INTRODUCTION:

Stroke or brain attack incidence has increased over the past few decades in India; it varies from 44.54 to 150/100000 population from 1960 to 2020¹. It is the 3^rd leading cause of death next to heart diseases and chronic obstructive pulmonary disease. It is the second major cause of death in people after 60 years of age and afflicting over 17 lakhs annually^2,3. In the US, it is still a leading cause of morbidity and mortality where every year >795,000 people have a stroke and about three fourth are new stroke cases, and the rests have a history of the previous stroke. The stroke cases increase by age but can occur at any age. About one-third of patients are hospitalized at less than 65 years of age⁴.

In India, there is a wide variation of the incidence rate of stroke; it differs state-wise in and between rural and urban areas. The crude annual incidence of stroke in Mumbai (four cities), Trivandrum, Ludhiana, Kolkata, Punjab, and West Bengal (12 villages of Baruipur) of India varies from 108 to 172 per 100,000 population. It accounts for a leading cause of death in northeastern states of India⁵. and about 90% of strokes are ischemic stroke³. Hemorrhagic stroke has a higher prevalence in Asian countries than worldwide due to the high prevalence of poorly controlled hypertension, and in India, it accounts for 17.7–32% of all strokes⁶. In a study conducted in Madurai (south India) in 2018, a higher prevalence of ischemic stroke (72.6%) as compared to hemorrhagic stroke (37.4%) and risk increased with age. Males have a comparatively higher prevalence than females^7,8,9Habitat-wise, the prevalence rate of stroke varies from state to state; it is higher among the urban population¹or, similar in Haryana and less in Bengaluru⁷ than the rural population.

Many modifiable factors, such as hypertension, diabetes mellitus, cardiac disease, dyslipidemia, physical inactivity, diet risk score, obesity, alcohol consumption, substance abuse, and smoking, contribute to a 90% risk of stroke.^10-16High blood pressure, hypertension is the major factors causing stroke in 80 percent of cases.^3,4 Age, gender (male), diabetes, hypertension, dyslipidemia, lack of exercise, overweight are associated with a high prevalence of stroke and ischemic stroke, which can be prevented.^17-20

During a stroke event, the patient experiences many warning signs such as trouble in walking, speaking, and understanding, sudden numbness or unilateral weakness/ paralysis of the body or face, sudden blurred or blackened vision in one/both eyes, and sudden severe headache accompanied by dizziness, vomiting, or altered consciousness. During these signs and symptoms, initiating treatment is the critical factor in determining the prognosis. It is a medical emergency; there is a delay in seeking medical attention, the greater the chance of brain damage and disability. It is best to approach a stroke facility within 60 minutes of first symptoms or within 3 hours of onset to maximize the effectiveness of treatment³. Despite recent advances in stroke therapy, many patients do not receive treatment due to delays in seeking medical treatment, lack of centers offering thrombolytic therapy, or lack of knowledge regarding risk factors (RFs) and warning signs and the importance of timeframe treatment of stroke. Each in developed countries such as the USA, UK, Spain, etc., and systematic reviews revealed a lack of knowledge among participants about stroke warning signs and risk factors^21-24. In a population-based study conducted in Zaragoza (Spain), more than half of subjects (63.5%) did not know any symptoms of stroke, nearly half of (48%) were not aware of any vascular risk factor 56% act appropriately²¹.

Strokes and their long-term neurological disabilities can be prevented or minimized by managing risk factors, identifying warning signs, and immediately seek medical care following the onset of stroke symptoms. Effective early treatment strategies require prompt admission to the hospital, which could be delayed for several reasons, including poor awareness of risk factors, warning signs of stroke, and a sense of urgency for treatment among people. The American Heart Association, National Stroke Association, the National Institute of Neurological Disorders and Stroke, and major Health Organizations have emphasized educating people regarding risk factors and warning signs of stroke and golden hours of seeking medical attention. A study conducted in Sweden also highlights that knowledge about stroke warning signs can reduce delayed hospital arrival²⁵. Many organizations use various media, including television, video, educational print materials, and organizing health melas to disseminate their messages.

OBJECTIVES OF THE STUDY:

· To assess the knowledge of risk factors, warning signs, and immediate response to stroke among patients attending the general outpatient department (OPD)

· To determine the relationship of participants' knowledge with their selected socio-demographic and clinical variables.

MATERIALS AND METHODS:

Study design, setting, and participants:

It is a cross-sectional hospital-based study carried out among the patients attending general OPD in a multispecialty hospital of Mohali (Punjab). A total of 200 patients attending OPD, aged ≥ 18 years, irrespective of gender and diagnosis, consented to participate were selected consecutively from the registration list used as a sampling frame. The seriously ill patients and children were excluded from the study.

