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Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut
ARTICLE IN PRESS
Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut Hussein Mohammad Khalil, MSc,* and Nathalie Lahoud, PharmD, PhD*,†,‡,§
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. Key Words: Stroke awareness—risk factors—warning signs—cross sectional— Lebanon © 2020 Elsevier Inc. All rights reserved.
Introduction Cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability worldwide.1 Globally, 70% of strokes and 87% of both strokerelated deaths and Disability-Adjusted Life Years occur in
low- and middle-income countries where there may be barriers to stroke care.2 In a 2016 review study, the incidence rate for all strokes in the Middle East ranged between 22.7 and 250 per 100,000 population per year and the prevalence rate ranged between 508 and 777 per 100,000 population.3
From the *Faculty of Pharmacy, Lebanese University, Hadat, Lebanon; †Faculty of Public Health, Lebanese University, Fanar, Lebanon; ‡CERIPH, Center for Research in Public Health, Pharmacoepidemiology Surveillance Unit, Faculty of Public Health, Lebanese University, Fanar, Lebanon; and §INSPECT-LB, Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Faculty of Public Health, Lebanese University, Fanar, Lebanon. Received August 7, 2019; revision received January 27, 2020; accepted January 28, 2020. Funding: None. Address correspondence to Hussein Mohammad Khalil RPH, MSc, Bpharm, MPCP, Faculty of Pharmacy, Lebanese University, Al Saeed Building, 6th floor, Main Street, Doha Aramoun, Choueifat, Lebanon. E-mail: [email protected]. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104716
Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104716
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Lebanon, an upper middle income country of the Middle Eastern region,4 suffers from a paucity of data on the prevalence of stroke. It is assumed that stroke is the second leading cause of mortality in Lebanon (9.4% of all deaths in 2012).4 A recent study revealed stroke prevalence in Lebanon may be higher than other developing countries in the region.5 This is not surprising as the prevalence of noncommunicable diseases in Lebanon is high (36% hypertension, 25% diabetes, 25% dyslipidemia).6,7 What is more, population aging in Lebanon is higher than in any other Arab country.8,9 Lebanon also has the highest smoking rates in the Middle East (up to 37% of the population)10 and a high level of obesity among adults (31%) with a projected increase in the future.11 Stroke is a medical emergency that requires immediate medical attention. Thrombolysis within 4.5 hours of onset of acute ischemic stroke has been shown to be effective in improving prognosis and survival of patients12 and results in subsequent reduction of dependency in activities of daily living.13 The narrow therapeutic window of thrombolysis requires prompt hospital arrival. Alarmingly, the majority of stroke patients fail to attend to the hospital within the treatment window.14 Many factors contribute to delays in seeking treatment for stroke but the principal factor is believed to be a lack of public knowledge regarding stroke symptoms and the need for a rapid response.15,16 In fact, better knowledge of stroke symptoms or risk factors, experience of living with stroke patients or experience of stroke education were significantly associated with stroke recognition and appropriate action by the general public.17 Knowledge of stroke risk factors may also improve primary prevention.18 Persons who perceive their own risk for stroke can promote the intervention of stroke risk factors and reduce their risk of stroke occurrence.19,20 Previous studies have shown that a large proportion of high risk stroke patients are unaware of their risk.15,21-23 Increasing awareness of stroke and its risk factors through public education can improve early recognition, reducing time to treatment and reducing the risk of stroke.24,25 To design effective stroke education strategies an assessment of public knowledge of stroke is required.
Knowledge of stroke risk factors and symptoms in the general population worldwide have been consistently found to be poor,15,18,26 with knowledge levels poorest in groups that have the highest risk of stroke: individuals aged 65 years or older, those of lower socioeconomic status and lower levels of education.15,18 Moreover, it appears that having stroke risk factors in general does not contribute to an increase in stroke knowledge.15 To date, there is no information regarding the pre-existing knowledge of stroke in the Lebanese population. Thus, we conducted a cross-sectional survey to assess the knowledge of stroke symptoms, risk factors, prevention, and early response in case of suspected stroke occurrence, and to identify characteristics associated with better stroke knowledge among people aged 50 and above visiting community pharmacies in the capital of Lebanon, Beirut.
Materials and Methods Subject Sampling A multistage sampling method was used. Twenty pharmacies were randomly selected from a list of all pharmacies in Beirut (235 pharmacies) on the Order of Pharmacists in Lebanon website. The selected pharmacies were then asked for written permission to collect survey data from customers at a suitable date. Pharmacies that refused to participate were excluded from the study and another 1 was randomly selected instead. Older adults of the general public who attended the selected pharmacies were approached by a well-trained investigator to be recruited consecutively (ie, the first 20 eligible participants who agreed to fill the questionnaire from each pharmacy; Fig 1). Sampling was carried out on a variety of days between the months of May and October 2018. Since the risk of stroke morbidity and mortality increase with age, individuals who were 50 years or older were eligible to participate in the study. Those who had a medical degree, were unable to answer questions due to speech difficulties or cognitive impairment, or were not Lebanese were excluded from the study.
Figure 1. Illustration of multistage sampling method.
ARTICLE IN PRESS STROKE KNOWLEDGE IN LEBANESE OLDER ADULTS IN BEIRUT
This study was waived approval by the ethical review board at the Lebanese University.
Study Design Participants were first given a brief explanation of the study, and verbal consent was obtained before participation. A face-to-face, interview-based questionnaire composed of both open and closed ended questions was used to collect information of stroke awareness and knowledge of stroke, stroke risk factors, stroke symptoms, primary prevention of stroke, immediate actions in response to observation of stroke symptoms, sociodemographic information, and clinical profile. The questionnaire was developed through literature review of stroke awareness and attitude studies.27-29 It was translated into Arabic and tested on 15 subjects who were not included in the study. The final version of the questionnaire comprised of 5 sections. The first section investigated knowledge of stroke, stroke symptoms, and stroke risk factors. Respondents were first asked “what do you understand by the term stroke? (Translated to Sakta dimaghiya in Arabic)”. Answers were recorded as either blood clot in the brain, brain hemorrhage, a condition that affects the brain, does not know, or other. They were then asked to freely recall as many stroke symptoms as they could. The remaining unrecalled symptoms were asked as closed ended questions integrated in a list containing 8 unrelated red herrings where respondents answered with “Yes”, “No”, or “I don’t know”. Eight symptoms or warning signs were considered, they are: dizziness, confusion, headache, problems with vision, slurred speech, weakness on 1 side of the body, facial weakness, and numbness or prickling sensations. The next part of this section was about stroke risk factors, including also an open-ended question asking to list as many as they could, followed closed-ended questions for the unrecalled ones. Twelve risk factors were studied, they are: hypertension, dyslipidemia, diabetes, arrhythmia, obesity, smoking, sedentary lifestyle, previous stroke, heavy alcohol consumption, family history of stroke, stress, and increasing age. Respondents were then asked whether they thought stroke may cause permanent disability or not. In the second section, 2 questions were asked to identify knowledge of primary prevention of stroke. The first question was whether they thought stroke risk could be decreased through certain practices. Respondents who replied with yes were asked to answer a second open ended question asking to name as many treatments or practices that reduce the risk of stroke. The third section of the questionnaire explored knowledge of appropriate actions to take when stroke symptoms are observed. This section included 1 open ended question: “What would you do if you thought that you or someone near you is having a stroke?” The final 2 sections were concerned with respondent sociodemographic and clinical profile. We registered the
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following data: age, gender, marital status, highest level of education obtained, occupation, self-reported height and weight, whether they lived alone, whether they had insurance, whether they have ever known anyone who has had a stroke and who (family member, friend or colleague, or other), and if they have been concerned with the possibility that they might have a stroke in the past 12 months. Presence of the following risk factors of stroke: hypertension, dyslipidemia, diabetes, and smoking (have ever smoked 100 cigarettes in their lifetime and current smoking frequency—everyday, some days, not at all), physical exercise and frequency (rarely, 1-2 times a week, and 3 or more times a week), heart rhythm disorders. Alcohol consumption, previous cerebrovascular disease (Transient Ischemic Attack or ischemic or hemorrhagic stroke), previous myocardial infarction, whether anyone in their immediate family (mother, father, brother, or sister) has ever had a stroke, and whether anyone in their immediate family has ever had a myocardial infarction.
