discharged with a diagnosis other than TIA/stroke were excluded from the study. All patients were interviewed by A.S. or K.W.F. within 72 hours of admission to the hospital, using a standardized, structured questionnaire, consisting of both closeended and open-ended questions. Both the patients and their relatives could answer the close-ended questions, whereas the open-ended questions had to be answered by the patients themselves. Those unable to answer the questions because of speech or language difficulties, reduced consciousness or cognitive impairment were excluded. We registered the following data regarding the patients’ background: age, sex, educational level (primary/secondary vs higher education [university or university college]), living situation (living in a household of at least 2 residents vs living alone), and the presence of the following risk factors of stroke: hypertension (on treatment with antihypertensive drugs), hypercholesterolemia (on treatment with lipid-lowering drugs or total cholesterol .5 mmol/L or low-density lipoprotein .3 mmol/
L), cardiovascular disease (previous myocardial infarction or angina pectoris, congestive heart failure), atrial fibrillation (paroxysmal or persistent), diabetes (on treatment with oral antidiabetic drugs or insulin), smoking, and previous cerebrovascular disease (TIA or ischemic or hemorrhagic stroke). On admission, severity of stroke was assessed by the 11-item version of the National Institutes of Health Stroke Scale,19 and global functioning was evaluated using the modified Rankin Scale .20,21 The type of cerebrovascular accident was recorded.
Knowledge of Stroke Symptoms and Risk Factors To explore the knowledge of stroke symptoms and risk factors, patients had to answer 2 following open-ended questions: ‘‘Which stroke symptoms do you know?’’ and ‘‘Which stroke risk factors do you know?’’. According to the National Institute of Neurological Disorders and Stroke,22 symptoms of stroke were defined as the following: (1) sudden numbness or weakness of face, arm, or leg, especially on one side of the body; (2) sudden confusion or trouble speaking or understanding speech; (3) sudden trouble seeing in one or both eyes; (4) sudden trouble walking, dizziness, or loss of balance or coordination; (5) sudden severe headache with no known cause. In addition to the established risk factors of stroke (hypertension, smoking, heart disease [cardiovascular disease including atrial fibrillation], diabetes, hypercholesterolemia, previous cerebrovascular disease, and alcohol overuse),9 the following were considered as risk factors: higher age, family history of cardiovascular disease, obesity, poor diet, and physical inactivity. In the present study, adequate knowledge of stroke symptoms or risk factors was considered to be more than just being able to mention any kind of stroke symptom or risk factor. In previous studies, the correct recognition of 3 of 5,23 or 4 of 6 warning signs of stroke13 was considered as sufficient knowledge of stroke symptoms. We defined adequate knowledge of stroke symptoms as being able to identify both ‘‘numbness or weakness of the face, arm or leg’’ and ‘‘confusion or trouble speaking or understanding speech’’ as symptoms of stroke, as hemiparesis, paresthesia, and speech abnormalities are the most common symptoms in acute ischemic stroke,6 and ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’ are the key elements of the Newcastle Face Arm Speech Test (FAST).24 Adequate knowledge of stroke risk factors was defined as knowing at least 2 of the 3 risk factors of stroke, that is, ‘‘hypertension,’’ ‘‘smoking,’’ and ‘‘diabetes’’, as they are well-documented modifiable risk factors25,26 and more than half of all ischemic strokes in the population can be attributed to them.25 Finally, the patients were asked whether they had received any kind of information on stroke at an earlier stage or not.
STROKE KNOWLEDGE IN A NORWEGIAN STROKE POPULATION
Ethics The Regional Committee for Medical and Health Research Ethics and the Data Protection Authorities approved the study. All patients gave their oral informed consent.
Statistical Analysis The statistical analyses were performed using SPSS version 18.0 (SPSS Inc, Chicago, IL) and 5% was the level of significance. Categorical variables are presented as frequencies and percentages, and continuous variables as means and standard deviations for normally distributed data, and medians and interquartile ranges for nonparametric data. Between-group differences for categorical variables were determined by c2 statistics or Fisher exact test, as appropriate, for normally distributed continuous variables by unpaired 2-sample t tests, and for nonparametric continuous variables by Mann–Whitney U test. To identify factors related to adequate knowledge of stroke symptoms and risk factors, logistic regression analyses were performed. Candidate variables in the binary model were age, sex, educational level, previous cerebrovascular disease, having at least 1 risk factor of stroke, living situation, and having received information on stroke at an earlier stage. Variables reaching a significance level of P , .20 were subjected to the multivariate analysis. Stepwise elimination was performed, removing variables with a significance level of P $ .05. Results are presented as odds ratios (OR) and 95% confidence intervals (CI).
Results In total, 440 patients were included in the study. Of these, 153 patients (34.8%; nonresponder group) were not able to answer the open-ended questions of the questionnaire leaving 287 patients (65.2%; responder group). The characteristics of the 2 groups are summarized in Table 1. Compared with the nonresponders, the responders were younger (P 5.003), had a lower prevalence of cardiovascular disease (P 5 .01) and atrial fibrillation (P 5 .004), had milder strokes (lower National Institutes of Health Stroke Scale and modified Rankin Scale score on admission, P , .001), and the cause of hospitalization was more often TIA (P , .001) and less often intracerebral hemorrhage (P , .001).
