Effectiveness of public stroke educational interventions: a review

Population-based approaches for reducing stroke risk: an update on their success and the challenges ahead

INTRODUCTION

Stroke is a significant public health challenge as it is the second most common cause of death and the third leading cause of disability globally. Additionally, stroke incidence and the number of stroke deaths have been rising. Efforts to prevent stroke have been made, including high-risk approaches where patients are screened for cardiovascular risk factors, and population-based approaches which attempt to reduce stroke rates by improving overall population health.

AREAS COVERED

We summarize studies of population-based approaches to stroke prevention involving greater than 1,000 participants identified on a PubMed database search. Based on these programs, challenges of population-based stroke prevention programs are discussed and potential keys to success are highlighted.

EXPERT OPINION

Population-based stroke prevention programs face challenges including cost and interest of the public and certain stakeholders. Additionally, secular trends for improvement in risk factors and catastrophic adverse environmental circumstances add to the complexity of analyzing program success. Factors leading to successful programs include validated digital solutions for self-monitoring of risks, backing by global policy and legislation, flexibility to the needs of the population, intersectoral programs, community engagement, information dissemination back to the populations, and high-risk screening to develop a complementary combination approach to stroke prevention.

Are digital social media campaigns the key to raise stroke awareness in low-and middle-income countries? A study of feasibility and cost-effectiveness in Nepal

BACKGROUND

Stroke is a major global health problem and was the second leading cause of death worldwide in 2020. However, the lack of public stroke awareness especially in low- and middle-income countries (LMICs) such as Nepal severely hinders the effective provision of stroke care. Efficient and cost-effective strategies to raise stroke awareness in LMICs are still lacking. This study aims to (a) explore the feasibility of a social media-based stroke awareness campaign in Nepal using a cost-benefit analysis and (b) identify best practices for social media health education campaigns.

METHODS

We performed a stroke awareness campaign over a period of 6 months as part of a Stroke Project in Nepal on four social media platforms (Facebook, Instagram, Twitter, TikTok) with organic traffic and paid advertisements. Adapted material based on the World Stroke Day Campaign and specifically created videos for TikTok were used. Performance of the campaign was analyzed with established quantitative social media metrics (impressions, reach, engagement, costs).

RESULTS

Campaign posts were displayed 7.5 million times to users in Nepal. 2.5 million individual social media users in Nepal were exposed to the campaign on average three times, which equals 8.6% of Nepal's total population. Of those, 250,000 users actively engaged with the posts. Paid advertisement on Facebook and Instagram proved to be more effective in terms of reach and cost than organic traffic. The total campaign cost was low with a "Cost to reach 1,000 users" of 0.24 EUR and a "Cost Per Click" of 0.01 EUR.

DISCUSSION

Social media-based campaigns using paid advertisement provide a feasible and, compared to classical mass medias, a very cost-effective approach to inform large parts of the population about stroke awareness in LMICs. Future research needs to further analyze the impact of social media campaigns on stroke knowledge.

Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria

OBJECTIVES

To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk.

MATERIALS AND METHODS

A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk.

RESULTS

The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application.

CONCLUSIONS

Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.

Effect of an educational intervention to increase stroke awareness among Italian high school students: A prospective study in Tuscany

INTRODUCTION

Stroke in young people shares traditional modifiable risk factors with older groups, and greatly affects quality of life. However, evidence on the effectiveness of educational interventions in young populations, aiming at spreading stroke knowledge and enhancing prevention, is still scarce. We evaluated baseline knowledge of stroke and possible improvements after an educational intervention among Italian high school students, also considering differences related to sex and type of school.

SUBJECTS AND METHODS

Using a mixed educational strategy, a prospective evaluation of stroke knowledge was performed in five humanities and sciences (lyceums) and five vocational high schools of Tuscany (students of the 12th and 13th grade). A baseline assessment with a structured questionnaire (21 questions) was followed by a standardized oral presentation, using audiovisual materials. After 3 months, the same questionnaire was re-administered to evaluate the long-term impact of the educational intervention.

RESULTS

Overall, 573 students (50.8% males; age range, 17-19 years) were enrolled; 288 (50.3%) were from lyceums and 285 (49.7%) from vocational schools. Follow-up participation was 97.2%. Baseline performances were comparable between groups for most variables examined. At 3 months, all groups showed a significant improvement from baseline regarding reaction to a stroke event, identification of stroke risk factors, such as smoking (from 62.9% to 83.7%; p < 0.001) and alcohol abuse (from 49.6% to 67.2%; p < 0.001), and symptoms. Knowledge of the existence of stroke units and thrombolysis increased from 25.4% to 60.7% (p < 0.001) and from 35.8% to 84.0% (p < 0.001), respectively.

CONCLUSIONS

Our educational intervention improved stroke awareness in high school students. The effects persisted after 3 months. Improved knowledge in young populations may reduce stroke burden in adult life, increase timely access to therapies, and spread knowledge across families.

Strengthening stroke prevention and awareness in the Philippines: a conceptual framework

Stroke is a leading cause of mortality and disability worldwide, with low and middle-income countries bearing the greatest burden. This article focuses on stroke prevention and awareness in the Philippines, a country grappling with high stroke incidence and limited healthcare resources. The two-pronged approach presented by the authors aims to address the challenges of stroke care by combining community-based prevention and targeted public awareness campaigns. The community-based stroke prevention component involves personalized risk factor assessments and tailored interventions conducted at local health centers. By identifying modifiable risk factors such as hypertension, diabetes, smoking, and elevated cholesterol levels, healthcare professionals can provide targeted education and interventions to individuals at risk. Additionally, the decentralized targeted stroke awareness campaigns emphasize public education through culturally adapted materials, engagement with local stakeholders, and media campaigns. These initiatives seek to increase awareness of stroke symptoms and prompt presentation in medical facilities. By implementing this comprehensive approach, we aim to mitigate the burden of stroke in the Philippines, improve stroke outcomes, and raise public awareness about stroke recognition and prevention.

Impact of the first response unit on prehospital on-scene time among paramedic-suspected stroke patients: a retrospective before-after cohort study in Finland

BACKGROUND

Revascularization of an occluded artery by either thrombolysis or mechanical thrombectomy is a time-critical intervention in ischaemic stroke. Each link in the stroke chain of survival should minimize the delay to definitive treatment in every possible way. In this study, we investigated the effect of routine dispatch of a first response unit (FRU) on prehospital on-scene time (OST) on stroke missions.

METHODS

Medical dispatch of FRU together with an emergency medical service (EMS) ambulance was a routine strategy in the Tampere University Hospital area before 3 October 2018, after which the FRU has only been dispatched to medical emergencies on the decision of an EMS field commander. This study presents a retrospective before-after analysis of 2,228 paramedic-suspected strokes transported by EMSs to Tampere University Hospital. We collected data from EMS medical records from April 2016 to March 2021, and used statistical tests and binary logistic regression to detect the associations between the variables and the shorter and longer half of OSTs.

RESULTS

The median OST of stroke missions was 19 min, IQR [14-25] min. The OST decreased when the routine use of the FRU was discontinued (19 [14-26] min vs. 18 [13-24] min, p < 0.001). The median OST with the FRU being the first at the scene (n = 256, 11%) was shorter than in cases where the FRU arrived after the ambulance (16 [12-22] min vs. 19 [15-25] min, p < 0.001). The OST with a stroke dispatch code was shorter than with non-stroke dispatches (18 [13-23] min vs. 22 [15-30] min, p < 0.001). The OST for thrombectomy candidates was shorter than that for thrombolysis candidates (18 [13-23] min vs. 19 [14-25], p = 0.01). The shorter half of OSTs were associated with the FRU arriving first at the scene, stroke dispatch code, thrombectomy transportation and urban location.