Statistical Analyses To obtain a 95% confidence interval (CI), a minimum sample of 384 participants was needed to allow adequate power for bivariate and multivariate analyses to be carried out. Calculation of sample size was performed using Epi info version 7 (CDC’s Epi InfoTM Version 7.2.2.2 2017) with an expected frequency of 50% to obtain largest sample size and a 5% acceptable margin of error. Data collected were entered and analyzed with the Statistical Package for Social Sciences version 23.0 (SPSS Inc, Chicago, IL). Continuous variables were expressed as mean § standard deviation and 95%CI. Categorical and ordinal variables were expressed as frequencies (n) and percentages (%) of the overall sample. We performed binary logistic regression analyses with forward stepwise selection to determine factors associated with the ability to spontaneously recall 2 or more stroke risk factors, 2 or more warning signs, and activation of emergency medical services in response to acute stroke suspicion. Only variables that showed a P less than .2 in the bivariate analysis were included in the adjusted model. Results were presented as odds ratios (OR) and 95%CI. Statistical tests were 2 tailed and reported statistically significant at P less than .05.
Results A total of 407 participants from 20 different locations completed the questionnaire. Seventeen questionnaires were excluded for incomplete information. Sociodemographic and clinical data are presented in Tables 1 and 2. The study population included 221 Lebanese men (56.7%) and 169 women (43.3%) with an average age of 62 § 7.17 years old. About 67.2 % of the population had completed an educational level of secondary school or higher.
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Of the 390 participants who completed the questionnaire, 232 (59.2%) knew someone who has experienced a stroke. The mean number of stroke risk factors per participant was 3.05 § 1.56. The most prevalent risk factor was hypertension (61%) followed by dyslipidemia (53.1%) and smoking (47.2%). Half of the participants were overweight (47.4%) and a quarter (25.9%) were obese. Almost 3 quarters of the sampled population (74.6 %) said they had heard of the term stroke (Sakta dimaghiya) in the past. Regarding what is understood by stroke, nearly half (44.6%) answered with a correct definition (blood clot in the brain [41%], brain hemorrhage [3.6%]) and 17.9% identified it was a condition affecting the brain but could not state the pathological mechanism. About 37% of the participants did not know the correct definition of stroke. The majority of participants believed stroke can cause disability (92.1%), can be treated (80.5%), and can be prevented (91.5%). Of the 357 responders that believed stroke can be prevented, the most commonly mentioned practices to decrease stroke risk were exercise (53.8%) and diet (37.2%).
Knowledge of Risk Factors (Table 3) The average number of stroke risk factors spontaneously recalled was 1.76 § 1.17 compared with an average of 8.7 § 1.617 when asked to identify risk factors from a list. Of the 12 risk factors considered, 57 participants (14.6%) could not recall any risk factor, 107 (27.4%) could
Table 1. Sociodemographic characteristics of the study participants Independent variables Age (y) mean § SD 95%CI Gender (n, %) Male Female Highest educational level attained (n, %) None Primary Intermediate Secondary University Marital status (n, %) Single Married Divorced Widowed Personally know a stroke patient (n, %) Yes Living Alone (n, %) Yes
Overall sample (n = 390) 62.03 § 7.17 61.32-62.74 221/56.7 169/43.3 16/4.1 48/12.3 64/16.4 138/35.4 124/31.8
Table 2. Clinical profile of study participants Independent variables BMI (n, %) Underweight Normal Overweight Obesity Smoking (n, %) Never smoker Former smoker Current smoker Hypertension (n, %) Dyslipidemia (n, %) Diabetes (n, %) Heart rhythm disorders (n, %) Previous MI (n, %) Family history of MI (n, %) Previous stroke (n, %) Family history of stroke (n, %) Number of risk factors per patient Mean § SD Categories (n, %) 0 Risk factors 1-2 risk factors 3-4 risk factors 5 and above
Overall sample (n = 390) 2/.5 100/25.6 185/47.4 101/25.9 171/43.8 35/9.0 184/47.2 238/61.0 207/53.1 114/29.2 70/17.9 36/9.2 121/31.0 16/4.1 77/19.7 3.05 § 1.56 12/3.1 131/33.6 186/47.7 61/15.6
Abbreviations: BMI, body mass index; MI, myocardial infarction.
name 1 risk factor, and 226 (57.9%) could name at least 2 or more. The most frequently recalled risk factors were hypertension, smoking, and dyslipidemia (48.2%, 20.5%, and 19.5% respectively). Less than half of the participants (43.1%) stated stress as a risk factor for stroke. Participants who had hypertension, dyslipidemia, and diabetes were significantly more able to recall these risk factors than those who did not (Table 4). In the multiple logistic regression analysis,knowing a stroke patient (OR = 1.84, P = .005) and having higher level of education (OR = 2.821 P = .005, OR = 3.101 P < .001, OR = 3.014 P = .001 for intermediate, secondary and university respectively compared with primary) were significantly associated with recall of 2 or more risk factors (Table 6).
Knowledge of Symptoms (Table 3) 19/4.9 305/78.2 20/5.1 46/11.8 232/59.49 42/10.8%
Abbreviations: CI, Confidence interval; SD, standard deviation.
For all of the symptoms, recognition from a list resulted in a much higher percentage than spontaneous recall. The mean number of freely recalled stroke symptoms answered per participant was 1.32 § 1.21 whereas an average 5.81 § 1.43 was obtained from closed ended questions. Of the 8 stroke symptoms considered, almost a third (31.8%) of all of the participants could not spontaneously recall any stroke symptom, 28.1% participants could
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Table 3. Knowledge of stroke risk factors & symptoms Independent Variables
Open ended
Closed ended
Total
Risk Factors (n, %) Hypertension Dyslipidemia Diabetes Arrhythmia Obesity Smoking Sedentary lifestyle Previous stroke Alcohol consumption Family history Stress Ageing
188/48.2 76/19.5 44/11.3 10/2.6 33/8.5 80/20.5 27/6.9 3/0.8 8/2.1 27/6.9 168/43.1 22/5.6
181/46.4 262/67.2 263/67.4 309/79.2 315/80.7 274/70.3 327/83.9 329/84.3 299/76.6 322/82.6 208/53.3 304/78.0
369/94.6 338/86.7 307/78.7 319/81.8 348/89.2 354/90.8 354/90.8 332/85.1 307/78.7 349/89.5 376/96.4 326/83.6
Number of risk factors per participant mean § SD 95%CI Symptoms (n, %) Dizziness/vertigo Headache Visual alterations Slurred speech Hemiparesis Fallen face Paresthesia
1.76 § 1.17 1.64-1.87
8.7 § 1.617 8.54-5.87
10.45 §1.45 10.31-10.6
76/19.5 70/17.9 114/29.2 25/6.4 37/9.5 99/25.4 48/12.3
268/68.7 290/74.4 251/64.4 307/78.7 309/79.2 252/64.6 299/76.7
344/88.2 360/92.3 365/93.6 332/85.1 346/88.7 351/90.0 347/89.0
Number of symptoms per participant mean § SD 95%CI
1.32 § 1.21 1.19-1.44
5.81 § 1.43 5.67-5.96
7.13 § 1.14 7.02-7.25
Abbreviations: CI, confidence interval; SD, standard deviation.