Knowledge of Stroke Symptoms Of the 287 responders, 203 (70.7%) knew at least 1 symptom of stroke. In all, 191 patients (66.6%) identified the stroke symptom ‘‘numbness or weakness of the face, arm or leg’’ and 131 (45.6%) the stroke symptom ‘‘confusion or trouble speaking or understanding speech,’’ whereas 123 (42.9%) were able to identify both symptoms of stroke. Only 48 patients (16.7%) knew the 3 FAST ele-
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ments ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’. From the binary logistic regression analyses (Table 2), the variables age, educational level, living situation, and having received information on stroke at an earlier stage were entered into the multivariate model, in addition to sex. After stepwise elimination of nonsignificant variables, knowledge of stroke symptoms was associated with lower age (OR, .96; 95% CI, .94-.99; P 5 .001), higher education (OR, 2.25; 95% CI, 1.17-4.30; P 5 .02), and having received information on stroke at an earlier stage (OR, 7.74; 95% CI, 3.82-15.67; P , .001).
Knowledge of Stroke Risk Factors In all, 124 patients (43.2%) were able to name at least 1 risk factor of stroke. Smoking and hypertension were the 2 most commonly cited risk factors of stroke with 22.3% and 19.5%, respectively (Table 3). Forty patients (13.9%) were able to identify at least 2 of the 3 risk factors, that is, ‘‘smoking,’’ ‘‘hypertension,’’ and ‘‘diabetes’’, and only 5 patients (1.7%) knew all 3. The proportion of patients having a particular risk factor of stroke and identifying it as such is shown in Table 4. A significantly higher percentage of those with the risk factors smoking, diabetes, and heart disease identified these as risk factors compared with those without these risk factors. None of those with previous cerebrovascular disease identified this as a risk factor. Performing binary logistic regression, the candidate variables age, educational level, having at least 1 risk factor of stroke, living situation, and having received information on stroke at an earlier stage reached P , .20 (Table 2). In multivariate regression analyses, also including sex, only lower age (OR, .94; 95% CI, .92-.97; P , .001) was associated with adequate knowledge of stroke risk factors.
Discussion The results of the present study indicate a deficiency of knowledge of stroke symptoms and risk factors in patients hospitalized with acute TIA or stroke. Two thirds of the patients identified numbness or weakness as stroke symptom, whereas less than half identified speech disturbances. Only 1 in 6 were able to name all 3 FAST elements ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’. Approximately 4 of 10 patients knew at least 1 risk factor of stroke, smoking and hypertension being the most frequently identified. The proportion of those with a certain risk factor and identifying it as such was low. Previous stroke was neither recognized as a risk factor nor associated with better knowledge. Lower age, higher education, and having received information on stroke at an earlier stage predicted adequate knowledge of stroke symptoms, whereas only lower age was related to adequate knowledge of stroke risk factors.
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Table 1. Baseline characteristics
Baseline characteristics
All, N 5 440
Responder group, N 5 287
Nonresponder group, N 5 153
Age, y, mean 6 SD Male sex, n (%) Living in a household of at least 2 residents, n (%) Higher education, n (%) Stroke risk factors, n (%) None Previous TIA/stroke Hypertension Hypercholesterolemia Cardiovascular disease Atrial fibrillation Diabetes Smoking NIHSS score on admission, median (IQR) mRS score on admission, median (IQR) Stroke type, n (%) TIA AIS ICH
71.4 6 13.0 245 (55.7) 254/434 (58.5) 86/346 (24.9)
70.0 6 12.9 167 (58.2) 170 (59.2) 71/273 (26.0)
73.9 6 12.8 78 (51.0) 84/147 (57.1) 15/73 (20.5)
37/438 (8.4) 145 (33.0) 295 (67.0) 245 (55.7) 149 (33.9) 111 (25.2) 71 (16.1) 104/403 (25.8) 3 (1-8) 2 (1-4)
26 (9.1) 97 (33.8) 190 (66.2) 169 (58.9) 85 (29.6) 60 (20.9) 42 (14.6) 71/286 (24.8) 2 (0-5) 2 (0-3)
11/151 (7.3) 48 (31.4) 105 (68.6) 76 (49.7) 64 (41.8) 51 (33.3) 29 (19.0) 33/117 (28.2) 9 (3-20) 4 (3-5)
100 (22.7) 290 (65.9) 50 (11.4)
80 (27.9) 190 (66.2) 17 (5.9)
20 (13.1) 100 (65.3) 33 (21.6)
Abbreviations: AIS, acute ischemic stroke; ICH, intracerebral hemorrhage; IQR, interquartile range; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; SD, standard deviation; TIA, transient ischemic attack.
The existing studies on knowledge of stroke symptoms and risk factors have used various definitions of good or adequate knowledge, that is, the number of symptoms or risk factors respondents had to identify. Furthermore, some used open-ended questions, whereas others used close-ended questions, which may have given an overestimation of the population’s knowledge. Hemiparesis, paresthesia, and speech abnormalities are the most common symptoms in acute ischemic stroke,6 and were most often mentioned in our study, which is in line with previous findings.6,11,13,27,28 In an Australian study,29 those making the call for ambulance assistance were asked which symptoms of the stroke event they
recalled. Recalling at least 2 of the 3 stroke symptoms, that is, ‘‘limb weakness,’’ ‘‘facial weakness,’’ and ‘‘speech problems,’’ was associated with stroke recognition and showed a trend toward calling for ambulance assistance. Adequate knowledge of stroke appears to be more than just being able to identify any symptom of stroke and comprises also recognition of the cerebrovascular event and appropriate action by calling an ambulance immediately. In previous studies, the proportion of respondents who could name 3 or more established warning signs of stroke ranged from 9% to 28%.10,14,28 Even in a study using close-ended questions, only 65% of the subjects correctly identified at least 4 of 6 stroke symptoms.13
Table 2. Binary logistic regression of factors associated with knowledge of stroke symptoms and risk factors Knowledge of stroke symptoms*
Knowledge of stroke risk factorsy
Binary logistic regression variables
OR (95% CI)
P value
OR (95% CI)
P value
Age Male Higher education Previous TIA/stroke Having at least 1 stroke risk factorz Living in a household of at least 2 residents Previous information on stroke
.95 (.93-.97) .81 (.51-1.30) 2.99 (1.71-5.25) .75 (.45-1.23) .62 (.27-1.38) 1.63 (1.00-2.63) 9.03 (4.62-17.64)
,.001 .39 ,.001 .25 .24 .05 ,.001
.94 (.92-.97) .77 (.39-1.50) 2.78 (1.39-5.56) .71 (.39-1.49) .39 (.15-1.01) 1.73 (.84-3.55) 2.52 (1.07-5.93)
,.001 .43 .004 .37 .05 .14 .04
Abbreviations: CI, confidence interval; OR, odds ratio; TIA, transient ischemic attack. *Knowledge of both ‘‘numbness/weakness of the face, arm or leg’’ and ‘‘confusion, trouble speaking or understanding speech’’. yKnowledge of at least 2 of the 3 risk factors ‘‘smoking’’, ‘‘hypertension’’, and ‘‘diabetes’’. zHypertension, hypercholesterolemia, cardiovascular disease, atrial fibrillation, diabetes, smoking, previous TIA/stroke.