Data collection tools:

Data were collected using a pre-designed pretested interview schedule which had five parts:

i. Socio-demographic characteristics: Age, gender, education, occupation, religion, marital status, habitat, and annual income.

ii. Clinical characteristics: It includes a history of chronic disease, family history of stroke/TIA, and source of information about stroke. Blood pressure, height, and weight record. The automatic sphygmomanometer was used to measure blood pressure. The stadiometer for height measurement and weighing machine for measuring weight.

iii. Knowledge questionnaire on stroke risk factors (RFs): It had 13 questions on well-established risk factors in 'yes,' 'no,' and 'don't know.'

iv. Knowledge questionnaire on stroke warning signs: It had five warning signs: sudden numbness/ weakness (arm, face, legs) especially unilateral, confusion and slurring speech; visual disturbances, dizziness and sudden difficulty in walking; and sudden severe headache without any cause, in 'yes,' 'no,' and 'don't know.'

v. Knowledge questionnaire on immediate response following stroke onset: It includes five semi-structured questions about the place to take a person after stroke onset, call the ambulance, an appropriate time to shift the patient and its importance from a treatment point of view, stroke facility, and thrombolytic therapy.

Interpretation of blood pressure staging (based on the American Heart Association):

Blood pressure staging	Systolic (mm Hg) Diastolic (mm Hg)
Low blood pressure (Hypotension):	< 80 or <60
Normal blood pressure:	80-120 and 60-80
Prehypertension:	120-139 or 80-89
High blood pressure (Hypertension stage 1):	140-159 or 90-99
High blood pressure (Hypertension stage 2):	≥160 or ≥ 100
High blood pressure (Hypertension stage 3) :	>180 or >110

Obesity classification based on BMI (Kg/m²):

It is calculated considering the height and weight and classified as:

1. Underweight: < 18.5

2. Normal range: 18.5-24.9

3. Overweight: ≥ 25.0

4. Preobese: 25.0-29.0

5. Obese: ≥30.0 :

· Obese class I: 30.0-34.9

· Obese class II: 35.0-39.9

· Obese class III: ≥ 40.0

Criteria for grading knowledge level of stroke risk factors (RFs):

1. Very good: Participants who identify 'hypertension' and 'dyslipidemia' as risk factors

2. Good: Those who identify 'hypertension' or 'dyslipidemia,' and any three well-established risk factors

3. Average: Those who identified two risk factors excluding 'hypertension' and 'dyslipidemia.'

4. Poor: Those who identified one or no risk factors other than hypertension and 'dyslipidemia.

Criteria for grading knowledge level of stroke warning signs:

1. Very good: The participants who identify 'sudden numbness or weakness and any other warning signs of stroke

2. Good: Those who identify 'sudden numbness or weakness on one side.'

3. Average: Those who identify 'any two well-established warning signs of stroke excluding 'sudden numbness or weakness.'

4. Poor: Those who identify 'one or no known warning signs excluding 'sudden numbness or weakness.'

The tools were prepared using the inductive (feedback from eight experts) and deductive (literature review) approaches and are pretested by conducting a pilot study on 20 patients (10% of sample size). Language experts translated the questionnaires in Hindi and Punjabi for their appropriateness and then back to English. Tools were checked for understanding during pretesting, and reliability was computed using Cronbach's α. The measured value of Cronbach's α was 0.86.

Data collection procedure:

Before data collection, ethical clearance was sought from the Institute Ethical Committee, and permission was taken from the hospital CEO and nursing superintendent. Data were gathered in general OPD from the eligible patients. Anonymity and confidentiality of data were maintained. Each participant's blood pressure, height, and weight were measured after filling socio-demographic sheet. All the collected data were documented in the prepared proforma. After gathering information, the participants were given the educational leaflets on critical factors in stroke prevention and think acronym 'FAST' (Face: drooping, Arm: weakness, Speech: slurring, and Time: rush to stroke ready hospital) to recognize a stroke and respond immediately; though it was not a part of the study.

Data processing and statistical analysis:

Data was checked for its completeness. Blood pressure staging was done as per American Heart Association, and obesity is calculated by height and weight of patients based on BMI. Data was exported to and analyzed using the SPSS-22 version. Descriptive statistics were used to describe categorical variables of study subjects' characteristics and study variables. Fisher Exact and c²were used to determine the association of study variables with selected socio-demographic and clinical aspects.