Table 4. Number of participants with a particular risk factor identifying it as such Stroke risk factor
Participants with risk factor identifying it as such (n, %)
Compared with those without risk factor, P value
Hypertension (n = 238) Dyslipidemia (n = 207) Diabetes (n = 114) Smoking (n = 219) Previous stroke (n = 16) Family history (n = 77) Arrhythmia (n = 70) Obesity (n = 101)
126/52.9
.019
51/24.6
.006
22/19.3
.001
43/19.6
.627
0/.8
1
9/11.7
.066
4/5.7
1
10/9.9
.546
name only 1 stroke symptom and 39% could recall 2 or more. The most frequently recalled symptoms were headache, hemiparesis and dizziness (29.2%, 25.4%, and 19.5% respectively). Multiple logistic regression analysis revealed that having a heart rhythm disorder (OR = 1.873, P = .025), knowing a stroke patient (OR = 2.51, P < .001), and having a higher level of education (OR = 2.806 P = .012, OR = 2826 P = .004, OR = 3.403 P = .001 for intermediate, secondary and university respectively compared with primary) are were related to recalling 2 or more symptoms.
Response to stroke suspicion (Table 5) Faced with stroke suspicion, 84.4% of participants recognized the need for immediate medical care (ie, replied with call doctor, take to hospital, or call ambulance). Those who would call an ambulance were 57.7% of the sample, those who would go to the hospital by themselves were 24.9%, and 7% would call a physician. Respondents who would call an ambulance were able to recall and recognize a greater number of symptoms
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Table 5. Respondents reaction to stroke symptom suspicion Action (n, %) Call an ambulance Go to hospital Wait and see Tell someone Self-medication Call doctor Don’t Know
225/57.7 97/24.9 24/6.2 18/4.6 6/1.5 7/1.8 13/3.3
than those who would not (P = .024). Despite a trend for identifying more risk factors in those who would call an ambulance compared to those who would not (10.56 § 1.44 versus 6.99 § 1.21) the difference between the 2 groups was not significant. In the multiple logistic regression analysis (Table 6), identifying more symptoms is positively associated with calling an ambulance (OR = 1.237, P = .021) in response to stroke suspicion and having diabetes is inversely associated with calling an ambulance (OR = .61, P = .03). Finally when asked whether participants had ever been concerned with having a stroke in the past 12 months 214 participants (54.9%) said they had and 176 (45.1%) said they were not.
Discussion To our knowledge, this is the first study conducted in Lebanon to report the current level of familiarity with stroke, its warning signs, risk factors, prevention, and early response actions. The results of this study reveal
that there is a lack of adequate knowledge to effectively identify symptoms of acute stroke and respond accordingly among the Lebanese older adult population in Beirut despite perceiving stroke as a disability causing disease that can be treated and prevented. Three quarters of the participants claimed to have heard of stroke before, and 62.5% were able to correlate stroke with the brain as the affected organ. This result is higher than in previous studies.27-29 However this is likely because of the Arabic translation of stroke (sakta dimaghiya) which is more descriptive. Nearly half of the participants (44.6%) stated the pathological mechanism of stroke and the majority of those answered it is caused by an occlusion of a blood vessel in the brain by a blood clot (41%). This result is lower than a similar study from Ireland (60.3%),30 but higher than that of a study from India (31%).31 The results of the survey indicate levels of symptom and risk factor knowledge obtained through face-to-face interviews is contingent upon the type of the questions administered, such that open-ended questions may underestimate the true level whereas closed-ended ones may highly overestimate them. This discrepancy has been discussed in previous studies.15,26 As a consequence, we have focused the analysis on the open ended questions. Among all the respondents, 85.4% were able to spontaneously recall at least 1 risk factor. Most studies that used open-ended questions reported percentages that range between 40% and 79%.32-39 The most frequently named risk factors in our study were hypertension, smoking, and stress (48.2%, 20.5%, and 43.1% respectively). A number of similar studies have reported these 3 are among the most perceived as stroke risk factors.27,35,38 Interestingly,
Table 6. Predictors of stroke awareness and attitude through multivariate logistic regression Predictors Recall of 2 or more risk factors Knowing a stroke patient Level of education Up to primary Intermediate Secondary University Recall of 2 or more symptoms Having a heart rhythm disorder Knowing a stroke patient Level of education Up to primary Intermediate Secondary University Activation of emergency response system upon stroke suspicion Having diabetes Total number of symptoms identified Abbreviations: CI, confidence interval; OR, odds ratio.
Adjusted OR (95%CI)
P value
1.842 (1.208-2.809)
.005
2.821 (1.366-5.823) 3.101 (1.662-5.786) 3.014 (1.599-5.680)
.002 .005 <.001 .001
1.873 (1.082-3.242) 2.517 (1.611-3.932)
.025 <.001
2.806 (1.251-6.294) 2.826 (1.393-5.734) 3.403 (1.672-6.926)
.008 .012 .004 .001
.610 (.391-.953) 1.237 (1.033-1.481)
.030 .021
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when considering the results of both open-ended and closed-ended questions, diabetes—despite being a welldocumented risk factor of stroke—was the least identified risk factor, having an equal percentage of identification with excess alcohol consumption of 78.7%. Other studies have also reported poor recognition of diabetes as a risk factor for stroke.22,35,38,40 Pancioli35 reported that respondents with a particular risk factor for stroke are likely to mention that factor as a risk for stroke. In this study, respondents who had diabetes (19.3%), hypertension (52%), or dyslipidemia (24.6%) were significantly more able to name those risk factors than participants who did not. Sundseth et al. only41 found a similar association with diabetes only whereas Hickey et al21 could not find any significant difference in identifying a self-reported risk factor. Despite this, only half of those with hypertension and the majority of patients with diabetes or dyslipidemia (19.3% and 24.6%, respectively) could not name these diseases as risk factors for stroke. Awareness of one’s own risk profile is a precondition for risk changing behavior and thus prevention of stroke,23 and the results of our study still show the majority of patients with risk factors for stroke are unaware of their own risk. Our data revealed that 68.2% of the participants were able to spontaneously recall at least 1 stroke symptom compared to 74.2% in a study conducted in Portugal,40 70.7% in Norway,41 68.0% in Oman,22 and 65% in Korea.42 In this study 39.7% were able to recall 2 or more symptoms while other studies have reported higher proportions (Duque et al 68.9%, Mikulk et al 46%,).40,43 Consistent with a similar study in Spain, headache was recalled by 29. Two percent of the participants whereas hemiparesis was recalled by 25.4%.44 This contrasts with a study conducted in the Gulf Cooperation Council countries where hemiparesis was the most frequently recalled stroke warning sign.27 Speech impairment and fallen face were each recalled by 1 in 10 patients. Only 6 participants were able to state these symptoms concomitantly with hemiparesis. In an Australian study, recalling at least 2 of the 3 stroke symptoms, ‘‘limb weakness,’’ ‘‘facial weakness,’’ and ‘‘speech problems,’’ was associated with stroke recognition and showed a trend toward calling for ambulance assistance.17 Our results thereby may reveal a deficit in ability in identifying stroke and immediately activating emergency services. Only 15.6% of the population were able to spontaneously recall one of “numbness, one sided weakness, or facial palsy” with “confusion or slurred speech”. Sundseth et al,41 who used this as a definition for adequate stroke symptom knowledge reported a much higher result (42.9%). Notably, chest pain was recognized as a symptom of stroke from a list by half of the respondents, which could reflect the confusion between stroke and heart attack. This was also noticed in other studies.37 Higher levels of education was a significant predictor of better stroke symptom and risk factor knowledge similar