CONCLUSION

The routine dispatch of the FRU to stroke missions did not decrease the OST unless the FRU was first to arrive at the scene. In addition, a correct stroke identification in the dispatch centre and thrombectomy candidate status decreased the OST.

Stroke care in Armenia: Recent developments

Introduction

Armenia is an upper-middle-income country with a population of nearly 3 million. Stroke is one of its major public health problems and ranks as the sixth leading cause of death, with a mortality of 75.5 per 100,000.

Methods and results

Until recently, modern stroke care was not available in Armenia. During the past 8 years substantial advances have been made in building medical infrastructure and delivering acute stroke care. This manuscript describes contributors to this progress, including extensive and long-term collaboration with international stroke experts, the development of hospital-based stroke teams, and a funding commitment for stroke care by the government.

Conclusion

The results of acute stroke revascularization procedures during the past 3 years are reviewed and found to meet international standards. Future directions are discussed including the immediate need to expand acute stroke care to underserved parts of the country by adding primary and comprehensive stroke centers. An active educational program for nurses and physicians and the TeleStroke system development will help support this expansion.

Inanspruchnahme der Notfallversorgung im Nordwesten Deutschlands

Hintergrund

Mangelnde Kenntnisse über die Zuständigkeiten der Notfallversorgung führen zu einem höheren Bedarf an Ressourcen in der Notfallrettung. Die vorliegende Studie untersucht, ob sich die Inanspruchnahme und das Verhalten in Notfällen nach soziodemografischen Faktoren unterscheiden lassen.

Methodik

Von Januar bis Juli 2021 wurde eine anonyme schriftliche Befragung von über 4000 Besuchern des Oldenburger Impfzentrums durchgeführt. Der Fragebogen umfasste allgemeine Fragen zur Inanspruchnahme der Notfallversorgung sowie Fragen zur Selbsteinschätzung des eigenen Verhaltens in Notfällen und die Frage nach der Rufnummer des ärztlichen Bereitschaftsdiensts. Alter, Geschlecht und höchster Schulabschluss wurden ebenfalls erfasst. Sonderimpftage für medizinisch-pflegerisches Personal ermöglichten eine gesonderte Betrachtung der Stichprobe.

Ergebnisse

Weibliche Befragte hatten häufiger Kontakt zum ärztlichen Bereitschaftsdienst (19,6 % bzw. 15,6 %), jüngere Befragte suchten häufiger die Notaufnahme aus Eigeninitiative auf (72,1 % bzw. 13,2 %). Bei Schlaganfallsymptomen würden sich 10 % der Befragten mit höherem Schulabschluss und 25 % der Befragten mit niedrigem Schulabschluss zuerst an den Hausarzt wenden. Die Rufnummer des ärztlichen Bereitschaftsdiensts konnten 54,7 % des medizinisch-pflegerischen Personals korrekt wiedergeben. Im Notfall konnten sich 76,4 % aller Befragten eine erste ärztliche Beratung per Telefon oder Video vorstellen.

Diskussion

Soziodemografische Faktoren wirken sich auf die Nutzung der Ressourcen der Notfallrettung aus. Aufklärungsaktionen, frühzeitige Wissensvermittlung, ein gemeinsames Notfallleitsystem sowie eine telemedizinische Beratung bei niedrigschwelligen Einsätzen könnten zu einer Entlastung des Gesundheitssystems beitragen.

Attention to acute cerebrovascular disease in Guipúzcoa: description of the results of a reference hospital in a centralized care model

INTRODUCTION

In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model.

MATERIAL AND METHODS

We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year.

RESULTS AND DISCUSSION

We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in < 6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2.

CONCLUSIONS

After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.

Attention to acute cerebrovascular disease in Guipúzcoa: Description of the results of a reference hospital in a centralized care model

INTRODUCTION

In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model.

MATERIAL AND METHODS

We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year.

RESULTS AND DISCUSSION

We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in <6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2.

CONCLUSIONS

After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.

Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016

To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.

The impact of a Danish stroke campaign: A cross-sectional study

OBJECTIVES

To investigate the impact of the Danish stroke campaign, 1 year after initiation.

MATERIALS & METHODS

The campaign ran in various media during 2019-2020. We performed a two-centre, repeated cross-sectional study in 2018 (before campaign) and again in 2020 based on data from structured interviews of patients and bystanders, medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay. Patient delay is defined as the time from symptom onset until the first contact to a healthcare professional, whereas system delay is the time from this contact until arrival at the stroke centre. Secondary outcomes were primary emergency medical services (EMS) contact, arrival at a stroke centre within 3 h of symptom onset, initiation of reperfusion therapy and knowledge of ≥2 core symptoms of stroke.

RESULTS

We included 852 patients with stroke or transient ischemic attack. Patient delay and system delay were a median of 166 min and 96 min before the campaign and were non-significantly reduced by 16 min (95% CI -128 to 97) and 7 min (95% CI -21 to 6) in the second period. We found no significant differences in the clinical outcomes. The knowledge of ≥2 core symptoms increased from 22% to 30% (OR 1.63; 95% CI 1.15 to 2.30) in patients and from 53% to 65% (OR 1.81; 95% CI 1.24 to 2.64) in bystanders.

CONCLUSION

Patient delay, system delay and clinical outcomes remained relatively unchanged. However, the knowledge of core symptoms had improved 1 year after campaign initiation.

Disparities in the Outcomes Following Ischemic Stroke Between the Floating Population and Indigenous Population of Shanghai

Background and Purposes: Through this study, we hope to gain more insights into the differences in outcome following an ischemic stroke between the floating population and the indigenous population of Shanghai.

Method: In this retrospective cohort study, we analyzed patients with first-ever acute ischemic stroke who were admitted to a comprehensive stroke center in the Minhang district, Shanghai, from January 1, 2019, to December 31, 2020. All patient's demographic data and medical histories were prospectively collected and they were followed up for at least 3 months. The Indigenous population of Shanghai was defined as patients with an identification number starting with 310. All others were treated as floating population. The primary outcome was defined as an unfavorable prognosis at 3 months, with a modified Rankin Scale (mRS) score above 1. Secondary outcomes included the use of emergency medical service (EMS), 3 h arrival rate, and endovascular therapy in eligible patients. Logistic regression analysis was applied to investigate the differences.

Results: Finally, 698 patients with first-ever acute ischemic stroke were included (with mean age of 65.32 years, 74.6% men). Of these, 302 patients belonged to the floating population group. Indigenous populations with ischemic stroke were older than the floating population (68.26 years vs. 61.47 years, P &lt; 0.001). The floating population was more likely to achieve favorable outcomes at 3 months compared with the indigenous population in multivariable logistic regression analysis [Odds ratio (OR): 0.49, 95% CI: 0.32–0.75, P = 0.001]. The use of EMS, 3 h arrival rate, and the application of endovascular therapy were comparable between the floating population and indigenous population (OR: 0.89, 95% CI: 0.62–1.27, P = 0.519; OR: 0.78, 95% CI: 0.56–1.09, P = 0.14; and OR: 0.82, 95% CI: 0.54–1.26, P = 0.365, respectively).