STROKE KNOWLEDGE IN A NORWEGIAN STROKE POPULATION
Table 3. Number of patients identifying stroke risk factors
Stroke risk factors
Responder group, n (%)
Smoking Hypertension Hypercholesterolemia Alcohol overuse Obesity Poor diet Diabetes Heart disease* Physical inactivity Heredity Age Previous cerebrovascular disease
64 (22.3) 56 (19.5) 29 (10.1) 28 (9.8) 27 (9.4) 24 (8.4) 23 (8.0) 20 (7.0) 20 (7.0) 16 (5.6) 2 (.7) 1 (.3)
*Cardiovascular disease including atrial fibrillation.
Regarding knowledge of stroke risk factors, only 43% of our patients could name at least 1 risk factor, which is in the lower range of what has been reported in the literature (40%-79%).4,6,8-10,14,15,28,30 In previous studies using open-ended questions, hypertension was identified by 20%-51% of the respondents,4,6,8-10,15,28 and smoking by 19%-39%.4,8-10,15,28 In another study,27 despite the use of close-ended questions, not more than 75% of the subjects identified hypertension as a risk factor of stroke, whereas only 30% identified smoking as a risk factor of stroke. Interestingly, our patients more often mentioned alcohol overuse, obesity, and poor diet as risk factors of stroke than the established risk factors diabetes, heart disease, and previous cerebrovascular disease, which is in line with previous results where heart disease and diabetes were among the least mentioned risk factors.4,6,8,9,28,31 The number of respondents able to identify more than 1 risk factor of stroke is generally low (25%-50%).6,8-10 Table 4. Number of patients with a particular stroke risk factor identifying it as such
Stroke risk factor Smoking, N 5 71 Hypertension, N 5 190 Diabetes, N 5 42 Heart disease,* N 5 119 Hypercholesterolemia, N 5 169 Previous cerebrovascular disease, N 5 97
Patients with risk factor identifying it as such, n (%)
Compared with those without risk factor, P value
30 (42.3) 39 (20.5) 8 (19.0) 13 (10.9) 13 (7.7)
,.001 .54 .01 .03 .11
0 (0)
*Cardiovascular disease including atrial fibrillation.
1.00
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Only a small proportion of our patients with certain risk factors of stroke identified them as such. This is considered a major problem, as awareness of one’s own risk profile is a precondition for risk changing behavior, and thus prevention of stroke. Regular contact with the health care system regarding these risk factors should have an expected effect on knowledge. Samsa et al32 showed that being informed about one’s own stroke risk by a physician was associated with an understanding of increased stroke risk, which in turn was related to a higher compliance with preventive measures of stroke. Importantly, none of our patients with previous cerebrovascular disease recognized it as a risk factor of stroke, as previously described by Carroll et al4 In fact, prior cerebrovascular disease was not associated with better knowledge of stroke symptoms or risk factors, which is in accordance with the findings of Hickey et al.27 The health care system’s provision of information to patients with previous TIA or stroke seems to be insufficient. The association between age and knowledge is inconsistent in previous studies,4,6,8,9,11,13,16,27,30,31 but the present study has shown better knowledge in the lower age group, which is in accordance with certain other studies.6,8,9,16 Education is likely to influence the knowledge of stroke symptoms and risk factors, and previous studies have shown better knowledge in those with higher education.8,9,15,16,31 However, we found only an effect on stroke symptom knowledge. Similar to several previous studies,6,10,13,16,27 we found no significant association between sex and knowledge of stroke symptoms or risk factors. Better knowledge of stroke symptoms was predicted by having received information on stroke at an earlier stage. Thus, educational efforts are needed to increase awareness of stroke symptoms, but information must be tailored to the audience. Mass media campaigns have shown to improve knowledge of warning signs of stroke, but may be less effective in those 65 years of age or older.27 As knowledge declines after the end of educational campaigns, continuous or long intermittent campaigns might be more effective.33,34 Furthermore, the type of information campaign is significant, with television advertising shown to increase knowledge, whereas newspaper advertising does not.35 According to Kleindorfer et al14 and Reeves et al,28 knowledge of stroke risk factors remained nearly unchanged over a 5 year period despite slightly higher educational level of the subjects and educational efforts over time. In addition, even having knowledge of stroke signs and recognizing stroke does not imply proper action in the case of stroke.5,6,29,36 Health care professionals should become more involved in educating patients, especially those at highest risk of stroke. Educational efforts should include both information on treatment of modifiable stroke risk factors and thus prevention of
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stroke and information about stroke symptoms and appropriate action in the event of stroke. The strength of the present study was the hospital’s well-defined catchment area with admission of all patients with acute TIA or stroke to the stroke unit. Furthermore, no patients refused participation. Nevertheless, because of the exclusion of 35% of the patients because of speech or language difficulties, reduced consciousness or cognitive impairment, our responder group does not reflect the whole population of stroke. It is, however, less likely that the nonresponders had better knowledge of stroke, as they had a lower educational level and were significantly older than the responders. All study participants were interviewed within 72 hours of admission to the hospital and may have received in-hospital information on stroke before the interview, meaning that the actual level of stroke knowledge may have been even lower than reported in this study. Using an open-ended questionnaire is a strength of this study as the results probably estimate a more accurate knowledge of stroke symptoms and risk factors. Finally, cognitive deficits and denial in the acute phase of stroke may have contributed to the poor level of knowledge in the present study. In conclusion, the present study revealed insufficient knowledge of stroke symptoms and risk factors in a Norwegian population hospitalized with acute TIA or stroke. Further efforts to improve knowledge are required. Better knowledge of stroke symptoms may contribute to an increased number of patients available for thrombolysis, whereas better knowledge of risk factors and awareness of own risk profile may result in improved compliance with recommended risk factor treatment and behavioral changes, thus leading to better prevention of stroke.
