VivekK.Nambiar,KarthikaRani,RemyaSudevan,AbishSudhakar
1Associate Professor, Department of Stroke Medicine,Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India.
2ClinicalResearchCoordinator,DepartmentofStrokeMedicine,AmritaInstituteofMedicalSciencesandResearchCentre,Kochi, Kerala,India.
3Clinical Epidemiologist, Department of Health Sciences Research, Amrita Institute of Medical Sciences and Research Centre, Kochi,Kerala,India.
4Statistician,AmritaInstituteofMedicalSciencesandResearchCentre,Kochi,Kerala,India.
ABSTRACT
Background:Strokeistheleadingcauseofdeathandfunctionalimpairmentaccountingamajorburdenofglobalnon-communicablediseases(1,2).Theknowledge aboutstroke,riskfactorsandwarningsignsamongthepatientsandbystandersisanunexploredarea(1).Theaimofthisstudywastoassesstheknowledgeofstroke riskfactorsandwarningsignsamongpatientsandbystanders.Materialsandmethods:Patientsdiagnosedwithcurrentandrecurrentstrokeofage>18yearswere recruited from in-patient units of stroke medicine department atAmrita institute of medical science and research centre from October 2020 toApril 2021.Those patientswithsufficientcommunicativeabilitywereincludedinthesurveyandthosewithsevereaphasia,limitingthecomprehensionwereexcludedfromthesurvey.A structured closed-ended study questionnaire was used to collect the data regarding the baseline characteristics and to assess the knowledge on stroke among the participants (patients and bystanders). Participants were interviewed to answer questions regarding the demographic characteristics, risk factors, awareness about strokeanditswarningsignsbytheresearchpersonal.ThedatawereanalysedusingSPSSversion21.Results:Atotalof91patientsparticipatedinthesurvey The mean age of the study population was 60.73 (13.38) years. The proportion of males was 61.5%.Patients from rural places (64.8%) was more compared to urban (34.1%).Majorityofthepatients(85.7%)couldnotidentifythattheyhavebeenhitwithstroke.Themostcommonlyrecognizedriskfactorswerehypertension(78%), diabetes(47.3%),dyslipidemia(38.5%)followedbycardiovasculardiseases(33.3%).Regardingstrokewarningsigns,themostcommonlyrecognizedwarningsigns wereupperandlowerlimbweakness(34.1%), bothupperandlowerlimbweaknesswithdeviationofmouth(17.6%),bothupperandlowerlimbweakness,deviation ofmouthandslurringofspeech(7.7%).Only12.1%bystanderswereawareaboutthesignsofstroke.Conclusion:Theresultsfromthecurrentsurveyshowedthatthe generalawarenessofstrokeisstillunsatisfactoryamongstrokepatientsandbystanders.Thehealthcareprovidershouldprovidestructuredinterventionstoincrease awarenessandknowledgeaboutstrokeinthepublic.
KEYWORDS:Strokeawareness,Riskfactorsofstroke,Strokeandawareness,Patientsandbystandersawarenessaboutstroke,strokesymptomsandriskfactors, strokeknowledge.
INTRODUCTION:
Stroke is theleadingcause of deathand functionalimpairmentaccountingto a major burden of global non-communicable diseases (1, 2). The prevalence of strokeinIndiavariesindifferentregionsofthecountryandrangesfrom40-270 per 100000 population.(3-4) it has been found that around 12% of people affectedwithstroke comeundertheagegroupabove40yrs.(3) Consideringthe presentscenarioinIndiawherethepopulationissurvivingbeyondthepeakyears (55-65yrs)fortheriskofstroke,thesocioeconomicburdentomeetthecostsof rehabilitationofstrokevictimsisenormous.(5).Theimplementationofspecialisedstrokeunitsandthrombolytictherapyhaveledtosignificantimprovement of acute stroke treatment(6,7).In spite of these advances in stroke therapy, the publicremainsuninformedaboutstrokes,andonlyfewstrokepatientsseekhospitalcare intermsofarrivingattimetoreceivetreatment.Multilevelinterventionandcoordinationisrequiredtoinfluencethebehaviourandknowledgeofthe publictoachievetheefficientuseofthrombolytictherapywithintherighttime window(6,7).
Thetimelyimplementationandsuccessofstrokemanagementgreatlydepends on the public knowledge about stroke, particularly individuals at high risk and theircaregiverswhichnecessitatestheimportanceofimprovingpublicknowledgeaboutstroke(8).
Theaimofthisstudywastoassesstheknowledgeofstrokeriskfactorsandwarningsignsamongpatientsandbystanders.