Conclusion: Compared with the indigenous population, the floating population with the first-ever ischemic stroke was more likely to have a favorable outcome at 3 months.

Effectiveness of Public Education Campaigns for Stroke Symptom Recognition and Response in Non-Elderly Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The incidence of stroke is on the rise among younger adults. Stroke educational campaigns are often used to raise public knowledge of stroke warning signs and response actions, but their effectiveness in non-elderly adults is unclear. This study investigated the effectiveness of stroke campaigns in improving stroke symptom recognition and intention to call emergency medical services in adults aged < 65 years, and described the characteristics of public stroke education in this demographic group.

MATERIALS AND METHODS

Seven databases (Cochrane Library, CINAHL, Embase, Medline, PsycINFO, Scopus, and ProQuest Dissertations and Theses) were searched from inception to 24 January 2021. A meta-analysis was conducted to synthesize the effects of stroke education campaigns on stroke symptom recognition and intention to call emergency medical services in adults < 65 years. A narrative synthesis approach was used to explore the types of educational content and campaign best suited to this demographic group.

RESULTS

Thirteen studies from 2001 to 2019 were included in this review. Out of the thirteen studies, five were included in the meta-analysis to synthesize the effects of stroke education campaigns on symptom recognition and four were included for synthesizing the effects on intention to call emergency medical services. The estimated pooled risk ratio for post-campaign compared with pre-campaign in stroke symptom recognition and intention to call emergency medical services was 1.20 (95% CI: 1.07-1.36, p = 0.002) and 1.19 (95% CI: 1.11-1.28, p < 0.00001), respectively. Usage of acronyms in broadcast and digital media campaigns appears promising in enhancing recognition of and responsiveness to stroke symptoms.

CONCLUSIONS

Public stroke education campaigns were found to have a significant impact on stroke symptom recognition and intention to call emergency medical services. The evidence generated from this review could be applied to inform future campaigns targeted at younger adults.

Public Stroke Knowledge, Awareness, and Response to Acute Stroke in Isfahan Iran: What is Less or Misinterpreted in Developing Countries

BACKGROUND

Considering the high burden of stroke in developing countries, it is important for the community to have adequate information and awareness of this disease. In this study, the baseline knowledge of an Iranian population towards stroke has been evaluated.

METHOD

This study was conducted in a governmental hospital in Isfahan, Iran. The participants were selected from the companions of non-cardio-vascular hospitalized patients. A self-administered questionnaire was designed for gathering information RESULTS: A total of 630 questionnaires were analysed. Hypertension and stress were the most frequently identified risk factors (recognised by 83.7% and 75.8% respectively), while pregnancy, oral contraceptives, and anti-coagulants were the least (recognised by 3.5%, 14.2% and 15.8% respectively). Knowledge of other important risk factors such as cardiac diseases was also relatively low (39.4%). Sudden visual difficulties and irrelevant speech were the least identified warning signs of stroke (45.3% and 34.6% respectively), however, knowledge towards all other warning signs was moderately good (each identified by 60-70%). Importantly only 44.2% of respondents were aware that stroke treatment should be started within the first 3 hours. Participants tended to have moderately good insight of most stroke complications and rehabilitation (60-70%). Urban residence, high level of education and knowing someone with a history of stroke were significant predictors of a higher level of stroke awareness.

CONCLUSION

The findings of this study indicate that there is a need to improve general knowledge of cardiac and hypercoagulable related risk factors. Furthermore, understanding of the importance of time critical stroke management and the ineffectiveness of traditional medicine needs to be raised in the general community.

Understanding the seriousness of a stroke is essential for appropriate help-seeking and early arrival at a stroke centre: A cross-sectional study of stroke patients and their bystanders

Introduction

Only a minority of patients with acute ischaemic stroke receive reperfusion treatment, primarily due to prehospital delay. We aimed to investigate predictors of a primary contact to the emergency medical services, arrival at stroke centre within 3 h of symptom onset and initiation of reperfusion therapy in patients with acute stroke.

Patients and methods

We conducted a cross-sectional study of consecutive patients with acute ischaemic stroke, intracerebral haemorrhage or transient ischaemic attack. Structured interviews of patients and bystanders were performed and combined with clinical information from the Danish Stroke Registry. Eligible patients were aged ≥18 years and were independent in activities of daily living before the stroke.

Results

We included 435 patients. Presence of a bystander at symptom onset and knowledge of ≥2 core symptoms of stroke were associated with a primary emergency medical services contact. Higher stroke severity and patients or bystanders perceiving the situation as very serious were associated with a primary emergency medical services contact (OR_patients 2.10; 95% CI 1.12-3.95 and OR_bystanders 22.60; 95% CI 4.98-102.67), <3 h from onset to arrival (OR_patients 3.01; 95% CI 1.46-6.21 and OR_bystanders 4.44; 95% CI 1.37-14.39) and initiation of reperfusion therapy (OR_patients 3.08; 95% CI 1.23-7.75 and OR_bystanders 4.70; 95% CI 1.14-19.5).Conclusion: Having a bystander, knowledge of ≥2 core symptoms and understanding that stroke is a serious event are associated with appropriate help-seeking behaviour, shorter prehospital delay and higher chance of reperfusion therapy in acute stroke patients.

Temporal trends and geographical disparities in comprehensive stroke centre capabilities in Japan from 2010 to 2018

OBJECTIVES

Comprehensive stroke centre (CSC) capabilities are associated with reduced in-hospital mortality due to acute stroke. However, it remains unclear whether there are improving trends in the CSC capabilities or how hospital-related factors determine quality improvement. This study examined whether CSC capabilities changed in Japan between 2010 and 2018 and and whether any changes were influenced by hospital characteristics.

DESIGN

A hospital-based cross-sectional study.

SETTING

We sent out questionnaires to the training institutions of the Japan Neurosurgical Society and Japan Stroke Society in 2010, 2014 and 2018.

PARTICIPANTS

749 hospitals in 2010, 532 hospitals in 2014 and 786 hospitals in 2018 participated in the J-ASPECT study, a nationwide survey of acute stroke care capacity for proper designation of a comprehensive stroke centre in Japan.

MAIN OUTCOME MEASURES

CSC capabilities were assessed using the validated scoring system (CSC score: 1-25 points) in 2010, 2014 and 2018 survey. The effect of hospital characteristics was examined using multiple logistic regression analysis.

RESULTS

Among the 323 hospitals that responded to all surveys, the implementation of 13 recommended items increased. The CSC score (median and IQR) was 16 (13-19), 18 (14-20) and 19 (15-21) for 2010, 2014 and 2018, respectively (p<0.001). There was a ≥20% increase in six items (eg, endovascular physicians, stroke unit and interventional coverage 24/7), and a ≤20% decrease in community education. A lower baseline CSC score (OR: 0.82, 95% CI 0.75 to 0.9), the number of beds≥500 (OR: 3.9, 95% CI 1.2 to 13.0) and the number of stroke physicians (7-9) (OR: 2.6, 95% CI 1.1 to 6.3) were associated with improved CSC capabilities, independent of geographical location.

CONCLUSIONS

There was a significant improvement in CSC capabilities between 2010 and 2018, which was mainly related to the availability of endovascular treatment and multidisciplinary care. Our findings may be useful to determine which hospitals should be targeted to improve CSC capabilities in a defined area.

Sex Differences in Prehospital Delay in Patients With Acute Stroke: A Systematic Review

BACKGROUND

In 2009, the window from symptom onset to administration of tissue plasminogen activator for acute ischemic stroke was extended from 3 to 4.5 hours. Yet no systematic review has addressed prehospital delay by sex for stroke symptoms since this change.