References 1. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2007;(4):CD000197. 2. Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet 2012;379:2364-2372. 3. de Los Rios la Rosa F, Khoury J, Kissela BM, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: The effect of the European Cooperative Acute Stroke Study (ECASS) III Trial. Stroke 2012;43:1591-1595. 4. Carroll C, Hobart J, Fox C, et al. Stroke in Devon: knowledge was good, but action was poor. J Neurol Neurosurg Psychiatry 2004;75:567-571. 5. Williams LS, Bruno A, Rouch D, et al. Stroke patients’ knowledge of stroke. Influence on time to presentation. Stroke 1997;28:912-915. 6. Kothari R, Sauerbeck L, Jauch E, et al. Patients’ awareness of stroke signs, symptoms, and risk factors. Stroke 1997; 28:1871-1875. 7. Nicol MB, Thrift AG. Knowledge of risk factors and warning signs of stroke. Vasc Health Risk Manag 2005; 1:137-147.
8. Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279:1288-1292. 9. Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledge of the warning signs and risk factors for stroke. JAMA 2003;289:343-346. 10. Sug Yoon S, Heller RF, Levi C, et al. Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population. Stroke 2001;32:1926-1930. 11. Greenlund KJ, Neff LJ, Zheng ZJ, et al. Low public recognition of major stroke symptoms. Am J Prev Med 2003; 25:315-319. 12. Ellis C, Barley J, Grubaugh A. Poststroke knowledge and symptom awareness: a global issue for secondary stroke prevention. Cerebrovasc Dis 2013;35:572-581. 13. Lundelin K, Graciani A, Garcia-Puig J, et al. Knowledge of stroke warning symptoms and intended action in response to stroke in Spain: a nationwide populationbased study. Cerebrovasc Dis 2012;34:161-168. 14. Kleindorfer D, Khoury J, Broderick JP, et al. Temporal trends in public awareness of stroke: warning signs, risk factors, and treatment. Stroke 2009;40:2502-2506. 15. Kim YS, Park SS, Bae HJ, et al. Public awareness of stroke in Korea: a population-based national survey. Stroke 2012;43:1146-1149. 16. Zeng Y, He GP, Yi GH, et al. Knowledge of stroke warning signs and risk factors among patients with previous stroke or TIA in China. J Clin Nurs 2012;21:2886-2895. 17. Faiz KW, Sundseth A, Thommessen B, et al. Prehospital delay in acute stroke and TIA. Emerg Med J 2013;30:669-674. 18. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 1976; 54:541-553. 19. Brott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20:864-870. 20. Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957;2:200-215. 21. van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604-607. 22. Know the signs. What are the symptoms of a stroke? National Institute of Neurological Disorders and Stroke web site. http://www.ninds.nih.gov/disorders/stroke/ knowstroke.htm#whatis. Accessed October 15, 2013. 23. Fussman C, Rafferty AP, Lyon-Callo S, et al. Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey. Stroke 2010;41:1501-1507. 24. Harbison J, Hossain O, Jenkinson D, et al. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke 2003;34:71-76. 25. Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2006;113:e873-e923. 26. O’Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010;376:112-123.
STROKE KNOWLEDGE IN A NORWEGIAN STROKE POPULATION 27. 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 Geriatr 2009;9:35. 28. Reeves MJ, Rafferty AP, Aranha AA, et al. Changes in knowledge of stroke risk factors and warning signs among Michigan adults. Cerebrovasc Dis 2008;25:385-391. 29. Mosley I, Nicol M, Donnan G, et al. What is stroke symptom knowledge? Int J Stroke 2014;9:48-52. 30. Croquelois A, Bogousslavsky J. Risk awareness and knowledge of patients with stroke: results of a questionnaire survey 3 months after stroke. J Neurol Neurosurg Psychiatry 2006;77:726-728. 31. Vibo R, K~ orv L, V€ ali M, et al. Stroke awareness in two Estonian cities: better knowledge in subjects with advanced age and higher education. Eur Neurol 2013;69:89-94.
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32. Samsa GP, Cohen SJ, Goldstein LB, et al. Knowledge of risk among patients at increased risk for stroke. Stroke 1997;28:916-921. 33. Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007;38:2115-2122. 34. Hodgson C, Lindsay P, Rubini F. Using paid mass media to teach the warning signs of stroke: the long and the short of it. Health Promot J Austr 2009;20:58-64. 35. Silver FL, Rubini F, Black D, et al. Advertising strategies to increase public knowledge of the warning signs of stroke. Stroke 2003;34:1965-1968. 36. Geffner D, Soriano C, Perez T, et al. Delay in seeking treatment by patients with stroke: who decides, where they go, and how long it takes. Clin Neurol Neurosurg 2012;114:21-25.
