Poor Awareness of Stroke—A Hospital-Based Study from South India: An Urgent Need For Awareness Programs

Knowledge of stroke and the window period for thrombolytic therapy in ischemic stroke among South Indians: A hospital-based survey with educational intervention

Objectives

The objective of this study was to determine the awareness of stroke in regards to the risk factors, warning symptoms, and knowledge of the therapeutic window period among varied strata of non-medical people attending a tertiary care center.

Materials and Methods

The interventional study involved the collection of data regarding awareness of stroke using a structured questionnaire with a total score of 16. Pre-intervention assessment was followed by intervention in the form of education regarding awareness of stroke administered one-on-one for personalized and effective comprehension by subjects. Then, subjects were asked to recall the information that was delivered to them and were scored accordingly.

Results

Among the 500 subjects included, 51% were female. About 76.8% of participants were young (age <50 years), and 83.4% were literate. Only 25.4% of participants were aware of the brain as the site of stroke. About 32.2% of candidates were aware of a few risk factors for stroke. Among them, the majority of participants were aware of hypertension (24%) as a risk factor. The most known warning symptom was "Numbness" or weakness of arm. The majority of the subjects (97.8%) were unaware of a therapeutic window period for stroke being 4.5 h or below. The mean pre-intervention score was 2.52 ± 1.65 while the mean post-intervention score was 15.10 ± 1.79 (P < 0.0001).

Conclusion

The study showed that even among literate participants, only a meager number of subjects were aware of the golden window period of intravenous thrombolysis. Educational intervention by means of an in-person and one-on-one explanation achieved significant levels of understanding of stroke. The study could be used to formulate large-scale educational programs that focus on spreading awareness of symptoms and risk factors while also instilling the importance of timely medical intervention for efficient thrombolytic therapy.

Effect of Community Education Program on Stroke Symptoms and Treatment on School and College Students from South India: A Longitudinal Observational Study

Community awareness regarding stroke signs, risk factors, and actions that help reduce the risk and complications of stroke is poorly addressed, as it is thought to be the best approach to control and prevent stroke. Aim: To establish the awareness of stroke and its management among high school and college students using an educational intervention. A questionnaire was administered to students from five high schools and four colleges with different areas of focus, (arts, science and commerce), types (public, semi-public and private), and economic locations before and after an educational lecture on stroke. The lecture covered the following elements: stroke definition, signs, risk factors, actions, time window for thrombolytic therapy, and types of rehabilitation interventions. This study included 1036 participants, of whom 36.3% were male and 56.4% were high school students, and the mean age was 17.15 ± 1.29 (15-22) years. Before the lecture, 147 participants were unaware of a single sign of stroke, and 124 did not know the risk factors. After the intervention, 439 participants knew four signs of stroke, and 196 knew 12 risk factors. Female students had better knowledge about stroke signs (odds ratio (OR), 3.08; 95% confidence interval (95% CI), 2.15-4.43). Hypertension (52.7%) and weakness (59.85%) were the most known signs and risk factors. The proportion of students who selected traditional medicine as the mode of treatment decreased from 34.75% to 8.59% after the lecture. Other rehabilitation methods (e.g., physical therapy, occupational therapy, speech therapy and counseling) were chosen by more than 80% of the students. The results of the current study showed that the awareness on stroke risk factors and management among the school and college students can be significantly improved with regular educational interventions, and therefore stroke can be prevented to some extent.

Awareness, Recognition, and Response to Stroke among the General Public-An Observational Study

Objective  To evaluate awareness and response to stroke among the general public.

Materials and Methods  In this prospective, observational study, self-reported stroke awareness questionnaire was administered in 2000 consecutive participants who visited outpatient clinic of a tertiary care hospital. For data analysis, comparison included for awareness of stroke and response in case of stroke.

Results  The average age of the study participants was 39.64 ± 15.55 (17–85), with 651(32.6%) women. Among the respondents, 786(39.3%) participants mentioned stroke as blood clot in the brain; 268(13.4%) stated it as brain hemorrhage. Awareness of stroke was higher in people in cities (71.0 vs. 8.5%; p  < 0.001) and graduates (75.3 vs. 60.9%; p  < 0.001) or knew a family member or friend who had stroke (42.7 vs. 30.4%; p  < 0.001). Most commonly recognized risk factors included stress (1,152; 57.6%) and hypertension (1,148; 57.4%). Most identified warning sign was weakness of one side of body (807; 40.4%) and speech impairment (658; 32.9%). Participants who were aware of stroke knew a greater number of risk factors (3.75 ± 2.88 vs. 2.45 ± 2.66; p  < 0.001) and warning signs (2.85 ± 2.25 vs. 1.49 ± 1.41; p <0.001). Among 1,138 participants who were aware of stroke, 166 (14.6%) participants knew one correct response in case of a stroke, either call a doctor (49.3 vs. 35.0%; p <0.001) or call an ambulance (41.1 vs. 34.9%; p  = 0.055). Participants who knew one correct response to stroke had at least a family member/friend who had stroke (44.1 vs. 34.3%; p  < 0.022).