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to several studies.26,31,35-37,40,41,45 In addition, having a heart rhythm disorder showed positive association with spontaneous recall of 2 or more symptoms. This can be explained by the fact that patients with atrial fibrillation are treated with anticoagulants and may associate their disease with stroke more than others. Nonetheless our results contrast that of a 2005 study that showed no difference in stroke knowledge between those who had atrial fibrillation and those who did not.46 Better knowledge of stroke symptoms and risk factors was related to knowing a stroke victim. A prior study in India showed stroke affected families possess better knowledge about the many symptoms and risk factors of stroke.47 Even though most participants in this study were not able to recall most of the alarming signs and symptoms of stroke, 84.4% of the populace recognized the need for immediate medical care (would call an ambulance, go to hospital, or call doctor). However only 57.7% of the sample would call an ambulance when stroke is suspected which is lower than other studies.36,40,44,48 We found that calling an ambulance was associated with identification of a greater number of symptoms similar to Lundelin et al.49 This suggests that better knowledge of stroke symptoms is related to the decision to call an ambulance. We also found that diabetic participants were less likely to call an ambulance having suspected a stroke. This is alarming considering diabetes is a major risk factor for stroke occurrence. A recent study from Sweden also showed that having diabetes was associated with a lower probability of stroke alert.50 It should be noted however that if participants were asked how they would react to particular symptoms without reference to stroke they might have responded differently.15 Furthermore, some studies have shown a discrepancy between intended behavior in case of stroke suspicion and their actual response in case of a real scenario, and have argued that the calling an ambulance might be related to perceptions on the seriousness and treatability of stroke rather than the level of knowledge (Mikulk et al).43 The strength of the present study was the utilization of both open and closed-ended questions to assess stroke risk factor and symptom knowledge as we believe that neither methods correspond to real knowledge. Another advantage of our study was personal contact between the interviewer and the participants which ensures greater reliability in comprehension of the questionnaire. Our study has encountered several limitations. First, the sampling design does not represent a random sample of all the Lebanese population, as all the participants were sampled from community pharmacies in Beirut. Thus individuals who reside in semiurban and rural areas were not included. There also may be a selection bias and overestimation of stroke knowledge as respondents visiting pharmacies for their medications may be health conscious. All of the participants characteristics were selfreported, thus the extent of truthful answers or verifying
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respondent’s claims is not possible in this type of study. This also extends to participants who were yet undiagnosed of a risk factor. Moreover, the exact translation of stroke in Arabic is more descriptive and exact than in English, thus we expect that the level of individuals who identified the pathological mechanism of stroke to be overestimated. Finally, we were not able to utilize the data collected concerning socioeconomic status due to the amount of missing values obtained.
Conclusions Findings from this study demonstrate low to moderate knowledge of stroke symptoms, risk factors, and appropriate actions to take when observing stroke in the older adult population of Beirut, Lebanon. This is alarming considering the rising incidence rate of stroke in Lebanon. Accordingly, culturally tailored awareness campaigns could be implemented at multiple levels to target vulnerable populations at higher risk for stroke and their families. Such campaigns could be developed through universities, institutions, medical care facilities, as well as governmental and nongovernmental organizations. Use of different media methods are required in dissemination of information and raising public knowledge. Additionally, health education messages about stroke symptoms, risk factors, and proper response should be provided for all patients receiving care in chronic disease clinics. This is critical for the future reduction of stroke incidence, morbidity, and mortality. Most important is the need to increase awareness of stroke warning signs and importance of timely activation of emergency medical services upon observing stroke symptoms, as these may contribute to a greater number of patients available for thrombolysis. Further studies are needed to address stroke knowledge in younger age groups, those residing in other cities and rural areas of Lebanon, and patients who have suffered a stroke in the past. Additionally, investigating the level of knowledge among stroke patients and their families who admit to hospital before or after 4.5 hours of stroke occurrence is needed to increase our understanding of what prompts people to call emergency services in real situations.
Conflict of Interest None.
References 1. WHO j Global Health Estimates [Internet]. WHO. [cited 2018 Mar 13]. Available at: http://www.who.int/healthinfo/global_burden_disease/en/. Accessed March 13, 2018. 2. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res 2017;120:439-448. 3. El-Hajj M, Salameh P, Rachidi S, et al. The epidemiology of stroke in the Middle East. Eur Stroke J 2016;1:180-198.
4. WHO j Lebanon [Internet]. WHO. [cited 2019 Jul 8]. Available at: http://www.who.int/countries/lbn/en/. Accessed July 8, 2019. 5. Lahoud N, Salameh P, Saleh N, et al. Prevalence of Lebanese stroke survivors: a comparative pilot study. J Epidemiol Glob Health 2016;6:169-176. 6. Matar D, Frangieh AH, Abouassi S, et al. Prevalence, awareness, treatment, and control of hypertension in Lebanon. J Clin Hypertens 2015;17:381-388. 7. Fahs I, Khalife Z, Malaeb D, et al. The prevalence and awareness of cardiovascular diseases risk factors among the Lebanese population: a prospective study comparing urban to rural populations. Cardiol Res Prac 2017;2017:10. 8. Abdulrahim S, Ajrouch KJ, Antonucci TC. Aging in Lebanon: challenges and opportunities. Gerontologist 2015;55: 511-518. 9. World Population Prospects - Population Division United Nations [Internet]. [cited 2018 Oct 20]. Available at: https://population.un.org/wpp/Maps/. Accessed October 20, 2018. 10. Rahim HFA, Sibai A, Khader Y, et al. Non-communicable diseases in the Arab world. Lancet North Am Ed 2014;383:356-367. 11. WHO j Noncommunicable diseases country profiles 2018 [Internet]. [cited 2018 Oct 23]. Available at: https://www. who.int/nmh/countries/en/#U. Accessed October 23, 2018. 12. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-1329. 13. Wardlaw JM, Murray V, Berge E, et al. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2014;2014:CD000213. 14. Pulvers JN, Watson JDG. If time is brain where is the improvement in prehospital time after stroke? Front Neurol 2017;8:617 617. 15. Jones SP, Jenkinson AJ, Leathley MJ, et al. Stroke knowledge and awareness: an integrative review of the evidence. Age Ageing 2010;39:11-22. 16. Faiz KW, Sundseth A, Thommessen B, et al. Reasons for low thrombolysis rate in a Norwegian ischemic stroke population. Neurol Sci 2014;35:1977-1982. 17. Mosley I, Nicol M, Donnan G, et al. What is stroke symptom knowledge? Int J Stroke 2014;9:48-52. 18. Stroebele N, M€ uller-Riemenschneider F, Nolte CH, et al. Knowledge of risk factors, and warning signs of stroke: a systematic review from a gender perspective. Int J Stroke 2011;6:60-66. 19. Harwell TS, Blades LL, Oser CS, et al. Perceived risk for developing stroke among older adults. Prev Med 2005;41:791-794. 20. Yang J, Zheng M, Chen S, et al. A survey of the perceived risk for stroke among community residents in western urban China. PLoS One 2013;8:e73578. 21. Hickey A, O’Hanlon A, McGee H, et al. Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults. BMC Geriatr 2009;9:35. 22. Al Shafaee MA, Ganguly SS, Al Asmi AR. Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke. BMC Neurol 2006;6:38. 23. Samsa GP, Cohen SJ, Goldstein LB, et al. Knowledge of risk among patients at increased risk for stroke. Stroke 1997;28:916-921. 24. Bray Janet E, Ian Mosley, Michael Bailey, et al. Stroke public awareness campaigns have increased ambulance
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dispatches for stroke in Melbourne, Australia. Stroke 2011;42:2154-2157. Rasura M, Baldereschi M, Carlo AD, et al. Effectiveness of public stroke educational interventions: a review. Eur J Neurol 2014;21:11-20. Nicol MB, Thrift AG. Knowledge of risk factors and warning signs of stroke. Vasc Health Risk Manag 2005;1:137-147. Kamran S, Bener AB, Deleu D, et al. The level of awareness of stroke risk factors and symptoms in the Gulf Cooperation Council countries: Gulf Cooperation Council stroke awareness study. Neuroepidemiology 2007;29:235-242. Kaddumukasa M, Kayima J, Kaddumukasa MN, et al. Knowledge, attitudes and perceptions of stroke: a crosssectional survey in rural and urban Uganda. BMC Research Notes 2015;8:819. Baldereschi M, Di Carlo A, Vaccaro C, et al. Promotion implementation of stroke care in Italy project working group. Stroke knowledge in Italy. Neurol Sci. 2015;36: 415-421. Parahoo K, Thompson K, Cooper M, et al. Stroke: awareness of the signs, symptoms and risk factors a population-based survey. Cerebrovasc Dis 2003;16:134-140. Pandian JD, Jaison A, Deepak SS, et al. Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India. Stroke 2005;36:644-648. Kleindorfer D, Kissela B, Schneider A, et al. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: a population-based study. Stroke 2004;35: e27-e29. Carroll C, Hobart J, Fox C, et al. Stroke in Devon: knowledge was good, but action was poor. J Neurol Neurosurg Psychiatry 2004;75:567-571. Kothari R, Sauerbeck L, Jauch E, et al. Patients’ awareness of stroke signs, symptoms, and risk factors. Stroke 1997;28:1871-1875. Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998;279:1288-1292. Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledge of the warning signs and risk factors for stroke. JAMA 2003;289:343-346. S Sug Yoon, F. Heller Richard, Levi C. Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population. Stroke 2001;32: 1926-1930.