RESULTS:

Participants' demographic and clinical characteristics:

Of 200 subjects, over half (59%) were below 45 years of age with a mean age of 41.75±16.01 years. The majority (60.0%) were males, and 71.0% were married. Slightly less than one-third (31.5%) were Sikh, and 22.5% were Hindu. Over half (52.2%) belong to the urban/semi-urban area, and nearly two-thirds (64.5%) were from a nuclear family. Out of 200, over half (50.5%) had an education level of higher secondary and above, and only a few (19.5%) were without any formal education or educated up to primary level. The majority (60.5%) were employed in private and government jobs, and only 11.5% were housewives/unemployed. Less than half (47.5%) had a family income of more than two lakhs, and only a few (7.5%) had Rs. ≤50,000/- annually.

Only 17.5% had chronic diseases, and most of them (87.5%) had no family history of stroke/TIA. Only 25% heard about the stroke, and relatives, newspapers, television, and health professionals were the primary source of information.

More than half of the subjects (57.0%) had normal Blood Pressure (BP), 22.5% were pre-hypertensive with blood pressure 120-139mm Hg (systolic) or 80-89mm Hg (diastolic). Only 13.5% were in the hypertensive stage-I with blood pressure 140-159mm Hg (systolic) or 90-99 mm Hg (diastolic). Rests 9.0% were in the hypertensive stage-II with blood pressure ≥160mm of Hg systolic or ≥ 110 mm of Hg (diastolic).

As per BMI, over half (52.2%) were under the normal BMI (18.5-24.9Kg/m²) category. Less than one-fourth (21.0%) were pre-obese (BMI 25.0-29.9Kg/m²), and almost the same number (21.5%) were underweight (BMI <18.5Kg/m²). Only a few (5.0%) were obese (≥ 30.0 Kg/m²), of which 3.5% were obese class I (BMI≥ 30.0 - 34.9Kg/m²), 0.5% obese class II (BMI≥ 35.0 - 39.9Kg/m²), and 1.0% obese class III (BMI≥ 40Kg/m²).

Participants' knowledge regarding risk factors of stroke:

Based on grading criteria, less than half (43%) participants had 'very-good knowledge; they could identify hypertension and high cholesterol level as critical stroke risk factors. Almost the same number of study participants (43.5%) had a good understanding as they could locate either hypertension or high cholesterol level and other three well-established stroke risk factors. A few (13%) had an average knowledge as they could pinpoint only two risk factors, excluding hypertension and high cholesterol level. Only one participant (0.5%) had poor knowledge as was unaware of any risk factor (Figure 1).

Fig. 1: Knowledge level of participants regarding risk factors of strokes (N=200)

Risk factor-wise, the maximum participants (77.0%) identified hypertension as the most common stroke risk factor, and overweight was the least identified (25%) risk factor. Nearly three-fourths of participants (73%) considered excessive alcohol consumption, over half (57.0%) identified previous stroke/TIA as another stroke risk factor. Other significant risk factors, high cholesterol level, and family history of stroke/TIA, were identified by 54.5% and 54.0%, respectively. Smoking as a risk factor was considered by half of the participants (50.0%). Whereas heart disease (47.5%), physical inactivity (47.5%), diabetes mellitus (46.0%), stress (45.0%), increasing age (40.5%), gender (35.0%), and overweight (25.0%) were the least commonly risk factors recognized for stroke (Table 1).

Table 1: Risk factor wise stroke knowledge of participants (N=200)

Stroke risk factor	f	% age
Hypertension	154	77.0
Excessive alcohol	147	73.5
Previous history of stroke/TIA	114	57.0
High cholesterol level	109	54.5
Family history of stroke/TIA	108	54.0
Smoking	100	50.0
Heart disease	95	47.5
Physical inactivity	95	47.5
Diabetes mellitus	92	46.0
Stress	90	45.0
Advanced age	81	40.5
Gender (Male)	70	35.0
Poor eating	50	25.0

Participants' knowledge regarding stroke warning signs:

Most participants (92.5%) had poor knowledge of any warning sign. A few (7.0%) had an average understanding of identifying only two warning signs, excluding sudden numbness/weakness. Only one participant (0.5%) had 'very good/perfect knowledge as could locate unilateral sudden numbness or weakness, including other warning signs' (Figure 2).

Fig. 2: Knowledge level of participants regarding warning signs of strokes (N=200)

Overall, 17.0% of participants recognized 'confusion and slurred speech are the primary warning signs of stroke, and 12.5% identified sudden severe headaches with no cause. Less than one-eighth of participants considered vision disturbances (11.5%) and 'dizziness and sudden difficulty in walking (11.0%). Only one participant (.05%) identified 'sudden numbness or weakness of one side of the body as the warning sign of stroke (Table 2).