Conclusion  We report that among 56.9% of the participants who were aware of stroke most could not name more than four risk factors or three warning signs of stroke. Only 14.6% of those aware of stroke knew appropriate response to stroke.

Risk factors predisposing to acute stroke in India: a prospective study

BACKGROUND

Stroke is an important neurological disorder with significant morbidity and mortality. In India, the risk factors for stroke (obesity, diabetes mellitus, alcoholism, hypertension, and sedentary lifestyle) are mounting with economic growth and increasing the disease burden.

OBJECTIVE

To assess the severity and risk factors of stroke in India and identify any new predisposing factors.

METHODS

A multicentric (six tertiary care hospitals across India) prospective observational study (from September 2016 to July 2017) was conducted on 526 stroke patients, presenting within the first 24 h to examine the risk factors for ischemic and hemorrhagic strokes. Severity was determined using the National Institutes of Health Stroke Scale (NIHSS).

RESULTS

Predominantly male (72.3%), 75% of the sample was >50 years old, with a mean body mass index (BMI) of 25.8 ± 4.3 kg/m2 and 14.6% obese patients. Hypertension and diabetes mellitus were the commonest comorbidities, followed by a history of ischemic heart disease and familial history of stroke. 20.5% of patients had mild strokes, 57.4% had moderate, 8.4% experienced moderate-severe strokes, whereas 7.2% had severe strokes. Regarding the admission diagnoses, 56.8% were ischemic, 18.6% were hemorrhagic, 1.1% had a transient ischemic attack, 6.6% suffered recurrent strokes, and 17% were other forms.

CONCLUSION

The foremost risk factors for stroke in India, hypertension and diabetes, need to be controlled and treated like other global high-risk populations for stroke prevention. The NIHSS scores highlight the relationship between risk factors and stroke severity.

Comparison of knowledge on stroke for stroke patients and the general population in Burkina Faso: a cross-sectional study

Background

In many parts of Africa, there is limited information on awareness of symptoms of stroke, risk factors for stroke and willingness for stroke prevention, both in the general population and in people with stroke. Knowledge and preventive efforts for stroke in patients with a history of the illness are rarely investigated. This study aims to investigate awareness of stroke symptoms in stroke patients who were admitted to hospitals within 72 hours of a confirmed stroke event in Burkina Faso. This study also aims to investigate preventive behavior for stroke for the general population.

Methods

Face-to-face interviews were conducted with the participants. The sample included 110 first-time stroke patients who had been admitted to one of three tertiary teaching hospitals in Burkina Faso within 72 hours and 750 participants from the general population, who were recruited through clustered sampling. Knowledge of stroke warning signs and current and future efforts on stroke prevention were also assessed.

Results

Only 30.9% of the stroke patients believed that they were at risk before the stroke episode. Obvious warning signs were unfamiliar to both groups. Only 1.3% of the respondents from the general population group knew sudden weakness face arm or leg as a sign of stroke. For all future efforts in stroke prevention, stroke patients demonstrated significantly lower willingness to undertake behavioral changes than the general population. Sixty-six percent and 85% of the stroke patients and the general population, respectively, were willing to take steps to reduce blood pressure.

Conclusion

Public education on stroke warning signs and strategies to increase willingness to engage in preventive behaviors are urgent in African countries. Strategies to improve public awareness for developing countries such as Burkina Faso should be designed differently from that of developed countries to incorporate local beliefs.

Stroke systems of care in low-income and middle-income countries: challenges and opportunities

The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.

Recognition of stroke-related knowledge among community residents and the improvement after intensive health education: a cross-sectional study

BACKGROUND

The high morbidity, mortality, and disability rates of stroke constitute a heavy burden to the society. The level of understanding about stroke warning symptoms and first aid systems among community residents was generally low. The aim of our work is to investigate stroke-related knowledge in community residents of Jinjiang district of Chengdu and to raise public awareness about stroke through an intensive educational program.

METHODS

Nine communities in Jinjiang district were sampled and a questionnaire about stroke-related knowledge was applied before and after stroke educational activities. We analyzed the impact of such activities in stroke recognition and management.