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38. Reeves MJ, Rafferty AP, Aranha AAR, et al. Changes in knowledge of stroke risk factors and warning signs among Michigan adults. CED 2008;25:385-391. 39. Croquelois A, Bogousslavsky J. Risk awareness and knowledge of patients with stroke: results of a questionnaire survey 3 months after stroke. J Neurol Neurosurg Psychiatry 2006;77:726-728. 40. Duque AS, Fernandes L, Correia AF, et al. Awareness of stroke risk factors and warning signs and attitude to acute stroke. International Archives of Medicine [Internet]. 2015 [cited 2018 Mar 6]; Available at: http://imed.pub/ojs/index. php/iam/article/view/1236. Accessed March 6, 2018. 41. Sundseth A, Faiz KW, Rønning OM, et al. Factors related to knowledge of stroke symptoms and risk factors in a Norwegian stroke population. J Stroke Cerebrovasc Dis 2014;23:1849-1855. 42. Kim JS, Yoon SS. Perspectives of stroke in persons living in Seoul, South Korea. A Survey of 1000 Subjects. Stroke 1997;28:1165-1169. 43. Mikulík R, Bunt L, Hrdlicka D, et al. Calling 911 in response to stroke: a nationwide study assessing definitive individual behavior. Stroke 2008;39:1844-1849. 44. Segura T, Vega G, L opez S, et al. Public perception of stroke in Spain. Cerebrovasc Dis 2003;16:21-26. 45. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation 2017;135: e146-e603. 46. Nolte CH, Rossnagel K, Jungehuelsing GJ, et al. Gender differences in knowledge of stroke in patients with atrial fibrillation. Prev Med 2005;41:226-231. 47. Das S, Hazra A, Ray BK, et al. Knowledge, attitude, and practice in relation to stroke: A community-based study from Kolkata, West Bengal. India. Ann Indian Acad Neurol 2016;19:221-227. 48. Alaqeel A, AlAmmari A, AlSyefi N, et al. Stroke awareness in the Saudi community living in Riyadh: prompt public health measures must be implemented. J Stroke Cerebrovasc Dis 2014;23:500-504. 49. Lundelin K, Graciani A, García-Puig J, et al. Knowledge of stroke warning symptoms and intended action in response to stroke in Spain: a nationwide populationbased study. CED 2012;34:161-168. 50. Eriksson M, Glader E-L, Norrving B, et al. Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden. Brain Behav 2017;7:e00654.
Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut Hussein Mohammad Khalil, MSc,* and Nathalie Lahoud, PharmD, PhD*,†,‡,§
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. Key Words: Stroke awareness—risk factors—warning signs—cross sectional— Lebanon © 2020 Elsevier Inc. All rights reserved.
Introduction Cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability worldwide.1 Globally, 70% of strokes and 87% of both strokerelated deaths and Disability-Adjusted Life Years occur in
low- and middle-income countries where there may be barriers to stroke care.2 In a 2016 review study, the incidence rate for all strokes in the Middle East ranged between 22.7 and 250 per 100,000 population per year and the prevalence rate ranged between 508 and 777 per 100,000 population.3
From the *Faculty of Pharmacy, Lebanese University, Hadat, Lebanon; †Faculty of Public Health, Lebanese University, Fanar, Lebanon; ‡CERIPH, Center for Research in Public Health, Pharmacoepidemiology Surveillance Unit, Faculty of Public Health, Lebanese University, Fanar, Lebanon; and §INSPECT-LB, Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Faculty of Public Health, Lebanese University, Fanar, Lebanon. Received August 7, 2019; revision received January 27, 2020; accepted January 28, 2020. Funding: None. Address correspondence to Hussein Mohammad Khalil RPH, MSc, Bpharm, MPCP, Faculty of Pharmacy, Lebanese University, Al Saeed Building, 6th floor, Main Street, Doha Aramoun, Choueifat, Lebanon. E-mail: [email protected]. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104716
Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104716
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Lebanon, an upper middle income country of the Middle Eastern region,4 suffers from a paucity of data on the prevalence of stroke. It is assumed that stroke is the second leading cause of mortality in Lebanon (9.4% of all deaths in 2012).4 A recent study revealed stroke prevalence in Lebanon may be higher than other developing countries in the region.5 This is not surprising as the prevalence of noncommunicable diseases in Lebanon is high (36% hypertension, 25% diabetes, 25% dyslipidemia).6,7 What is more, population aging in Lebanon is higher than in any other Arab country.8,9 Lebanon also has the highest smoking rates in the Middle East (up to 37% of the population)10 and a high level of obesity among adults (31%) with a projected increase in the future.11 Stroke is a medical emergency that requires immediate medical attention. Thrombolysis within 4.5 hours of onset of acute ischemic stroke has been shown to be effective in improving prognosis and survival of patients12 and results in subsequent reduction of dependency in activities of daily living.13 The narrow therapeutic window of thrombolysis requires prompt hospital arrival. Alarmingly, the majority of stroke patients fail to attend to the hospital within the treatment window.14 Many factors contribute to delays in seeking treatment for stroke but the principal factor is believed to be a lack of public knowledge regarding stroke symptoms and the need for a rapid response.15,16 In fact, better knowledge of stroke symptoms or risk factors, experience of living with stroke patients or experience of stroke education were significantly associated with stroke recognition and appropriate action by the general public.17 Knowledge of stroke risk factors may also improve primary prevention.18 Persons who perceive their own risk for stroke can promote the intervention of stroke risk factors and reduce their risk of stroke occurrence.19,20 Previous studies have shown that a large proportion of high risk stroke patients are unaware of their risk.15,21-23 Increasing awareness of stroke and its risk factors through public education can improve early recognition, reducing time to treatment and reducing the risk of stroke.24,25 To design effective stroke education strategies an assessment of public knowledge of stroke is required.