MATERIALSANDMETHODS:
Patients diagnosed with current and recurrent stroke of age > 18 years were recruitedfromin-patientunitsofstrokemedicinedepartmentatAmritainstitute ofmedicalscienceandresearchcentrefromOctober2020toApril2021.Those patients with sufficient communicative ability were included in the survey and thosewithsevereaphasia,limitingthecomprehensionwereexcludedfromthe survey A structured closed-ended study questionnaire was used to collect the dataregardingthebaselinecharacteristicsandtoassesstheknowledgeonstroke amongtheparticipants(patientsandbystanders).Participantswereinterviewed to answer questions regarding the demographic characteristics, risk factors, awarenessaboutstrokeanditswarningsignsbytheresearchpersonal.Thedata
wereanalysedusingSPSSversion21.
RESULTS:
Atotal of 91 patients participated in the survey.The participant's demographic detailsandbaselinecharacteristics:gender,placeofresidence,occupation,type ofstroke,education,occurrenceofstrokeandriskfactorsarepresentedinTable 1.Thelevelofawarenessaboutstrokeamongpatients/bystanders,actionstaken, symptomsandvariousmeasuresadoptedareillustratedinTable2.
Themeanageofthestudypopulationwas60.73(13.38)years.Theproportionof males was 61.5%.Patientsfrom rural places (64.8%) were more compared to urban(34.1%).Majorityofthepatients(85.7%)couldnotidentifythattheyhave beenhitwithstroke.
Themostcommonlyrecognizedriskfactorswerehypertension(78%),diabetes (47.3%),dyslipidemia(38.5%)followedbycardiovasculardiseases(33.3%).
Regardingstrokewarningsigns,themostcommonlyrecognizedwarningsigns wereupperandlowerlimbweakness(34.1%), bothupperandlowerlimbweaknesswithdeviationofmouth(17.6%),bothupperandlowerlimbweaknesswith deviationofmouth(17.6%),bothupperandlowerlimbweakness,deviationof mouthandslurringofspeech(7.7%).Only12.1%bystanderswereawareabout thesignsofstroke.
Table1:Baselinecharacteristicsofstudypopulation
Typeofstroke
Ischemic 69 75.8 Haemorrhagic 22 24.2
Occupation
Professional 46 50.6 Skilled 34 37.4 Unskilled 11 12.1 Education
Low 10 11 Medium 65 71.5 High 16 17.6
Occurrenceofstroke
Firststroke 74 81.3 Recurrentstroke 17 18.7 Riskfactors
Hypertension 71 78 Diabeticmellitus 43 47.3 Dyslipidemia 35 38.5 CVD 30 33.3
Table2:Awarenessaboutstrokeamongpatients/bystanders
Variables
Patient'squestions
Awareaboutstrokewarningsigns
Frequency Percentage(%)
Aware 13 14.3 Unaware 78 85.7 Symptoms
Upperandlowerlimbweakness 31 34.1
Upperandlowerlimbweaknessand deviationofmouth 16 17.6
Whoidentifiedstroke Family 88 96.7 Self 3 3.3 Actiontaken Rushedtohospital 84 92.3 Stayedhome 7 7.7
Consciouswhenreachedhospital Yes 67 73.6 No 24 26.4 No:ofhospitalsvisited 1 61 67 Morethan1 30 33
Bystander'squestions
Haveyouhelpedanyonetoreachhospital
Yes 13 14.3 No 78 85.7
Awarethatstrokeisadangerouscondition Yes 45 49.5 No 46 50.5
Areyouabletoidentifythatpatientisgetting hitbystroke
Yes 12 13.2 No 79 86.8
Didyouknowsignsofstroke
Yes 11 12.1 No 80 87.9
Awareofanyemergencynumbertocallwhen youseesomeoneindanger
Yes 14 15.4 No 77 84.6
DISCUSSION:
Strokeisthemajorcauseofdisabilityintheworldanditsincidencehasincreased duringthepastfourdecades(9).Themainfactorsthatcontributetohighmortality and morbidity in stroke is delay in hospitalization (10).Various population studiesconductedovertheyearsshowssuboptimalawarenessontheriskfactors ofstrokeandwarningsignsassociatedwithstrokeonset.(13,14,15,16,17,18).
The present study was done to assess the knowledge of stroke risk factors and warningsignsamongstrokepatientsandbystandersinSouthIndia. Thisstudy wasconductedamongthestrokepatientsandtheirbystandersadmittedtothehospital and supposed to get increased accuracy of responses. This was mainly because,thesubjectwhoseeksmedicalcarewouldbemoreawareabouttheproblem rather than someone who is completely unaware. This is a hospital-based crosssectionalsurvey Itisnoticeablethateveninpatientsandfamilywithgood educational and occupational status the awareness percentage was not appreciable.Itimpliesthatirrespectiveofthesebackgroundswehavetogoahead withaggressivepublicawarenesscampaignsstartingfromprimarycarephysicianstoalllevelsofstrokecare.