Background: Previous studies have identified insufficient knowledge of stroke symptoms and risk factors both among survivors of stroke and in the general population. The purpose of this study was to investigate knowledge of stroke symptoms and risk factors in a Norwegian stroke population and to identify factors associated with good knowledge. Methods: This prospective study included patients with acute transient ischemic attack, ischemic stroke, and intracerebral hemorrhage. Knowledge of stroke symptoms and risk factors was explored by asking open-ended questions. Bivariate and multivariate regression analyses were performed to identify factors related to good knowledge. Results: In total, 287 patients (mean age 6 standard deviation, 70.0 6 12.9 years) answered the open-ended questionnaire of which 71% knew at least 1 symptom of stroke whereas 43% knew at least 1 risk factor. Knowledge of both numbness/weakness and speech difficulties as symptoms of stroke (43% of the patients) was associated with lower age (odds ratio [OR], .96; 95% confidence interval [CI], .94-.99), higher education (OR, 2.25; 95% CI, 1.17-4.30), and having previously received information regarding stroke (OR, 7.74; 95% CI, 3.82-15.67). Knowing at least 2 of the 3 risk factors of stroke ‘‘smoking’’, ‘‘hypertension’’, and ‘‘diabetes’’ (14% of the patients) was associated with lower age (OR, .94; 95% CI, .92-.97). Conclusions: Knowledge of stroke symptoms and risk factors in patients with acute cerebrovascular disease seems to be insufficient. Further educational efforts are needed, as better knowledge may improve prevention of stroke and increase the number of patients who can receive thrombolysis. Key Words: Stroke patients—knowledge—stroke symptoms—stroke risk factors—predictors. Ó 2014 by National Stroke Association
The burden of cerebrovascular disease can be reduced by providing optimal acute care in stroke units,1 including time-dependent reperfusion therapy. Intrave-
From the *Department of Neurology, Medical Division, Akershus University Hospital, Lørenskog; and †Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Received November 26, 2013; revision received February 26, 2014; accepted February 27, 2014. Supported by the South-Eastern Norway Regional Health Authority (project number 2007039). Address correspondence to Antje Sundseth, MD, Department of Neurology, Medical Division, Akershus University Hospital, N-1478 Lørenskog, Norway. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.02.026
nous thrombolytic therapy within the time window of 4.5 hours after stroke offers beneficial effect in selected patients with acute ischemic stroke.2 Admission to hospital within this narrow time window presupposes the patients’ recognition of stroke symptoms and knowledge of the necessity of rapid hospitalization. However, the lack of stroke awareness often results in delayed admission, making thrombolysis accessible only for a small proportion of patients.3 Furthermore, knowledge of risk factors of cerebrovascular disease in the population is essential to improve risk profiles and thus prevent stroke. A number of studies regarding knowledge of stroke symptoms and risk factors, both in the general population and in stroke patients, were conducted in the 1990s and early 2000s, at the beginning of the thrombolysis era. A weakness of many of these studies is the use of
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2014: pp 1-7
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close-ended questions instead of open-ended questions that may have resulted in better performance regarding knowledge compared with what patients might actually recall when experiencing a stroke. The respondents’ knowledge of stroke in most of the previous studies was generally poor,4-11 especially among those at highest risk.4,6,7,12 One would expect that increased media focus on public health, people’s increased awareness of their own health, and widespread access to health information would have improved knowledge and awareness of stroke. Recent studies, however, indicate that knowledge of stroke is still inadequate.13-16 The aims of the present study were to explore the current knowledge of stroke symptoms and risk factors, using open-ended questions in a Norwegian population with acute cerebrovascular disease, and to identify factors associated with good knowledge.
Methods The present study is part of a prospective trial on prehospital delay in patients with acute transient ischemic attack (TIA), or stroke, admitted to the stroke unit of the Department of Neurology, Akershus University Hospital, during a 1-year period.17 No public campaigns regarding stroke were conducted before or during the study period. Patients 18 years of age or older with a suspected TIA or stroke (acute ischemic stroke or intracerebral hemorrhage, first-ever or recurrent), were included. Stroke was defined, according to the World Health Organization definition, as ‘‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin’’.18 Patients with subarachnoid hemorrhage, in-hospital TIA/stroke, and those discharged with a diagnosis other than TIA/stroke were excluded from the study. All patients were interviewed by A.S. or K.W.F. within 72 hours of admission to the hospital, using a standardized, structured questionnaire, consisting of both closeended and open-ended questions. Both the patients and their relatives could answer the close-ended questions, whereas the open-ended questions had to be answered by the patients themselves. Those unable to answer the questions because of speech or language difficulties, reduced consciousness or cognitive impairment were excluded. We registered the following data regarding the patients’ background: age, sex, educational level (primary/secondary vs higher education [university or university college]), living situation (living in a household of at least 2 residents vs living alone), and the presence of the following risk factors of stroke: hypertension (on treatment with antihypertensive drugs), hypercholesterolemia (on treatment with lipid-lowering drugs or total cholesterol .5 mmol/L or low-density lipoprotein .3 mmol/
L), cardiovascular disease (previous myocardial infarction or angina pectoris, congestive heart failure), atrial fibrillation (paroxysmal or persistent), diabetes (on treatment with oral antidiabetic drugs or insulin), smoking, and previous cerebrovascular disease (TIA or ischemic or hemorrhagic stroke). On admission, severity of stroke was assessed by the 11-item version of the National Institutes of Health Stroke Scale,19 and global functioning was evaluated using the modified Rankin Scale .20,21 The type of cerebrovascular accident was recorded.