Knowledge of stroke risk factors and symptoms in the general population worldwide have been consistently found to be poor,15,18,26 with knowledge levels poorest in groups that have the highest risk of stroke: individuals aged 65 years or older, those of lower socioeconomic status and lower levels of education.15,18 Moreover, it appears that having stroke risk factors in general does not contribute to an increase in stroke knowledge.15 To date, there is no information regarding the pre-existing knowledge of stroke in the Lebanese population. Thus, we conducted a cross-sectional survey to assess the knowledge of stroke symptoms, risk factors, prevention, and early response in case of suspected stroke occurrence, and to identify characteristics associated with better stroke knowledge among people aged 50 and above visiting community pharmacies in the capital of Lebanon, Beirut.
Materials and Methods Subject Sampling A multistage sampling method was used. Twenty pharmacies were randomly selected from a list of all pharmacies in Beirut (235 pharmacies) on the Order of Pharmacists in Lebanon website. The selected pharmacies were then asked for written permission to collect survey data from customers at a suitable date. Pharmacies that refused to participate were excluded from the study and another 1 was randomly selected instead. Older adults of the general public who attended the selected pharmacies were approached by a well-trained investigator to be recruited consecutively (ie, the first 20 eligible participants who agreed to fill the questionnaire from each pharmacy; Fig 1). Sampling was carried out on a variety of days between the months of May and October 2018. Since the risk of stroke morbidity and mortality increase with age, individuals who were 50 years or older were eligible to participate in the study. Those who had a medical degree, were unable to answer questions due to speech difficulties or cognitive impairment, or were not Lebanese were excluded from the study.
Figure 1. Illustration of multistage sampling method.
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This study was waived approval by the ethical review board at the Lebanese University.
Study Design Participants were first given a brief explanation of the study, and verbal consent was obtained before participation. A face-to-face, interview-based questionnaire composed of both open and closed ended questions was used to collect information of stroke awareness and knowledge of stroke, stroke risk factors, stroke symptoms, primary prevention of stroke, immediate actions in response to observation of stroke symptoms, sociodemographic information, and clinical profile. The questionnaire was developed through literature review of stroke awareness and attitude studies.27-29 It was translated into Arabic and tested on 15 subjects who were not included in the study. The final version of the questionnaire comprised of 5 sections. The first section investigated knowledge of stroke, stroke symptoms, and stroke risk factors. Respondents were first asked “what do you understand by the term stroke? (Translated to Sakta dimaghiya in Arabic)”. Answers were recorded as either blood clot in the brain, brain hemorrhage, a condition that affects the brain, does not know, or other. They were then asked to freely recall as many stroke symptoms as they could. The remaining unrecalled symptoms were asked as closed ended questions integrated in a list containing 8 unrelated red herrings where respondents answered with “Yes”, “No”, or “I don’t know”. Eight symptoms or warning signs were considered, they are: dizziness, confusion, headache, problems with vision, slurred speech, weakness on 1 side of the body, facial weakness, and numbness or prickling sensations. The next part of this section was about stroke risk factors, including also an open-ended question asking to list as many as they could, followed closed-ended questions for the unrecalled ones. Twelve risk factors were studied, they are: hypertension, dyslipidemia, diabetes, arrhythmia, obesity, smoking, sedentary lifestyle, previous stroke, heavy alcohol consumption, family history of stroke, stress, and increasing age. Respondents were then asked whether they thought stroke may cause permanent disability or not. In the second section, 2 questions were asked to identify knowledge of primary prevention of stroke. The first question was whether they thought stroke risk could be decreased through certain practices. Respondents who replied with yes were asked to answer a second open ended question asking to name as many treatments or practices that reduce the risk of stroke. The third section of the questionnaire explored knowledge of appropriate actions to take when stroke symptoms are observed. This section included 1 open ended question: “What would you do if you thought that you or someone near you is having a stroke?” The final 2 sections were concerned with respondent sociodemographic and clinical profile. We registered the
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following data: age, gender, marital status, highest level of education obtained, occupation, self-reported height and weight, whether they lived alone, whether they had insurance, whether they have ever known anyone who has had a stroke and who (family member, friend or colleague, or other), and if they have been concerned with the possibility that they might have a stroke in the past 12 months. Presence of the following risk factors of stroke: hypertension, dyslipidemia, diabetes, and smoking (have ever smoked 100 cigarettes in their lifetime and current smoking frequency—everyday, some days, not at all), physical exercise and frequency (rarely, 1-2 times a week, and 3 or more times a week), heart rhythm disorders. Alcohol consumption, previous cerebrovascular disease (Transient Ischemic Attack or ischemic or hemorrhagic stroke), previous myocardial infarction, whether anyone in their immediate family (mother, father, brother, or sister) has ever had a stroke, and whether anyone in their immediate family has ever had a myocardial infarction.
Statistical Analyses To obtain a 95% confidence interval (CI), a minimum sample of 384 participants was needed to allow adequate power for bivariate and multivariate analyses to be carried out. Calculation of sample size was performed using Epi info version 7 (CDC’s Epi InfoTM Version 7.2.2.2 2017) with an expected frequency of 50% to obtain largest sample size and a 5% acceptable margin of error. Data collected were entered and analyzed with the Statistical Package for Social Sciences version 23.0 (SPSS Inc, Chicago, IL). Continuous variables were expressed as mean § standard deviation and 95%CI. Categorical and ordinal variables were expressed as frequencies (n) and percentages (%) of the overall sample. We performed binary logistic regression analyses with forward stepwise selection to determine factors associated with the ability to spontaneously recall 2 or more stroke risk factors, 2 or more warning signs, and activation of emergency medical services in response to acute stroke suspicion. Only variables that showed a P less than .2 in the bivariate analysis were included in the adjusted model. Results were presented as odds ratios (OR) and 95%CI. Statistical tests were 2 tailed and reported statistically significant at P less than .05.
Results A total of 407 participants from 20 different locations completed the questionnaire. Seventeen questionnaires were excluded for incomplete information. Sociodemographic and clinical data are presented in Tables 1 and 2. The study population included 221 Lebanese men (56.7%) and 169 women (43.3%) with an average age of 62 § 7.17 years old. About 67.2 % of the population had completed an educational level of secondary school or higher.
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Of the 390 participants who completed the questionnaire, 232 (59.2%) knew someone who has experienced a stroke. The mean number of stroke risk factors per participant was 3.05 § 1.56. The most prevalent risk factor was hypertension (61%) followed by dyslipidemia (53.1%) and smoking (47.2%). Half of the participants were overweight (47.4%) and a quarter (25.9%) were obese. Almost 3 quarters of the sampled population (74.6 %) said they had heard of the term stroke (Sakta dimaghiya) in the past. Regarding what is understood by stroke, nearly half (44.6%) answered with a correct definition (blood clot in the brain [41%], brain hemorrhage [3.6%]) and 17.9% identified it was a condition affecting the brain but could not state the pathological mechanism. About 37% of the participants did not know the correct definition of stroke. The majority of participants believed stroke can cause disability (92.1%), can be treated (80.5%), and can be prevented (91.5%). Of the 357 responders that believed stroke can be prevented, the most commonly mentioned practices to decrease stroke risk were exercise (53.8%) and diet (37.2%).