PURPOSE

We aimed to (1) compare prehospital delay times-the time from symptom onset to hospital arrival-between women and men with acute stroke or transient ischemic attack and (2) summarize factors influencing prehospital delay by sex.

METHODS

The CINAHL, MEDLINE, PubMed, Scopus, and PsycINFO databases were searched using PRISMA guidelines. Inclusion criteria were as follows: (1) quantitative research articles published between May 2008 and April 2019, (2) investigation of prehospital delay among women and men 15 years or older who were given a diagnosis of acute stroke or transient ischemic attack, and (3) English-language publications. The Crowe Critical Appraisal Tool was used to evaluate the quality of studies.

RESULTS

Fifteen publications (n = 162 856) met inclusion criteria. Most studies (n = 11) showed no sex differences in prehospital delay. Four studies from Asian-Pacific countries and the United States showed that women had significantly longer prehospital delay compared with men. Older age, minority race/ethnicity (black and Mexican American), and underuse of emergency medical services were associated with prolonged prehospital delay in women.

CONCLUSIONS

Most study authors found no differences in prehospital delay between women and men; however, women delayed longer in some Asian-Pacific and American studies. Findings of sex differences were inconclusive.

Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut

BACKGROUND AND OBJECTIVES

Stroke is a global burden. In Lebanon, recent studies have shown that stroke prevalence may be higher than other developing countries. While older people are particularly vulnerable to stroke, research suggests that they have poor stroke awareness. Since awareness is crucial for early hospital admission, thereby outcome, the main objectives of this study were to assess knowledge of stroke ie, symptoms, risk factors, and intended behavior in case of stroke suspicion.

METHODS

A community-based survey targeting adults aged 50 and above was conducted at 20 random pharmacies in Beirut from May to October 2018 through face to face interviews utilizing a structured questionnaire composed of open and closed ended questions. Descriptive and multivariable analyses were performed.

MAIN RESULTS

In total, 390 participants completed the questionnaire. Sixty-eight percent were able to spontaneously recall at least 1 stroke symptom, most frequently headache (29.2%), hemiparesis (25.4%), and dizziness (19.5%). Furthermore, 85.4% spontaneously recalled at least 1 risk factor, most frequently hypertension (48.2%), smoking (20.5%), and stress (43.1%). In case of stroke suspicion 57.69% would call an ambulance. Knowing a stroke patient and educational level were predictors for recall of more symptoms and risk factors for stroke. Adequate response to stroke was positively associated with identification of more stroke symptoms but inversely associated with having diabetes.

CONCLUSIONS AND RECOMMENDATIONS

There are major gaps in stroke knowledge among Beirut's older population. Culturally tailored awareness campaigns should be implemented at multiple levels using different media methods to target vulnerable populations at higher risk for stroke and their families. These campaigns should focus on improving stroke symptoms awareness and actions to take when suspecting stroke.

Does a Mobile app improve patients' knowledge of stroke risk factors and health-related quality of life in patients with stroke? A randomized controlled trial

Background

Developing a stroke health-education mobile app (SHEMA) and examining its effectiveness on improvement of knowledge of stroke risk factors and health-related quality of life (HRQOL) in patients with stroke.

Methods

We recruited 76 stroke patients and randomly assigned them to either the SHEMA intervention (n = 38) or usual care where a stroke health-education booklet was provided (n = 38). Knowledge of stroke risk factors and HRQOL were assessed using the stroke-knowledge questionnaire and European Quality of Life–Five Dimensions (EQ-5D) questionnaire, respectively.

Results

Sixty-three patients completed a post-test survey (the SHEMA intervention, n = 30; traditional stroke health-education, n = 33). Our trial found that patients’ mean knowledge score of stroke risk factors was improved after the SHEMA intervention (Mean difference = 2.83; t = 3.44; p = .002), and patients’ knowledge was also improved in the after traditional stroke health-education (Mean difference = 2.79; t = 3.68; p = .001). However, patients after the SHEMA intervention did not have significantly higher changes of the stroke knowledge or HRQOL than those after traditional stroke health-education.

Conclusions

Both the SHEMA intervention and traditional stroke health-education can improve patients’ knowledge of stroke risk factors, but the SHEMA was not superior to traditional stroke health-education.

Trial registration

NCT02591511 Verification Date 2015-10-01.

Differences in the awareness of stroke symptoms and emergency response by occupation in the Korean general population

We evaluated the difference in awareness of stroke warning signs (SWS) and emergency response among occupational groups in the community-dwelling population. From the 2016 Korea Community Health Survey, a total of 10,445 individuals without stroke were included in the analysis. Multiple logistic regression analysis was used to explore the association of occupation with awareness of SWS and correct emergency response. SWS included the following: sudden numbness or weakness, sudden difficulty speaking or understanding speech, sudden dizziness, sudden visual impairment, and sudden severe headache. Respondents’ occupation was classified into six groups: managers and professionals (MP); clerks; service and sales workers (SSW); agricultural, forestry, and fishery workers (AFFW); mechanical and manual laborers (MML); or housewives and unemployed people (HUP). Awareness of each SWS was the same with the highest for MP and lowest for AFFW. After adjusting for socio-demographic factors, compared to MP (reference), AFFW (odds ratio 0.49; 95% confidence interval 0.36–0.67), HUP (0.55; 0.40–0.75), MML (0.57; 0.42–0.79), and SSW (0.62; 0.45–0.86) had significantly lower ORs for knowing at least one of the SWS. Additionally, AFFW (0.79; 0.66–0.96) and MML (0.76; 0.63–0.91) had significantly lower ORs for knowing all five SWS compared to MP. However, there was no significant occupational difference in correct emergency response when a stroke occurred. To improve stroke literacy and to reduce the disparity of awareness of SWS in community settings, public health efforts with an emphasis on AFFW and MML are needed.

Planning a campaign to fight stroke: an educational pilot project in La Spezia, Italy

INTRODUCTION

Best medical treatments of ischemic stroke are admission to stroke unit, intravenous thrombolysis and, in selected cases, thrombectomy. Time from symptom onset to interventions is the best predictor of clinical outcome. In order to verify the effectiveness of an active education programme of awareness on the knowledge of stroke, we performed a local campaign "on the field".

SUBJECTS AND METHODS

We selected 101 subjects from the general population who took part in the "stroke awareness campaign" organised by the Italian Association for the fight against stroke (A.L.I.Ce). Mean age was 59 years (50% female; 50% male); 55% of the sample reported a high level of education (> 8 years: high school or university degree). After a short multiple-choice questionnaire, we administered a face-to-face standard educational protocol (15 min). The efficacy of that educational intervention was then verified after a period of 12 months, by telephone interview.

RESULTS

There was improvement both in the definition of stroke (66% vs. 92%, p < .001) and in recognizing symptoms and signs (19% vs. 72%, p < .001). Knowledge of the importance of stroke unit in the acute treatment of stroke did not improve, as it was already high on baseline (92% vs. 97%, p: n.s.). The improvement was evident in particular in younger and higher educated people, without difference in gender. There was no difference based on risk factor profiles of participants.

CONCLUSIONS

Our results suggest that a personalised education can improve knowledge on stroke symptoms and signs, independently of gender and personal risk factors. The results should be verified in larger and less selection population.