Knowledge of Stroke Symptoms and Risk Factors To explore the knowledge of stroke symptoms and risk factors, patients had to answer 2 following open-ended questions: ‘‘Which stroke symptoms do you know?’’ and ‘‘Which stroke risk factors do you know?’’. According to the National Institute of Neurological Disorders and Stroke,22 symptoms of stroke were defined as the following: (1) sudden numbness or weakness of face, arm, or leg, especially on one side of the body; (2) sudden confusion or trouble speaking or understanding speech; (3) sudden trouble seeing in one or both eyes; (4) sudden trouble walking, dizziness, or loss of balance or coordination; (5) sudden severe headache with no known cause. In addition to the established risk factors of stroke (hypertension, smoking, heart disease [cardiovascular disease including atrial fibrillation], diabetes, hypercholesterolemia, previous cerebrovascular disease, and alcohol overuse),9 the following were considered as risk factors: higher age, family history of cardiovascular disease, obesity, poor diet, and physical inactivity. In the present study, adequate knowledge of stroke symptoms or risk factors was considered to be more than just being able to mention any kind of stroke symptom or risk factor. In previous studies, the correct recognition of 3 of 5,23 or 4 of 6 warning signs of stroke13 was considered as sufficient knowledge of stroke symptoms. We defined adequate knowledge of stroke symptoms as being able to identify both ‘‘numbness or weakness of the face, arm or leg’’ and ‘‘confusion or trouble speaking or understanding speech’’ as symptoms of stroke, as hemiparesis, paresthesia, and speech abnormalities are the most common symptoms in acute ischemic stroke,6 and ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’ are the key elements of the Newcastle Face Arm Speech Test (FAST).24 Adequate knowledge of stroke risk factors was defined as knowing at least 2 of the 3 risk factors of stroke, that is, ‘‘hypertension,’’ ‘‘smoking,’’ and ‘‘diabetes’’, as they are well-documented modifiable risk factors25,26 and more than half of all ischemic strokes in the population can be attributed to them.25 Finally, the patients were asked whether they had received any kind of information on stroke at an earlier stage or not.
STROKE KNOWLEDGE IN A NORWEGIAN STROKE POPULATION
Ethics The Regional Committee for Medical and Health Research Ethics and the Data Protection Authorities approved the study. All patients gave their oral informed consent.
Statistical Analysis The statistical analyses were performed using SPSS version 18.0 (SPSS Inc, Chicago, IL) and 5% was the level of significance. Categorical variables are presented as frequencies and percentages, and continuous variables as means and standard deviations for normally distributed data, and medians and interquartile ranges for nonparametric data. Between-group differences for categorical variables were determined by c2 statistics or Fisher exact test, as appropriate, for normally distributed continuous variables by unpaired 2-sample t tests, and for nonparametric continuous variables by Mann–Whitney U test. To identify factors related to adequate knowledge of stroke symptoms and risk factors, logistic regression analyses were performed. Candidate variables in the binary model were age, sex, educational level, previous cerebrovascular disease, having at least 1 risk factor of stroke, living situation, and having received information on stroke at an earlier stage. Variables reaching a significance level of P , .20 were subjected to the multivariate analysis. Stepwise elimination was performed, removing variables with a significance level of P $ .05. Results are presented as odds ratios (OR) and 95% confidence intervals (CI).
Results In total, 440 patients were included in the study. Of these, 153 patients (34.8%; nonresponder group) were not able to answer the open-ended questions of the questionnaire leaving 287 patients (65.2%; responder group). The characteristics of the 2 groups are summarized in Table 1. Compared with the nonresponders, the responders were younger (P 5.003), had a lower prevalence of cardiovascular disease (P 5 .01) and atrial fibrillation (P 5 .004), had milder strokes (lower National Institutes of Health Stroke Scale and modified Rankin Scale score on admission, P , .001), and the cause of hospitalization was more often TIA (P , .001) and less often intracerebral hemorrhage (P , .001).
Knowledge of Stroke Symptoms Of the 287 responders, 203 (70.7%) knew at least 1 symptom of stroke. In all, 191 patients (66.6%) identified the stroke symptom ‘‘numbness or weakness of the face, arm or leg’’ and 131 (45.6%) the stroke symptom ‘‘confusion or trouble speaking or understanding speech,’’ whereas 123 (42.9%) were able to identify both symptoms of stroke. Only 48 patients (16.7%) knew the 3 FAST ele-
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ments ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’. From the binary logistic regression analyses (Table 2), the variables age, educational level, living situation, and having received information on stroke at an earlier stage were entered into the multivariate model, in addition to sex. After stepwise elimination of nonsignificant variables, knowledge of stroke symptoms was associated with lower age (OR, .96; 95% CI, .94-.99; P 5 .001), higher education (OR, 2.25; 95% CI, 1.17-4.30; P 5 .02), and having received information on stroke at an earlier stage (OR, 7.74; 95% CI, 3.82-15.67; P , .001).
Knowledge of Stroke Risk Factors In all, 124 patients (43.2%) were able to name at least 1 risk factor of stroke. Smoking and hypertension were the 2 most commonly cited risk factors of stroke with 22.3% and 19.5%, respectively (Table 3). Forty patients (13.9%) were able to identify at least 2 of the 3 risk factors, that is, ‘‘smoking,’’ ‘‘hypertension,’’ and ‘‘diabetes’’, and only 5 patients (1.7%) knew all 3. The proportion of patients having a particular risk factor of stroke and identifying it as such is shown in Table 4. A significantly higher percentage of those with the risk factors smoking, diabetes, and heart disease identified these as risk factors compared with those without these risk factors. None of those with previous cerebrovascular disease identified this as a risk factor. Performing binary logistic regression, the candidate variables age, educational level, having at least 1 risk factor of stroke, living situation, and having received information on stroke at an earlier stage reached P , .20 (Table 2). In multivariate regression analyses, also including sex, only lower age (OR, .94; 95% CI, .92-.97; P , .001) was associated with adequate knowledge of stroke risk factors.