Knowledge of Risk Factors (Table 3) The average number of stroke risk factors spontaneously recalled was 1.76 § 1.17 compared with an average of 8.7 § 1.617 when asked to identify risk factors from a list. Of the 12 risk factors considered, 57 participants (14.6%) could not recall any risk factor, 107 (27.4%) could
Table 1. Sociodemographic characteristics of the study participants Independent variables Age (y) mean § SD 95%CI Gender (n, %) Male Female Highest educational level attained (n, %) None Primary Intermediate Secondary University Marital status (n, %) Single Married Divorced Widowed Personally know a stroke patient (n, %) Yes Living Alone (n, %) Yes
Overall sample (n = 390) 62.03 § 7.17 61.32-62.74 221/56.7 169/43.3 16/4.1 48/12.3 64/16.4 138/35.4 124/31.8
Table 2. Clinical profile of study participants Independent variables BMI (n, %) Underweight Normal Overweight Obesity Smoking (n, %) Never smoker Former smoker Current smoker Hypertension (n, %) Dyslipidemia (n, %) Diabetes (n, %) Heart rhythm disorders (n, %) Previous MI (n, %) Family history of MI (n, %) Previous stroke (n, %) Family history of stroke (n, %) Number of risk factors per patient Mean § SD Categories (n, %) 0 Risk factors 1-2 risk factors 3-4 risk factors 5 and above
Overall sample (n = 390) 2/.5 100/25.6 185/47.4 101/25.9 171/43.8 35/9.0 184/47.2 238/61.0 207/53.1 114/29.2 70/17.9 36/9.2 121/31.0 16/4.1 77/19.7 3.05 § 1.56 12/3.1 131/33.6 186/47.7 61/15.6
Abbreviations: BMI, body mass index; MI, myocardial infarction.
name 1 risk factor, and 226 (57.9%) could name at least 2 or more. The most frequently recalled risk factors were hypertension, smoking, and dyslipidemia (48.2%, 20.5%, and 19.5% respectively). Less than half of the participants (43.1%) stated stress as a risk factor for stroke. Participants who had hypertension, dyslipidemia, and diabetes were significantly more able to recall these risk factors than those who did not (Table 4). In the multiple logistic regression analysis,knowing a stroke patient (OR = 1.84, P = .005) and having higher level of education (OR = 2.821 P = .005, OR = 3.101 P < .001, OR = 3.014 P = .001 for intermediate, secondary and university respectively compared with primary) were significantly associated with recall of 2 or more risk factors (Table 6).
Knowledge of Symptoms (Table 3) 19/4.9 305/78.2 20/5.1 46/11.8 232/59.49 42/10.8%
Abbreviations: CI, Confidence interval; SD, standard deviation.
For all of the symptoms, recognition from a list resulted in a much higher percentage than spontaneous recall. The mean number of freely recalled stroke symptoms answered per participant was 1.32 § 1.21 whereas an average 5.81 § 1.43 was obtained from closed ended questions. Of the 8 stroke symptoms considered, almost a third (31.8%) of all of the participants could not spontaneously recall any stroke symptom, 28.1% participants could
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Table 3. Knowledge of stroke risk factors & symptoms Independent Variables
Open ended
Closed ended
Total
Risk Factors (n, %) Hypertension Dyslipidemia Diabetes Arrhythmia Obesity Smoking Sedentary lifestyle Previous stroke Alcohol consumption Family history Stress Ageing
188/48.2 76/19.5 44/11.3 10/2.6 33/8.5 80/20.5 27/6.9 3/0.8 8/2.1 27/6.9 168/43.1 22/5.6
181/46.4 262/67.2 263/67.4 309/79.2 315/80.7 274/70.3 327/83.9 329/84.3 299/76.6 322/82.6 208/53.3 304/78.0
369/94.6 338/86.7 307/78.7 319/81.8 348/89.2 354/90.8 354/90.8 332/85.1 307/78.7 349/89.5 376/96.4 326/83.6
Number of risk factors per participant mean § SD 95%CI Symptoms (n, %) Dizziness/vertigo Headache Visual alterations Slurred speech Hemiparesis Fallen face Paresthesia
1.76 § 1.17 1.64-1.87
8.7 § 1.617 8.54-5.87
10.45 §1.45 10.31-10.6
76/19.5 70/17.9 114/29.2 25/6.4 37/9.5 99/25.4 48/12.3
268/68.7 290/74.4 251/64.4 307/78.7 309/79.2 252/64.6 299/76.7
344/88.2 360/92.3 365/93.6 332/85.1 346/88.7 351/90.0 347/89.0
Number of symptoms per participant mean § SD 95%CI
1.32 § 1.21 1.19-1.44
5.81 § 1.43 5.67-5.96
7.13 § 1.14 7.02-7.25
Abbreviations: CI, confidence interval; SD, standard deviation.
Table 4. Number of participants with a particular risk factor identifying it as such Stroke risk factor
Participants with risk factor identifying it as such (n, %)
Compared with those without risk factor, P value
Hypertension (n = 238) Dyslipidemia (n = 207) Diabetes (n = 114) Smoking (n = 219) Previous stroke (n = 16) Family history (n = 77) Arrhythmia (n = 70) Obesity (n = 101)
126/52.9
.019
51/24.6
.006
22/19.3
.001
43/19.6
.627
0/.8
1
9/11.7
.066
4/5.7
1
10/9.9
.546
name only 1 stroke symptom and 39% could recall 2 or more. The most frequently recalled symptoms were headache, hemiparesis and dizziness (29.2%, 25.4%, and 19.5% respectively). Multiple logistic regression analysis revealed that having a heart rhythm disorder (OR = 1.873, P = .025), knowing a stroke patient (OR = 2.51, P < .001), and having a higher level of education (OR = 2.806 P = .012, OR = 2826 P = .004, OR = 3.403 P = .001 for intermediate, secondary and university respectively compared with primary) are were related to recalling 2 or more symptoms.
Response to stroke suspicion (Table 5) Faced with stroke suspicion, 84.4% of participants recognized the need for immediate medical care (ie, replied with call doctor, take to hospital, or call ambulance). Those who would call an ambulance were 57.7% of the sample, those who would go to the hospital by themselves were 24.9%, and 7% would call a physician. Respondents who would call an ambulance were able to recall and recognize a greater number of symptoms
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Table 5. Respondents reaction to stroke symptom suspicion Action (n, %) Call an ambulance Go to hospital Wait and see Tell someone Self-medication Call doctor Don’t Know
225/57.7 97/24.9 24/6.2 18/4.6 6/1.5 7/1.8 13/3.3
than those who would not (P = .024). Despite a trend for identifying more risk factors in those who would call an ambulance compared to those who would not (10.56 § 1.44 versus 6.99 § 1.21) the difference between the 2 groups was not significant. In the multiple logistic regression analysis (Table 6), identifying more symptoms is positively associated with calling an ambulance (OR = 1.237, P = .021) in response to stroke suspicion and having diabetes is inversely associated with calling an ambulance (OR = .61, P = .03). Finally when asked whether participants had ever been concerned with having a stroke in the past 12 months 214 participants (54.9%) said they had and 176 (45.1%) said they were not.
Discussion To our knowledge, this is the first study conducted in Lebanon to report the current level of familiarity with stroke, its warning signs, risk factors, prevention, and early response actions. The results of this study reveal
that there is a lack of adequate knowledge to effectively identify symptoms of acute stroke and respond accordingly among the Lebanese older adult population in Beirut despite perceiving stroke as a disability causing disease that can be treated and prevented. Three quarters of the participants claimed to have heard of stroke before, and 62.5% were able to correlate stroke with the brain as the affected organ. This result is higher than in previous studies.27-29 However this is likely because of the Arabic translation of stroke (sakta dimaghiya) which is more descriptive. Nearly half of the participants (44.6%) stated the pathological mechanism of stroke and the majority of those answered it is caused by an occlusion of a blood vessel in the brain by a blood clot (41%). This result is lower than a similar study from Ireland (60.3%),30 but higher than that of a study from India (31%).31 The results of the survey indicate levels of symptom and risk factor knowledge obtained through face-to-face interviews is contingent upon the type of the questions administered, such that open-ended questions may underestimate the true level whereas closed-ended ones may highly overestimate them. This discrepancy has been discussed in previous studies.15,26 As a consequence, we have focused the analysis on the open ended questions. Among all the respondents, 85.4% were able to spontaneously recall at least 1 risk factor. Most studies that used open-ended questions reported percentages that range between 40% and 79%.32-39 The most frequently named risk factors in our study were hypertension, smoking, and stress (48.2%, 20.5%, and 43.1% respectively). A number of similar studies have reported these 3 are among the most perceived as stroke risk factors.27,35,38 Interestingly,
Table 6. Predictors of stroke awareness and attitude through multivariate logistic regression Predictors Recall of 2 or more risk factors Knowing a stroke patient Level of education Up to primary Intermediate Secondary University Recall of 2 or more symptoms Having a heart rhythm disorder Knowing a stroke patient Level of education Up to primary Intermediate Secondary University Activation of emergency response system upon stroke suspicion Having diabetes Total number of symptoms identified Abbreviations: CI, confidence interval; OR, odds ratio.