Evaluation of the Swedish National Stroke Campaign: A population-based time-series study

BACKGROUND

Time delay from stroke onset to hospital arrival is an important obstacle to recanalization therapy. To increase knowledge about stroke symptoms and potentially reduce delayed hospital arrival, a 27-month national public information campaign was conducted in Sweden.

AIM

To assess the effects of a national stroke campaign in Sweden.

METHODS

This nationwide study included 97,840 patients with acute stroke, admitted to hospital and registered in the Swedish Stroke Register from 1 October 2010 to 31 December 2014 (one year before the campaign started to one year after the campaign ended). End points were (1) proportion of patients arriving at hospital within 3 h of stroke onset and (2) the proportion < 80 years of age receiving recanalization therapy.

RESULTS

During the campaign, both the proportion of patients arriving at hospital within 3 h (p < 0.05) and the proportion receiving recanalization therapy (p < 0.001) increased. These proportions remained stable the year after the campaign, and no significant improvements with respect to the two end points were observed during the year preceding the campaign. In a multivariable logistic regression model comparing the last year of the campaign with the year preceding the campaign, the odds ratio of arriving at hospital within 3 h was 1.05 (95% confidence interval (CI): 1.00-1.09) and that of receiving recanalization was 1.34 (95% CI: 1.24-1.46).

CONCLUSION

The Swedish National Stroke Campaign was associated with a sustained increase in the proportion of patients receiving recanalization therapy and a small but significant improvement in the proportion arriving at hospital within 3 h.

Improving Community Stroke Preparedness in the HHS (Hip-Hop Stroke) Randomized Clinical Trial

BACKGROUND AND PURPOSE

Deficiencies in stroke preparedness cause major delays to stroke thrombolysis, particularly among economically disadvantaged minorities. We evaluated the effectiveness of a stroke preparedness intervention delivered to preadolescent urban public school children on the stroke knowledge/preparedness of their parents.

METHODS

We recruited 3070 fourth through sixth graders and 1144 parents from 22 schools into a cluster randomized trial with schools randomized to the HHS (Hip-Hop Stroke) intervention or attentional control (nutrition classes). HHS is a 3-hour culturally tailored, theory-based, multimedia stroke literacy intervention targeting school children, which systematically empowers children to share stroke information with parents. Our main outcome measures were stroke knowledge/preparedness of children and parents using validated surrogates.

RESULTS

Among children, it was estimated that 1% (95% confidence interval [CI], 0%-1%) of controls and 2% (95% CI, 1%-4%; P=0.09) of the intervention group demonstrated optimal stroke preparedness (perfect scores on the knowledge/preparedness test) at baseline, increasing to 57% (95% CI, 44%-69%) immediately after the program in the intervention group compared with 1% (95% CI, 0%-1%; P<0.001) among controls. At 3-month follow-up, 24% (95% CI, 15%-33%) of the intervention group retained optimal preparedness, compared with 2% (95% CI, 0%-3%; P<0.001) of controls. Only 3% (95% CI, 2%-4%) of parents in the intervention group could identify all 4 letters of the stroke FAST (Facial droop, Arm weakness, Speech disturbance, Time to call 911) acronym at baseline, increasing to 20% at immediate post-test (95% CI, 16%-24%) and 17% at 3-month delayed post-test (95% CI, 13%-21%; P=0.0062), with no significant changes (3% identification) among controls. Four children, all in the intervention group, called 911 for real-life stroke symptoms, in 1 case overruling a parent's wait-and-see approach.

CONCLUSIONS

HHS is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT01497886.

A Pilot Primary Stroke Prevention Program for Elderly Korean Americans

BACKGROUND

Stroke is a significant health issue with devastating consequences among older adults in the United States. However, it can be prevented by improving stroke knowledge and managing risk factors. Many stroke education programs have been shown to be effective. Unfortunately, a minority of older adults, such as older Korean Americans, have not benefited from the programs because of language barriers.

OBJECTIVE

The purpose of this study was to examine the feasibility and preliminary impact of a primary stroke prevention program on stroke knowledge, healthy eating, and physical activity behaviors among Korean Americans.

METHODS

A randomized controlled pilot trial was conducted. A total of 73 persons were randomly assigned to either an intervention group (n = 37) or a control group (n = 36). The intervention program included in-person lectures and discussions. Sociodemographic data were analyzed using descriptive statistics. Analyses of covariance and logistic regression analysis were used to evaluate the effects of the intervention program.

RESULTS

The mean age of participants was 71.49 ± 6.25 years, and most participants were female (74.0%) and married (65.8%). Upon intervention completion, the intervention group showed greater improvements than the control group in stroke knowledge and intake of sodium and total fats (F = 11.89, P = .001, ηp = 0.151; F = 4.04, P = .048, ηp = 0.057; and F = 4.51, P = .037,= ηp = 0.062, respectively). Step counts showed marginal effects (F = 3.27, P = .075, ηp = 0.049).

CONCLUSION

This study demonstrated feasibility and effectiveness of the program to improve stroke knowledge and healthy behaviors in elderly Korean Americans.

Patient knowledge on stroke risk factors, symptoms and treatment options

Background

Public campaigns focus primarily on stroke symptom and risk factor knowledge, but patients who correctly recognize stroke symptoms do not necessarily know the reason for urgent hospitalization. The aim of this study was to explore knowledge on stroke risk factors, symptoms and treatment options among acute stroke and transient ischemic attack patients.

Methods

This prospective study included patients admitted to the stroke unit at the Department of Neurology, Akershus University Hospital, Norway. Patients with previous cerebrovascular disease, patients receiving thrombolytic treatment and patients who were not able to answer the questions in the questionnaire were excluded. Patients were asked two closed-ended questions: “Do you believe that stroke is a serious disorder?” and “Do you believe that time is of importance for stroke treatment?”. In addition, patients were asked three open-ended questions where they were asked to list as many stroke risk factors, stroke symptoms and stroke treatment options as they could.

Results

A total of 173 patients were included, of whom 158 (91.3%) confirmed that they regarded stroke as a serious disorder and 148 patients (85.5%) considered time being of importance. In all, 102 patients (59.0%) could not name any treatment option. Forty-one patients (23.7%) named one or more adequate treatment options, and they were younger (p<0.001) and had higher educational level (p<0.001), but had a nonsignificant shorter prehospital delay time (p=0.292).

Conclusion

The level of stroke treatment knowledge in stroke patients seems to be poor. Public campaigns should probably also focus on information on treatment options, which may contribute to reduce prehospital delay and onset-to-treatment-time.

Does stroke health promotion increase awareness of appropriate behavioural response? Impact of the face, arm, speech and time (FAST) campaign on population knowledge of stroke risk factors, warning signs and emergency response

Introduction

Inability to identify stroke warning signs accurately is an important cause of delay in seeking medical attention, leading to potential ineligibility for acute intervention. We report on post-campaign findings (wave 2) of national surveys to estimate changes in population knowledge following a media-based Face, Arm, Speech, Time stroke awareness campaign, comparing findings to those of a pre-campaign population survey (wave 1).Participants and methods: One thousand and ten randomly selected adults (18+) completed the Stroke Awareness Questionnaire on knowledge of warning signs, risk factors and response to stroke at wave 2 and findings were compared to wave 1 survey results. Logistic regression was used to examine the association between demographic characteristics and self-reported risk factors with knowledge of stroke and emergency response.