Discussion The results of the present study indicate a deficiency of knowledge of stroke symptoms and risk factors in patients hospitalized with acute TIA or stroke. Two thirds of the patients identified numbness or weakness as stroke symptom, whereas less than half identified speech disturbances. Only 1 in 6 were able to name all 3 FAST elements ‘‘facial weakness,’’ ‘‘arm weakness,’’ and ‘‘speech disturbance’’. Approximately 4 of 10 patients knew at least 1 risk factor of stroke, smoking and hypertension being the most frequently identified. The proportion of those with a certain risk factor and identifying it as such was low. Previous stroke was neither recognized as a risk factor nor associated with better knowledge. Lower age, higher education, and having received information on stroke at an earlier stage predicted adequate knowledge of stroke symptoms, whereas only lower age was related to adequate knowledge of stroke risk factors.
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Table 1. Baseline characteristics
Baseline characteristics
All, N 5 440
Responder group, N 5 287
Nonresponder group, N 5 153
Age, y, mean 6 SD Male sex, n (%) Living in a household of at least 2 residents, n (%) Higher education, n (%) Stroke risk factors, n (%) None Previous TIA/stroke Hypertension Hypercholesterolemia Cardiovascular disease Atrial fibrillation Diabetes Smoking NIHSS score on admission, median (IQR) mRS score on admission, median (IQR) Stroke type, n (%) TIA AIS ICH
71.4 6 13.0 245 (55.7) 254/434 (58.5) 86/346 (24.9)
70.0 6 12.9 167 (58.2) 170 (59.2) 71/273 (26.0)
73.9 6 12.8 78 (51.0) 84/147 (57.1) 15/73 (20.5)
37/438 (8.4) 145 (33.0) 295 (67.0) 245 (55.7) 149 (33.9) 111 (25.2) 71 (16.1) 104/403 (25.8) 3 (1-8) 2 (1-4)
26 (9.1) 97 (33.8) 190 (66.2) 169 (58.9) 85 (29.6) 60 (20.9) 42 (14.6) 71/286 (24.8) 2 (0-5) 2 (0-3)
11/151 (7.3) 48 (31.4) 105 (68.6) 76 (49.7) 64 (41.8) 51 (33.3) 29 (19.0) 33/117 (28.2) 9 (3-20) 4 (3-5)
100 (22.7) 290 (65.9) 50 (11.4)
80 (27.9) 190 (66.2) 17 (5.9)
20 (13.1) 100 (65.3) 33 (21.6)
Abbreviations: AIS, acute ischemic stroke; ICH, intracerebral hemorrhage; IQR, interquartile range; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; SD, standard deviation; TIA, transient ischemic attack.
The existing studies on knowledge of stroke symptoms and risk factors have used various definitions of good or adequate knowledge, that is, the number of symptoms or risk factors respondents had to identify. Furthermore, some used open-ended questions, whereas others used close-ended questions, which may have given an overestimation of the population’s knowledge. Hemiparesis, paresthesia, and speech abnormalities are the most common symptoms in acute ischemic stroke,6 and were most often mentioned in our study, which is in line with previous findings.6,11,13,27,28 In an Australian study,29 those making the call for ambulance assistance were asked which symptoms of the stroke event they
recalled. Recalling at least 2 of the 3 stroke symptoms, that is, ‘‘limb weakness,’’ ‘‘facial weakness,’’ and ‘‘speech problems,’’ was associated with stroke recognition and showed a trend toward calling for ambulance assistance. Adequate knowledge of stroke appears to be more than just being able to identify any symptom of stroke and comprises also recognition of the cerebrovascular event and appropriate action by calling an ambulance immediately. In previous studies, the proportion of respondents who could name 3 or more established warning signs of stroke ranged from 9% to 28%.10,14,28 Even in a study using close-ended questions, only 65% of the subjects correctly identified at least 4 of 6 stroke symptoms.13
Table 2. Binary logistic regression of factors associated with knowledge of stroke symptoms and risk factors Knowledge of stroke symptoms*
Knowledge of stroke risk factorsy
Binary logistic regression variables
OR (95% CI)
P value
OR (95% CI)
P value
Age Male Higher education Previous TIA/stroke Having at least 1 stroke risk factorz Living in a household of at least 2 residents Previous information on stroke
.95 (.93-.97) .81 (.51-1.30) 2.99 (1.71-5.25) .75 (.45-1.23) .62 (.27-1.38) 1.63 (1.00-2.63) 9.03 (4.62-17.64)
,.001 .39 ,.001 .25 .24 .05 ,.001
.94 (.92-.97) .77 (.39-1.50) 2.78 (1.39-5.56) .71 (.39-1.49) .39 (.15-1.01) 1.73 (.84-3.55) 2.52 (1.07-5.93)
,.001 .43 .004 .37 .05 .14 .04
Abbreviations: CI, confidence interval; OR, odds ratio; TIA, transient ischemic attack. *Knowledge of both ‘‘numbness/weakness of the face, arm or leg’’ and ‘‘confusion, trouble speaking or understanding speech’’. yKnowledge of at least 2 of the 3 risk factors ‘‘smoking’’, ‘‘hypertension’’, and ‘‘diabetes’’. zHypertension, hypercholesterolemia, cardiovascular disease, atrial fibrillation, diabetes, smoking, previous TIA/stroke.