Thepresentstudywasahospitalbasedstudywhichindicatestheimportanceof improvingthelevelofpublicknowledgeofstrokeriskfactorsandwarningsigns. Themeanageofthestudypopulationwas60.73(13.38)andproportionofmales was 61.5%.Similarlyin a systematicreviewmeanagefor menwas 68.6 years, and72.9yearsforwomenand malestrokeincidenceratewas33%higherand strokeprevalencewas41%higherthanthefemale(28).
Inourstudy,85.7%oftherespondentswerenotawareofanyestablishedstroke warningsigns.Ina hospital-basedstudyinNorthwestIndia,majority(73%)of respondentsdidnotrealizethatthesymptomswereduetostroke(21).
Inthisstudythemostfrequentlyidentifiedriskfactorwerehighbloodpressure (78%). Population-based studies in South Korea(22)and Hong Kong (23) also reportedthathighbloodpressurewasthemostfrequentlyidentifiedriskfactorof stroke. The other risk factors observed in our study were diabetes (47.3%), dyslipidemia(38.5%)andCVD(33.3%).Theseresultssuggestthatcommunitybasedstrokepreventionstrategiesshouldfocusontheestablishedstrokeriskfactors .Increasing public awareness of stroke prevention and warning signs and symptomsisdesirable,particularlyintheat-riskpopulation.
Upper and lower limb weakness(34.1%)was themost common stroke warning sign listed by respondents. Alower proportion of respondents listed weakness andparalysisofonesideofbodyas strokewarningsign.Thisresultissimilarina studyofpatientswithacutestroke,Kotharietalreportedthatthemostcommonly documented stroke warning sign was“weakness of limb” (11).In a populationbasedtelephoneinterviewsurvey,Panciolietalreportedthatthemostcommon strokewarningsignslistedbyrespondentsweredizzinessandnumbness(13).A community-basedtelephoneinterviewsurveythemostcommonwarningsignof strokedescribedbyrespondentswas"blurredanddoublevisionorlossofvision inaneye"(19).Thisfindingsuggeststhatacommunityeducationprogramshould includeteachingthewarningsignsofstrokeaswellastheappropriateresponses. In this study patients from rural places (64.8%) were more compared to urban (34.1%).Similarlyinasurvey-basedstudy,theruralpopulationhadmoreprevalencerateofstroke whereasurbanpopulation(12%)wasunawareofthewarningsignsofthestroke(27).
Wefoundanegativerelationshipbetweenstrokeknowledgeandhighereducation.Majority(59%)ofourpatientswerefromruralareabutinIndiaeducational opportunitiesaremoreintheurbanthanintheruralareas.However,Kotharietal didnotfindanycorrelationbetweenbetterawarenessandeducation(11).Most studiesonawarenessofstrokefromdevelopedcountrieshavefoundthatknowledgeofstrokevaries witheducation(21,24).Ithasbeenfoundthateventhepeople who are aware that they have risk factors for stroke, have poor knowledge aboutthestrokewarningsignssimilartothosewithoutriskfactors(20).
Majorityoftherespondents(92.3%)tookthepatienttothehospitalwhenthey experienced symptoms of stroke. Similar responses were seen in other studies(25.26).ButinaKoreanstudyonly46%ofthemmentionedthattheywould visitahospital(22).
This study indicates that there is lack of awareness among the patients and bystanders about stroke warning symptoms and risk factors .We found that awareness of stroke warning signs and risk factors was low in both the stroke patients and bystanders. The study population's lack of knowledge about the warningsignsofstroke,strokeriskfactorsandthedelayinhospitalizationhave been highlighted in this study Widespread awareness about stroke symptoms andtheimportanceofreceivingearlymedicalattentionwithinthefirstfewhours afterstrokeonsetisverynecessarytominimisethedisabilityduetostrokeand maximisethequalityoflife(11,12).
CONCLUSION: Theresultsfromthecurrentsurveyshowedthatthegeneralawarenessofstroke is very minimal among stroke patients and family members. This points the urgentneedforenhancedpublicawarenesseffortstoimprovethetreatmentand outcome of stroke patients. The healthcare provider starting from the primary
care physicians should provide structured interventions to increase awareness andknowledgeaboutstrokeinpublic.Implementationofawarenessprogramsis imperativeinordertoimprovetheawarenessandmanagementofstroke.
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