Results

No significant differences existed in the ability of respondents to define stroke or to identify two or more stroke risk factors between waves 1 and 2 surveys (71% and 70%, respectively). Respondents to the wave 2 survey were five times more likely (odds ratio 4.9, p < .001) than those responding at wave 1 to know at least two warning signs of stroke (67% vs. 31%, respectively), specifically those targeted by the Face, Arm, Speech, Time campaign. While significant improvement in intention to call an ambulance was noted (odds ratio 1.5, p < .001, 57% at wave 2 compared to 47% at wave 1), for almost half of respondents (43%) this would not have been their first response to stroke. Less than 5% of respondents to both surveys identified thrombolysis as an emergency treatment for stroke (3.9% at wave 2 compared to 1.8% at wave 1).

Discussion

Although significant improvements were made in several areas of stroke knowledge and intended response, awareness of acute stroke interventions was poor and intended behavioural response was suboptimal.

Conclusion

Findings from this study indicate need for targeted campaigns to improve population understanding of the reasons underlying the importance of rapid emergency response to stroke.

Community Interventions to Increase Stroke Preparedness and Acute Stroke Treatment Rates

PURPOSE OF REVIEW

Acute stroke treatments reduce the risk of post-stroke disability. These treatments, tissue plasminogen activator (tPA) and intra-arterial treatment, are highly time-dependent; thus, one of the main barriers to treatment is pre-hospital delay. Stroke preparedness is defined as the ability to recognize stroke symptoms and the intent to activate emergency medical services (EMS). This review describes types of acute stroke treatment and preparedness interventions, including recent mass media interventions to increase acute stroke treatment rates, and adult and youth community interventions to increase stroke preparedness.

RECENT FINDINGS

The mass media campaigns show mixed results regarding acute stroke treatment rates, possibly attributed to the various media platforms utilized and resources available. The adult and youth community interventions reveal an overall increase in stroke symptom recognition and behavioral intent to call EMS. However, most of these community interventions were not grounded in health behavior theory, and they were tested in single group, pre-post test study designs that assessed behavioral rather than clinical outcomes. The delivery of stroke preparedness information by youth to adults, for example via home assignments, is a promising and innovative approach to stroke preparedness. Mass media and community interventions show promise to increase stroke preparedness and acute stroke treatment rates. The development of health behavior theory-based interventions that are tested via scientifically rigorous study designs are needed to prioritize which interventions should be disseminated to culturally and socially similar communities.

Impact on Prehospital Delay of a Stroke Preparedness Campaign: A SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial)

BACKGROUND AND PURPOSE

Public campaigns to increase stroke preparedness have been tested in different contexts, showing contradictory results. We evaluated the effectiveness of a stroke campaign, designed specifically for the Italian population in reducing prehospital delay.

METHODS

According to an SW-RCT (Stepped-Wedge Cluster Randomized Controlled Trial) design, the campaign was launched in 4 provinces in the northern part of the region Emilia Romagna at 3-month intervals in randomized sequence. The units of analysis were the patients admitted to hospital, with stroke and transient ischemic attack, over a time period of 15 months, beginning 3 months before the intervention was launched in the first province to allow for baseline data collection. The proportion of early arrivals (within 2 hours of symptom onset) was the primary outcome. Thrombolysis rate and some behavioral end points were the secondary outcomes. Data were analyzed using a fixed-effect model, adjusting for cluster and time trends.

RESULTS

We enrolled 1622 patients, 912 exposed and 710 nonexposed to the campaign. The proportion of early access was nonsignificantly lower in exposed patients (354 [38.8%] versus 315 [44.4%]; adjusted odds ratio, 0.81; 95% confidence interval, 0.60-1.08; P=0.15). As for secondary end points, an increase was found for stroke recognition, which approximated but did not reach statistical significance (P=0.07).

CONCLUSIONS

Our campaign was not effective in reducing prehospital delay. Even if some limitations of the intervention, mainly in terms of duration, are taken into account, our study demonstrates that new communication strategies should be tested before large-scale implementation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01881152.

[Knowledge of the population about leading symptoms of cardiovascular emergencies and the responsibility and accessibility of medical facilities in emergencies : Results of the KZEN study in Western Palatinate]

BACKGROUND

The Westpfalz is a mainly rural region in the southwestern part of the German state of Rhineland-Palatinate with 527,000 inhabitants and demonstrates a higher than average cardiovascular mortality compared to the rest of Germany. The reasons are not known. Our study attempted to investigate whether significant deficits in knowledge of the population on cardiovascular emergencies, the accessibility of emergency medical services (EMS) or the different responsibilities and abilities of the medical facilities could be held responsible for this. These factors are of the utmost importance for the timely initiation and administration of curative therapeutic strategies.

METHODS

We conducted standardized telephone interviews with 1126 inhabitants of Westpfalz as a representative sample of the population in the study area. The interviewees were asked about demographic data, participation in first aid courses, knowledge of emergency telephone numbers and the different responsibilities of preclinical emergency physicians which are a part of the EMS and the doctor-on-call system for non-life-threatening conditions (ÄBD). Moreover, we asked about the leading symptoms of myocardial infarction and stroke. Finally, we enquired how the respondents would react in fictitious cardiovascular emergencies.

RESULTS

Of the participants 651 (57.8%) were female and 475 (42.2%) male. The mean age in our study was 51 ± 18 years and 1002 of the participants (89%) had some formal first aid training. The current telephone number of the EMS system (112) was known to 29.5% of the interviewees and 15.4% could only recall the old number (19222) which is no longer in use. In the case of participants who gave the correct telephone number the first aid course took place 10 years ago (median), whereas for participants who did not know the correct number, the course dated back 15 years (median, p < 0.01). The telephone number 116117 of the ÄBD, usually a family physician, was familiar to only 23 of the people interviewed (2.0%). The basic differences in the functions and responsibilities of the ÄBD and the emergency physician within the EMS were known to only 235 participants (20.2%), 231 (20.5%) were not able to name a single leading symptom of a myocardial infarction and 354 did not know a leading symptom (31.4%) of stroke. In the fictitious case report of an unconscious patient with respiratory arrest (as a sign of cardiac arrest) 96.8% of the interviewees would have correctly informed the EMS, for patients with acute coronary syndrome 81.8% and for a stroke patient 76.8% (cardiac arrest vs. acute coronary syndrome: p < 0.001, cardiac arrest vs. stroke: p < 0.001, acute coronary syndrome vs. stroke: p = 0.005).

CONCLUSION AND RECOMMENDATIONS

A large proportion of the population were found to be ignorant about the telephone numbers for medical emergency calls and the different functions of the ÄBD and emergency physicians within the EMS. Moreover, our results indicate that a significant percentage of the population would neither be in a position to recognize a stroke or myocardial infarction in an emergency situation nor be informed enough to communicate with the correct part of the emergency system. The association of these deficits with the time elapsed since the last first aid course should be reason enough to continuously motivate the population, especially at risk patients and their relatives, to repeat such courses several times. Furthermore, digital media should be used more intensively in providing first aid instructions. In our opinion, this study clearly shows that in Germany a uniform number for medical emergency calls is mandatory.

Impact of the Swedish National Stroke Campaign on stroke awareness

BACKGROUND

Time delay from stroke onset to arrival in hospital is an important obstacle to widespread reperfusion therapy. To increase knowledge about stroke, and potentially decrease this delay, a 27-month national public information campaign was carried out in Sweden.

AIMS

To assess the effects of a national stroke campaign in Sweden.