STROKE KNOWLEDGE IN A NORWEGIAN STROKE POPULATION
Table 3. Number of patients identifying stroke risk factors
Stroke risk factors
Responder group, n (%)
Smoking Hypertension Hypercholesterolemia Alcohol overuse Obesity Poor diet Diabetes Heart disease* Physical inactivity Heredity Age Previous cerebrovascular disease
64 (22.3) 56 (19.5) 29 (10.1) 28 (9.8) 27 (9.4) 24 (8.4) 23 (8.0) 20 (7.0) 20 (7.0) 16 (5.6) 2 (.7) 1 (.3)
*Cardiovascular disease including atrial fibrillation.
Regarding knowledge of stroke risk factors, only 43% of our patients could name at least 1 risk factor, which is in the lower range of what has been reported in the literature (40%-79%).4,6,8-10,14,15,28,30 In previous studies using open-ended questions, hypertension was identified by 20%-51% of the respondents,4,6,8-10,15,28 and smoking by 19%-39%.4,8-10,15,28 In another study,27 despite the use of close-ended questions, not more than 75% of the subjects identified hypertension as a risk factor of stroke, whereas only 30% identified smoking as a risk factor of stroke. Interestingly, our patients more often mentioned alcohol overuse, obesity, and poor diet as risk factors of stroke than the established risk factors diabetes, heart disease, and previous cerebrovascular disease, which is in line with previous results where heart disease and diabetes were among the least mentioned risk factors.4,6,8,9,28,31 The number of respondents able to identify more than 1 risk factor of stroke is generally low (25%-50%).6,8-10 Table 4. Number of patients with a particular stroke risk factor identifying it as such
Stroke risk factor Smoking, N 5 71 Hypertension, N 5 190 Diabetes, N 5 42 Heart disease,* N 5 119 Hypercholesterolemia, N 5 169 Previous cerebrovascular disease, N 5 97
Patients with risk factor identifying it as such, n (%)
Compared with those without risk factor, P value
30 (42.3) 39 (20.5) 8 (19.0) 13 (10.9) 13 (7.7)
,.001 .54 .01 .03 .11
0 (0)
*Cardiovascular disease including atrial fibrillation.
1.00
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Only a small proportion of our patients with certain risk factors of stroke identified them as such. This is considered a major problem, as awareness of one’s own risk profile is a precondition for risk changing behavior, and thus prevention of stroke. Regular contact with the health care system regarding these risk factors should have an expected effect on knowledge. Samsa et al32 showed that being informed about one’s own stroke risk by a physician was associated with an understanding of increased stroke risk, which in turn was related to a higher compliance with preventive measures of stroke. Importantly, none of our patients with previous cerebrovascular disease recognized it as a risk factor of stroke, as previously described by Carroll et al4 In fact, prior cerebrovascular disease was not associated with better knowledge of stroke symptoms or risk factors, which is in accordance with the findings of Hickey et al.27 The health care system’s provision of information to patients with previous TIA or stroke seems to be insufficient. The association between age and knowledge is inconsistent in previous studies,4,6,8,9,11,13,16,27,30,31 but the present study has shown better knowledge in the lower age group, which is in accordance with certain other studies.6,8,9,16 Education is likely to influence the knowledge of stroke symptoms and risk factors, and previous studies have shown better knowledge in those with higher education.8,9,15,16,31 However, we found only an effect on stroke symptom knowledge. Similar to several previous studies,6,10,13,16,27 we found no significant association between sex and knowledge of stroke symptoms or risk factors. Better knowledge of stroke symptoms was predicted by having received information on stroke at an earlier stage. Thus, educational efforts are needed to increase awareness of stroke symptoms, but information must be tailored to the audience. Mass media campaigns have shown to improve knowledge of warning signs of stroke, but may be less effective in those 65 years of age or older.27 As knowledge declines after the end of educational campaigns, continuous or long intermittent campaigns might be more effective.33,34 Furthermore, the type of information campaign is significant, with television advertising shown to increase knowledge, whereas newspaper advertising does not.35 According to Kleindorfer et al14 and Reeves et al,28 knowledge of stroke risk factors remained nearly unchanged over a 5 year period despite slightly higher educational level of the subjects and educational efforts over time. In addition, even having knowledge of stroke signs and recognizing stroke does not imply proper action in the case of stroke.5,6,29,36 Health care professionals should become more involved in educating patients, especially those at highest risk of stroke. Educational efforts should include both information on treatment of modifiable stroke risk factors and thus prevention of
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stroke and information about stroke symptoms and appropriate action in the event of stroke. The strength of the present study was the hospital’s well-defined catchment area with admission of all patients with acute TIA or stroke to the stroke unit. Furthermore, no patients refused participation. Nevertheless, because of the exclusion of 35% of the patients because of speech or language difficulties, reduced consciousness or cognitive impairment, our responder group does not reflect the whole population of stroke. It is, however, less likely that the nonresponders had better knowledge of stroke, as they had a lower educational level and were significantly older than the responders. All study participants were interviewed within 72 hours of admission to the hospital and may have received in-hospital information on stroke before the interview, meaning that the actual level of stroke knowledge may have been even lower than reported in this study. Using an open-ended questionnaire is a strength of this study as the results probably estimate a more accurate knowledge of stroke symptoms and risk factors. Finally, cognitive deficits and denial in the acute phase of stroke may have contributed to the poor level of knowledge in the present study. In conclusion, the present study revealed insufficient knowledge of stroke symptoms and risk factors in a Norwegian population hospitalized with acute TIA or stroke. Further efforts to improve knowledge are required. Better knowledge of stroke symptoms may contribute to an increased number of patients available for thrombolysis, whereas better knowledge of risk factors and awareness of own risk profile may result in improved compliance with recommended risk factor treatment and behavioral changes, thus leading to better prevention of stroke.
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