RESULTS

We collected 1685 valid questionnaires. The awareness about stroke risk before educational activities was 11.4%. The recognition of stroke warning signs among community residents was 29.8-59.5%. Among them, the recognition of major signs, such as limb weakness, language disorder, and imbalance was more than 50%. When faced with five stroke warning signs, the proportion of participants who chose to make an emergency call was 41.5%. Less than 10% of the participants chose to consult a doctor, take medicine, or wait. After strengthening publicity and educational activities regarding stroke, there was a significant improvement in the identification of stroke risk factors, warning signs, and stroke management. The percentage of participants who chose to make an emergency call increased from 53.2 to 82.7%.

CONCLUSIONS

The knowledge about stroke among community residents in Jinjiang District of Chengdu was low. Strengthening publicity and educational activities may raise awareness about stroke prioritizing call emergency after the onset of stroke signs.

Stroke Awareness in Patients with Incident Stroke Compared to Patients without Stroke or Ischemic Heart Disease

BACKGROUND

Stroke awareness is known to influence treatment seeking and risk reduction behavior, but there is limited data from Sri Lanka and South Asia.

AIM

To describe stroke awareness in incident stroke patients and to compare with patients without stroke and/or ischemic heart disease (IHD) in a Sri Lankan tertiary-care center.

METHODS

We studied awareness of stroke in all incident stroke patients admitted to a tertiary-care center in Sri Lanka and compared with a group of age- and sex-matched patients without stroke and/or IHD, over 2 years. Knowledge on stroke mechanisms, risk factors, symptoms, prognosis, treatment, and prevention were evaluated using a 40-item interviewer-administered questionnaire and converted to a composite score of 100%. Total awareness was categorized as Very poor (<24%), Poor (25%-49%), Good (50%-74%), and Very good (>74%).

RESULTS

One hundred and sixty four incident stroke patients (mean age 62.0 ± 11.5 years; 64.6% males) and 164 patients without stroke and/or IHD were studied. Mean stroke awareness was 47.79% ± 14.6 in stroke patients, and 47.73% ± 14.9 in the nonstroke and/or IHD patients (P = .95). Of the associations studied, better stroke awareness (>50%) was associated only with higher education levels (OR 1.90, 95%CI 1.33-2.72, P < .001) in stroke patients.

CONCLUSIONS

Stroke awareness is not satisfactory in incident stroke patients and is no better than in patients without stroke and/or IHD. Better stroke awareness was associated with higher education levels.

Assessment of Knowledge on Risk Factors, Warning Signs, and Early Treatment Approaches of Stroke among Community Adults in North India: A Telephone Interview Survey

Background As stroke is a catastrophic illness, knowing its risk factors, early signs and symptoms, and management strategies could potentially prevent morbidity and mortality among the people.

Objectives The aim of this study is to determine the public cognizance of risk factors, signs and symptoms, and early treatment options available for stroke with particular emphases on thrombolysis, and its window period.

Materials and Methods A cross-sectional telephonic interview-based survey was conducted in the states of Punjab, Haryana, and Himachal Pradesh of North India from August 2017 to December 2017.

Results Of 350 respondents those participated in the survey with a mean age ± standard deviation of 39.93 ± 13.41  years, hypertension was found to be the most common risk factor among the study participants ( n = 205, 58.57%) and 28.85% of the study participants were not aware of the risk factors, whereas 46% of the participants were not aware of warning signs of stroke. The window period of thrombolysis was compared with gender, and it was found that the higher number of male participants ( n = 49) adduced the right window of thrombolysis (0–4.5  hours) as compared with the female participants ( n = 26).

Conclusions Survey results suggested that there exists scant information about risk factors, alarming signs, and early treatment approaches among community adults toward stroke. In this regard, there is an immense need to conduct awareness camps related to stroke to educate the vulnerable public.

Documenting the impact of stroke in a middle-income country: a Malaysian case study

Purpose: Stroke is an abrupt event that often leaves survivors with long term disabilities, causing role changes, and financial strains on households. The profound impact of stroke on survivors may lead to a decline in quality of life due to the physical, psychological, and social difficulties they experience. Taking Malaysia as an example, this study aimed to explore the impact of stroke on survivors and how health services influence their recovery in low and middle-income countries (LMIC).Method: An ethnographic approach with data obtained primarily through in-depth interviews was used. Twenty-seven participants identified as having suffered a stroke were drawn from a health and demographic surveillance system in Malaysia.Results: The physical and social disruption of the lives of stroke survivors was intensified by the resultant financial constraints placed upon individuals, families and households, compounded by inadequate support from the health, and welfare systems. Despite the disruption to their lives, most participants were, at least in part, able to reestablish their lives through various factors that include a strong family support and active coping strategies.Conclusion: In LMIC, recovery can be shaped by the family unit and through active coping strategies especially those in relation to spirituality.Implications for rehabilitationThe impact of stroke on survivors and lack of specialized stroke care compromise the recovery process and quality of life for stroke survivors in low and middle-income countries.Support from the family and reinforcement of religious coping were judged to successfully aid recovery.Physical and emotional impairments as well as psychosocial wellbeing of survivors in the context of environmental factors need to be addressed.