METHODS

The variables used to measure campaign effects were knowledge of the AKUT test [a Swedish equivalent of the FAST (Face-Arm-Speech-Time)] test and intent to call 112 (emergency telephone number) . Telephone interviews were carried out with 1500 randomly selected people in Sweden at eight points in time: before, three times during, immediately after, and nine, 13 and 21 months after the campaign.

RESULTS

Before the campaign, 4% could recall the meaning of some or all keywords in the AKUT test, compared with 23% during and directly after the campaign, and 14% 21 months later. Corresponding figures were 15%, 51%, and 50% for those remembering the term AKUT and 65%, 76%, and 73% for intent to call 112 when observing or experiencing stroke symptoms. During the course of the campaign, improvement of stroke knowledge was similar among men and women, but the absolute level of knowledge for both items was higher for women at all time points.

CONCLUSION

The nationwide campaign substantially increased knowledge about the AKUT test and intention to call 112 when experiencing or observing stroke symptoms, but knowledge declined post-intervention. Repeated public information therefore appears essential to sustain knowledge gains.

Mortality and morbidity among hospitalized adult patients with neurological diseases in Cameroon

BACKGROUND

There is inadequate information on the morbidity and mortality (M&M) from neurological diseases in sub-Saharan Africa.

OBJECTIVE

To record the M&M from neurological diseases in adults in Cameroon from 2013 to 2015 using a registry and surveillance from two urban health care centers.

METHODS

Records from all adult admissions from two urban hospitals over a two year period were reviewed. Adult cases with neurological diagnosis as the main cause for admission were identified. The neurological diagnosis was made by a neurologist in all cases. Variables analyzed were: demographics, neurological diagnosis, medical history, medical center characteristics, morbidity and mortality (M&M). Neurological diseases were classified according to ICD-10.

RESULTS

Among the 2225 neurological admissions of adults, death from neurological disease was recorded in 423 patients (19.01%), and disability in 819 of the survivors (53.6%). The factors that were significantly associated with death in the multivariate analysis were age, history of ischemic cardiac disease, and neurological diagnoses of CNS infection, cerebrovascular disease, and CNS tumor. Similarly, factors associated with disability were medical history of HIV, and cerebrovascular disease, and neurological diagnoses of cerebrovascular disease and CNS tumor. Higher educational level and epilepsy were associated with less disability.

CONCLUSIONS

As expected in this sample, older patients with neurological diseases had more M&M. Morbidity was inversely associated with education, which given that cerebrovascular disease is by far the most common cause of morbidity, indicates the power of risk factor control in preventing neurological disability.

Can Children Reduce Delayed Hospital Arrival for Ischemic Stroke?: A Systematic Review of School-Based Stroke Education

BACKGROUND

Delayed hospital arrival after onset of ischemic stroke reduces the number of patients eligible for tissue plasminogen activator, which must be given soon after stroke onset. There are conflicting results about the impact of mass media stroke education on timing of hospital arrival and tissue plasminogen activator administration rates. School-based programs are a new way to communicate stroke information.

METHODS

A search of MEDLINE, CINAHL, PsycINFO, and ERIC databases from 1995 to 2014 identified school-based stroke education interventions. Twelve studies involving 3,312 children and 612 parents met criteria for review.

RESULTS

School-based stroke education interventions were effective to improve knowledge of stroke symptoms among children in kindergarten through junior high. Improvement for stroke risk factors was less robust. Interventions were effective regardless of format, length, or who delivered the information. Despite low parental response rates in some studies, there was evidence that children transmitted stroke information to parents.

CONCLUSIONS

School-based stroke education programs appear effective to improve knowledge of stroke symptoms. Research is needed to determine if children who participate are able to recognize stroke and respond appropriately by calling 911 in the real world. More study is needed about transfer of stroke knowledge from child to parent. Strategies to improve parent participation are needed.

Prehospital path in acute stroke

BACKGROUND

Too few patients with acute stroke receive thrombolytic therapy owing to the limited time window for treatment and prehospital delay. The purpose of this study is to describe the prehospital path for patients with acute stroke and, in particular, what distinguishes patients who contact the Emergency Medical Communication Centre (EMCC) from those who contact their general practitioner (GP) or Out-of-hours (OOH) services.

MATERIAL AND METHOD

Patients with acute cerebral infarction and intracerebral haemorrhage admitted to the Stroke Unit, Department of Neurology, Akershus University Hospital, were included. Data on the prehospital path (prehospital delay, medical contacts) were collected over the period 15 April 2009 – 1 April 2010.

RESULTS

A total of 299 patients were included in the study. The median age was 75 years and 48.5 % were women. In all, 63.9 % of patients with acute stroke called the EMCC, and 93.7 % of these were taken directly to hospital by ambulance. Of those who called the GP’s office or OOH services, 60.7 % were asked to go to the GP’s office or OOH services in person. Patients who called and attended the GP’s office or OOH services had milder neurological deficits (p < 0.001) and longer patient delay (p = 0.018) than those who called the EMCC.

INTERPRETATION

Six out of ten patients who contacted the primary health care services were asked to go to the GP’s office/OOH services in person, which resulted in unnecessary delay. The findings from this study may indicate a need for specific training of this group of health care professionals in the prompt handling of patients with possible stroke.

A cross-sectional population survey on stroke knowledge and attitudes in Greater Kampala, Uganda

Background

Stroke is a neurological condition with rapidly increasing burden in many low- and middle income countries. Africa is particularly hard-hit due to rapid population growth, patterns of industrialization, adoption of harmful western diets, and increased prevalence of risk factors such as hypertension and obesity. Reducing stroke risk factors and teaching people to respond to stroke warning signs can prevent stroke and reduce burden. However, being able to address gaps in knowledge and improving both preventative and early-response care requires a clear understanding of practical and potentially modifiable topics. In this cross sectional study, we assessed the knowledge and attitudes among an urban population residing within the greater Kampala, Uganda.

Methods

A population cross sectional survey was conducted in urban Mukono, district, central Uganda. Through the systematic sampling method, data were gathered from 440 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception using a pretested structured questionnaire.

Results

A total of 440 study participants were enrolled. The leading risk factors for stroke identified by the participants were stress (75.7%) and hypertension (45.2%) respectively. Only two (0.5%) of the study participants identified cigarette smoking as a stroke risk factor. Individuals with hypertension have poor knowledge regarding stroke in spite their high risk for stroke.

Conclusion

Stroke knowledge is poor while, stress and hypertension are the leading perceived risk factors in our settings. While stress is contributing factor, hypertension is likely a more amenable and practical intervention target. Targeting individuals with stroke risk factors to increase stroke knowledge and education is crucial for engagement in healthcare. Implementing a self-management program to support and motivate this high-risk group as well as adopting healthy life-styles may be a way to reduce stroke burden in Uganda.

Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden

OBJECTIVES

Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy.

METHODS

This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012.

RESULTS

The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n = 9), 0.5% to 38.7% in specialized nonuniversity hospitals (n = 22), and 4.2% to 40.3% in community hospitals (n = 41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r = .75).

CONCLUSION

Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.

Improving stroke knowledge through a 'volunteer-led' community education program in Australia

BACKGROUND

Public awareness of stroke risks and warning signs remains poor. The National Stroke Foundation (NSF) in Australia has been undertaking a StrokeSafe Ambassador Education program to raise awareness of stroke. The format includes presentations by volunteers trained to be 'ambassadors' to spread standard information about stroke to the public. Our aim was to determine the change in knowledge of participants who attended presentations.