Adjusted OR (95%CI)
P value
1.842 (1.208-2.809)
.005
2.821 (1.366-5.823) 3.101 (1.662-5.786) 3.014 (1.599-5.680)
.002 .005 <.001 .001
1.873 (1.082-3.242) 2.517 (1.611-3.932)
.025 <.001
2.806 (1.251-6.294) 2.826 (1.393-5.734) 3.403 (1.672-6.926)
.008 .012 .004 .001
.610 (.391-.953) 1.237 (1.033-1.481)
.030 .021
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when considering the results of both open-ended and closed-ended questions, diabetes—despite being a welldocumented risk factor of stroke—was the least identified risk factor, having an equal percentage of identification with excess alcohol consumption of 78.7%. Other studies have also reported poor recognition of diabetes as a risk factor for stroke.22,35,38,40 Pancioli35 reported that respondents with a particular risk factor for stroke are likely to mention that factor as a risk for stroke. In this study, respondents who had diabetes (19.3%), hypertension (52%), or dyslipidemia (24.6%) were significantly more able to name those risk factors than participants who did not. Sundseth et al. only41 found a similar association with diabetes only whereas Hickey et al21 could not find any significant difference in identifying a self-reported risk factor. Despite this, only half of those with hypertension and the majority of patients with diabetes or dyslipidemia (19.3% and 24.6%, respectively) could not name these diseases as risk factors for stroke. Awareness of one’s own risk profile is a precondition for risk changing behavior and thus prevention of stroke,23 and the results of our study still show the majority of patients with risk factors for stroke are unaware of their own risk. Our data revealed that 68.2% of the participants were able to spontaneously recall at least 1 stroke symptom compared to 74.2% in a study conducted in Portugal,40 70.7% in Norway,41 68.0% in Oman,22 and 65% in Korea.42 In this study 39.7% were able to recall 2 or more symptoms while other studies have reported higher proportions (Duque et al 68.9%, Mikulk et al 46%,).40,43 Consistent with a similar study in Spain, headache was recalled by 29. Two percent of the participants whereas hemiparesis was recalled by 25.4%.44 This contrasts with a study conducted in the Gulf Cooperation Council countries where hemiparesis was the most frequently recalled stroke warning sign.27 Speech impairment and fallen face were each recalled by 1 in 10 patients. Only 6 participants were able to state these symptoms concomitantly with hemiparesis. In an Australian study, recalling at least 2 of the 3 stroke symptoms, ‘‘limb weakness,’’ ‘‘facial weakness,’’ and ‘‘speech problems,’’ was associated with stroke recognition and showed a trend toward calling for ambulance assistance.17 Our results thereby may reveal a deficit in ability in identifying stroke and immediately activating emergency services. Only 15.6% of the population were able to spontaneously recall one of “numbness, one sided weakness, or facial palsy” with “confusion or slurred speech”. Sundseth et al,41 who used this as a definition for adequate stroke symptom knowledge reported a much higher result (42.9%). Notably, chest pain was recognized as a symptom of stroke from a list by half of the respondents, which could reflect the confusion between stroke and heart attack. This was also noticed in other studies.37 Higher levels of education was a significant predictor of better stroke symptom and risk factor knowledge similar
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to several studies.26,31,35-37,40,41,45 In addition, having a heart rhythm disorder showed positive association with spontaneous recall of 2 or more symptoms. This can be explained by the fact that patients with atrial fibrillation are treated with anticoagulants and may associate their disease with stroke more than others. Nonetheless our results contrast that of a 2005 study that showed no difference in stroke knowledge between those who had atrial fibrillation and those who did not.46 Better knowledge of stroke symptoms and risk factors was related to knowing a stroke victim. A prior study in India showed stroke affected families possess better knowledge about the many symptoms and risk factors of stroke.47 Even though most participants in this study were not able to recall most of the alarming signs and symptoms of stroke, 84.4% of the populace recognized the need for immediate medical care (would call an ambulance, go to hospital, or call doctor). However only 57.7% of the sample would call an ambulance when stroke is suspected which is lower than other studies.36,40,44,48 We found that calling an ambulance was associated with identification of a greater number of symptoms similar to Lundelin et al.49 This suggests that better knowledge of stroke symptoms is related to the decision to call an ambulance. We also found that diabetic participants were less likely to call an ambulance having suspected a stroke. This is alarming considering diabetes is a major risk factor for stroke occurrence. A recent study from Sweden also showed that having diabetes was associated with a lower probability of stroke alert.50 It should be noted however that if participants were asked how they would react to particular symptoms without reference to stroke they might have responded differently.15 Furthermore, some studies have shown a discrepancy between intended behavior in case of stroke suspicion and their actual response in case of a real scenario, and have argued that the calling an ambulance might be related to perceptions on the seriousness and treatability of stroke rather than the level of knowledge (Mikulk et al).43 The strength of the present study was the utilization of both open and closed-ended questions to assess stroke risk factor and symptom knowledge as we believe that neither methods correspond to real knowledge. Another advantage of our study was personal contact between the interviewer and the participants which ensures greater reliability in comprehension of the questionnaire. Our study has encountered several limitations. First, the sampling design does not represent a random sample of all the Lebanese population, as all the participants were sampled from community pharmacies in Beirut. Thus individuals who reside in semiurban and rural areas were not included. There also may be a selection bias and overestimation of stroke knowledge as respondents visiting pharmacies for their medications may be health conscious. All of the participants characteristics were selfreported, thus the extent of truthful answers or verifying
ARTICLE IN PRESS H.M. KHALIL AND N. LAHOUD
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respondent’s claims is not possible in this type of study. This also extends to participants who were yet undiagnosed of a risk factor. Moreover, the exact translation of stroke in Arabic is more descriptive and exact than in English, thus we expect that the level of individuals who identified the pathological mechanism of stroke to be overestimated. Finally, we were not able to utilize the data collected concerning socioeconomic status due to the amount of missing values obtained.
Conclusions Findings from this study demonstrate low to moderate knowledge of stroke symptoms, risk factors, and appropriate actions to take when observing stroke in the older adult population of Beirut, Lebanon. This is alarming considering the rising incidence rate of stroke in Lebanon. Accordingly, culturally tailored awareness campaigns could be implemented at multiple levels to target vulnerable populations at higher risk for stroke and their families. Such campaigns could be developed through universities, institutions, medical care facilities, as well as governmental and nongovernmental organizations. Use of different media methods are required in dissemination of information and raising public knowledge. Additionally, health education messages about stroke symptoms, risk factors, and proper response should be provided for all patients receiving care in chronic disease clinics. This is critical for the future reduction of stroke incidence, morbidity, and mortality. Most important is the need to increase awareness of stroke warning signs and importance of timely activation of emergency medical services upon observing stroke symptoms, as these may contribute to a greater number of patients available for thrombolysis. Further studies are needed to address stroke knowledge in younger age groups, those residing in other cities and rural areas of Lebanon, and patients who have suffered a stroke in the past. Additionally, investigating the level of knowledge among stroke patients and their families who admit to hospital before or after 4.5 hours of stroke occurrence is needed to increase our understanding of what prompts people to call emergency services in real situations.
Conflict of Interest None.
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