Family-led rehabilitation in India (ATTEND)-Findings from the process evaluation of a randomized controlled trial

BACKGROUND

Training family carers to provide evidence-based rehabilitation to stroke patients could address the recognized deficiency of access to stroke rehabilitation in low-resource settings. However, our randomized controlled trial in India (ATTEND) found that this model of care was not superior to usual care alone.

AIMS

This process evaluation aimed to better understand trial outcomes through assessing trial implementation and exploring patients', carers', and providers' perspectives.

METHODS

Our mixed methods study included process, healthcare use data and patient demographics from all sites; observations and semi-structured interviews with participants (22 patients, 22 carers, and 28 health providers) from six sampled sites.

RESULTS

Intervention fidelity and adherence to the trial protocol was high across the 14 sites; however, early supported discharge (an intervention component) was not implemented. Within both randomized groups, some form of rehabilitation was widely accessed. ATTEND stroke coordinators provided counseling and perceived that sustaining patients' motivation to continue with rehabilitation in the face of significant emotional and financial stress as a key challenge. The intervention was perceived as an acceptable community-based package with education as an important component in raising the poor awareness of stroke. Many participants viewed family-led rehabilitation as a necessary model of care for poor and rural populations who could not access rehabilitation.

CONCLUSION

Difficulty in sustaining patient and carer motivation for rehabilitation without ongoing support, and greater than anticipated access to routine rehabilitation may explain the lack of benefit in the trial. Nonetheless, family-led rehabilitation was seen as a concept worthy of further development.

Eclectic/mixed model method for upper extremity functional recovery in stroke rehabilitation: A pilot study

Background:

Eclectic treatment method is a flexible approach that uses techniques drawn from various schools of thought involving several treatment methods and allows the therapist to adapt to each client's individual needs. Wider application for eclectic approach is however limited in stroke rehabilitation.

Aim:

The objective is to find out whether eclectic approach improves upper extremity (UE) functional recovery in acute stroke rehabilitation.

Methodology:

Twenty-five postacute unilateral supratentorial stroke subjects recruited from tertiary care hospitals recovered with Stage 2–5 in Brunnstorm stage of UE motor recovery (BRS-UE) underwent 45 min of eclectic approach for UE every day involving seven different treatment methods (5 min for each method) for 6 days consecutively. The outcome was UE subscale of the Fugl-Meyer Motor test (UE-FM), UE subscale of the Stroke Rehabilitation Assessment of Movement (UE-STREAM), Wolf Motor Function test (WMFT-FAS), and Stroke Impact Scale-16 (SIS-16) was collected at the end of the sixth session.

Results:

All the participants showed significant improvement in all the outcome measures. The Stage 2 and 3 subjects showed UE-STREAM (P = 0.007) WMFT-FAS (P < 0.001), SIS (P = 0.023) respectively and for Stage 4 and 5 the subjects have shown UE FM (P < 0.001), WMFT-FAS (P < 0.001), SIS (P = 0.004) with large magnitude of treatment effect for all stages of BRS-UE.

Conclusion:

Our study findings are in favor of integrating eclectic approach than single intervention/approach in clinical practice to improve the UE functional recovery for motor rehabilitation when the stroke occurs.

Fifty years of stroke researches in India

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Early Emergency Medical Service Calls for Stroke: Was the Long-Term Education Program Based on the Experience of West Pomerania Successful?

BACKGROUND

Our objectives are to investigate whether the percentage of early emergency calls for stroke had increased and to assess current factors determining the time of deciding to seek medical help in the event of early stroke symptoms.

MATERIALS AND METHODS

We analyzed data concerning the decision to call for medical help in relation to observed stroke symptoms. Group I comprised 287 people who made the decision to call emergency medical service (EMS) in the first 10 minutes after observing stroke symptoms. Group II included 275 people who called EMS after that time. Data from the current database (2013-2014) were compared with relevant data from the period 2003-2005.

RESULTS

In 2013-2014, awareness of stroke signs was 2.5 times greater than in 2003-2005. Among the groups of early and delayed EMS calls during 2003-2005 and 2013-2014, there were no significant differences in the number of people who suspected stroke. Advanced patient age, young caller age, hemiparesis, facial weakness, and the severity of neurological deficit were independent factors that correlated strongly with an early EMS call, whereas feelings of numbness and dizziness correlated significantly with delayed EMS calls.

CONCLUSIONS

In the West Pomeranian community, general knowledge of stroke is not a significant factor when making appropriate decisions at the onset of stroke symptoms. The education campaign regarding the initial symptoms of stroke and the possible fatal consequences appears to have been ineffective.