METHODS

Participants completed questionnaires before immediately after presentations, and at 3months following the presentation. Information was collected on knowledge of risk factors and signs of stroke. McNemar's test was used to compare paired-responses over time. A p value of <0.05 was considered significant.

RESULTS

Between March and April 2014, 591 participants attended 185 presentations and 591 (100%) completed them before and immediately after presentation questionnaires: 68% were female and 75% were aged 65years or more. 258 consented for further follow-up with 192 completing follow-up. Comparing immediately after with before presentation showed significantly improved knowledge for all 10 stroke risk factors and all signs of stroke. Significantly improved knowledge for 7/10 risk factors and 1/3 signs of stroke was found when comparing follow-up and immediately after presentation results. Knowledge of 5/10 risk factors and 2/3 signs of stroke improved when comparing follow-up and before presentation.

CONCLUSION

This study describes a novel approach to support the use of trained volunteers to provide a community-based, standardised education program for stroke. This program shows that community presentations can improve immediate and short-term knowledge of signs and risk factors for stroke.

Cerebrovascular disease

With 16.9 million people who suffered a first-ever stroke in 2010 worldwide, stroke is a very common vascular disease. Epidemiologic studies have played an essential role in assessing this burden and in detecting the risk factors for stroke. Primary prevention of these risk factors, primarily hypertension, smoking, diabetes, and atrial fibrillation, has reduced the incidence in high-income countries. However, stroke remains a major cause of death and disability, and therefore research should be continued. Subarachnoid hemorrhages are less prevalent than strokes but have an even higher risk of death. Similar to stroke, epidemiologic studies identified smoking and hypertension as its most important risk factors, together with excessive alcohol intake. Although rare, arterial dissections, CADASIL, arteriovenous malformations, venous sinus thrombosis, moyamoya disease, and vasculitis can lead to serious symptoms. The burden and risk factors of those rare diseases are more challenging to assess. Whenever possible, they should be recognized in a timely manner for their increased risk of stroke, but most often they are diagnosed only at the time of stroke. Some cerebrovascular abnormalities do not result in immediate symptoms. This subclinical cerebrovascular disease includes silent infarcts, white-matter lesions, and microbleeds, and is incidentally found by neuroimaging. These lesions are not innocent, as several epidemiologic studies have associated subclinical cerebrovascular disease with an increased risk of stroke, cognitive decline, dementia, and death.

Knowledge, attitudes and perceptions of stroke: a cross-sectional survey in rural and urban Uganda

BACKGROUND

Information regarding the increasing burden of non-communicable diseases such as stroke is largely unknown among the vulnerable communities. This analysis, which is part of a larger U.S. National Institute of Heath-funded Medical Education Partnership Initiative neurological disorder survey, assessed community knowledge and attitudes on stroke and stroke risk factors.

METHODS

A population cross-sectional survey was conducted in urban and rural Mukono, district, central Uganda. Through the systematic sampling method, data were gathered from 377 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception using a pretested structured questionnaire.

RESULTS

A total of 377 participants were enrolled (47% urban). The leading risk factors identified by the participants were stress (36.6%) and hypertension (28.9%) respectively. None of the study participants identified cigarette smoking as a stroke risk factor. Seventy six percent of the participants did not recognize stroke as a disease of the brain.

CONCLUSION

Stroke knowledge is poor in both rural and urban Uganda. Tailored public health approaches that improve stroke awareness, knowledge and self management approaches are urgently needed to develop effective preventive measures and community response to stroke.

Stroke patients' knowledge about cardiovascular family history - the Norwegian Stroke in the Young Study (NOR-SYS)

Background

Family history (FH) is a risk factor for cardiovascular disease, especially coronary artery disease (CAD). The impact on risk of stroke is less clear. This study investigated young and middle-aged ischemic stroke patients’ knowledge on FH of stroke, CAD, and peripheral artery disease (PAD) with a special regard to sex differences.

Methods

From September 2010 to February 2014, all ischemic stroke patients aged 15–60 years were prospectively included in the Norwegian Stroke in the Young Study (NOR-SYS). FH of stroke, CAD and PAD in offspring, siblings, parents, and grandparents was assessed using a standardized face-to-face interview. In addition to ‘yes’ and ‘no’, the optional reply ‘don’t know’ was included to improve accuracy. McNemar’s test was used to compare paired proportions, i.e. FH in male vs. female relatives. Multiple logistic regression analyses were used to test the influence of patient sex on FH reporting and to adjust for possible confounding factors.

Results

Altogether 257 patients were included. Mean age was 49.5 years and 68.1% were males. FH of cardiovascular disease was reported by 59% of patients. When asked about FH of stroke, 48 (18.7%) and 46 (17.9%) patients reported yes, whereas 17 (6.6%) and 9 (3.5%) reported ‘don’t know’ regarding father and mother respectively, similarly patients reported ‘don’t know’ regarding 117 (45.5%) paternal vs. 83 (32.4%) maternal grandmothers (p < 0.001). Female patients reported less ‘don’t know’ and were more likely to report a positive cardiovascular FH than males (OR: 3.4; 95% CI: 1.5 to 7.7; p = 0.004). Patients had more detailed knowledge about CAD than stroke in fathers (p < 0.001), mothers (p < 0.001) and siblings (p = 0.01).

Conclusions

Young and middle-aged stroke patients reported a high FH burden of cardiovascular disease. Females are more likely to report a positive FH than males. Detailed knowledge on FH was best for CAD. Our results suggest sex has a big impact on FH knowledge. Females have more knowledge of FH than males and knowledge is better for relatives with a female than male linkage.

Clinical trial registration

http://www.clinicaltrials.gov, unique identifier: NCT01597453.

Stroke awareness in luxemburg: deficit concerning symptoms and risk factors

BACKGROUND

Awareness of stroke risk factors is important for stroke prevention. Knowledge of stroke symptoms and awareness regarding the necessity of seeking urgent stroke treatment are vital to provide rapid admission to a stroke unit. Data on this specific knowledge in Luxemburg are lacking.

METHODS

We investigated 420 patients from the Department of Neurology and their relatives using a questionnaire. There were 44% men and 56% women; 25% were immigrants and 75% Luxemburgish nationals; 13% already had had a stroke or transient ischemic attack (TIA); and the mean age was 55 years ranging from 18 to 87 years.

RESULTS

A total of 88% of participants knew that a stroke occurs in the head/brain. In all, 10% of participants did not know any symptom of a stroke. The most frequently quoted symptoms (>15%) were paralysis/weakness (36%), speech disorders (32%), cranial nerve deficit (16%), vertigo (15%), and visual disorders (15%). Sensory deficits were mentioned by only 4% of patients. Known risk factors (>15%) were smoking (40%), hypertension (32%), alcohol (32%), poor nutrition (28%), high cholesterol (26%), stress (23%), and lack of exercise (19%). Age (4%), diabetes (6%), carotid stenosis (2%), and heart disease (1%) were less frequently known. In all, 11% of participants did not know any risk factor of a stroke. A total of 89% of participants would correctly call the 112 (emergency phone number). The following groups were better informed: Luxemburgish nationals, younger people, and participants with higher education level. Stroke/TIA patients were better informed concerning stroke symptoms, but unfortunately not concerning how to react in the case of a stroke. There was no relevant gender difference.

DISCUSSION

Although most of the participants knew what to do in the case of a stroke, they did not know the relevant stroke symptoms and risk factors. Future campaigns should therefore focus on risk factors and symptoms, and should address immigrants, elderly persons, less-educated persons, and patients who had already suffered a stroke/TIA.