Table 2: Warning signs wise stroke knowledge of participants (N=200)

Warning sign	f	% age
Sudden numbness or unilateral weakness of the body	1	0.5
Confusion and sudden slurred speech	34	17.0
Vision disturbance in one or both eyes	23	11.5
Dizziness and sudden difficulty in walking	22	11.0
Sudden severe headache with no cause	25	12.5

Participants' knowledge about immediate response following acute stroke:

Asking the participants if s/he will notice that someone else or you have signs of acute stroke, what will be your immediate action/response? All participants answered that they would call an ambulance or take patients to the hospital emergency outpatient department within 72 hours and give first aid. No one was sure about the exact timeline and importance of seeking medical assistance within 0-4.5 hours, and also not aware of stroke facility hospitals and thrombolytic treatment.

Association of participants' knowledge regarding stroke risk factors and warning signs with selected socio-demographic and clinical variables:

The data revealed no association between participants' knowledge of stroke risk factors and warning signs with selected socio-demographic, clinical, and source of information variables (p>.05).

DISCUSSION:

Acute stroke is a primary cause of disability and mortality. To reduce the risk factors of stroke and seek timely medical attention after the onset of stroke both depend on people's knowledge about the stroke risk factors, warning signs, and early response to acute stroke. The present study aims to assess the baseline knowledge of stroke risk factors, warning signs, and immediate response among selected patients attending the general outpatient department and determine the association of patients' knowledge with their selected socio-demographic and clinical variables.

Risk factors:

In the present study, hypertension was identified as the most common stroke risk factor (77%), followed by excessive alcohol consumption (73%), previous stroke/TIA (57.0%), and overweight (25%) was least identified. Nearly similar findings were documented from Utter Pradesh (India), where almost 80% were aware that hypertension is the most common risk factor of stroke²⁶. In contrast, nearly or less than half of participants knew it in studies reported from New Delhi, North India, and Assam^27--29 and 67.49% and 67.6% from the study from Spain and Italyrespectively^22,30.

In contrast, to present study findings, a study from the Australian urban population reported smoking (39.4%) and stress (33.7%) as the most common risk factor of stroke³¹. In a study from Iran, 65.9% identified stress as the most common risk factor, followed by hypertension (38.3%), diabetes (16.2%), and other factors³². Nearly half of the subjects (47.5%) in this study identified physical inactivity as a risk factor. In contrast, a higher response was reported in a study from Ethiopia (61.7%)²³ and inadequate response from Iran (1.1%)and Northwest Ethiopia (21.58%)^32,33.

Based on grading criteria, less than half (43%) participants had 'very good/perfect knowledge, (43.5%) had a good understanding, and only a few (13%) had average knowledge about stroke risk factors. Only one participant (0.5%) had poor knowledge as was unaware of any risk factor. On the contrary, Chhabra et al., 2019 from North India reported that 28.85% of the study participants were unaware of the risk factors¹⁷. Melak et al. (2021), in a systematic review of 42 articles, reported overall knowledge of stroke was ranging from 4.4% to 79%²⁴. Koushal et al reported 15.4% of stroke patients and 25.9% of high-risk patients had excellent knowledge of risk factors³⁴.The range of risk factor knowledge was 10.5% to 86.6%. Participants' knowledge in this study is higher than reported from Northwest Ethiopia (18.3% and 77% subjects were unaware of any risk factor), Zaragoza (48%), and Iran (20.2%)^33,21,32. In Ethiopia, only 45.81% had adequate knowledge of stroke risk factors.²³A study from Australia documented that 76.2% of subjects were able to identify ≥one established stroke risk factor.³¹

Warning signs:

In the current study, only one participant (0.5%) had 'very good/perfect knowledge and could locate sudden numbness or weakness of one side of the body, including other warning signs. 92.5% had poor knowledge of any warning sign, and 7.0% had an average understanding of identifying only two warning signs, excluding sudden numbness/weakness. Stroke knowledge of the signs/symptoms varied from 23.6% to 87%, and 15% to 77% of subjects were unaware of any sign of stroke.²⁴ In contrast, a study conducted by Chhabra et al. (2019) from North India reported 46% of the participants^27,and from Assam (India), 45.9% were unaware of warning signs of stroke.²⁹

Koushal reported 18.9% of stroke patients and 26.4% of high-risk patients had excellent knowledge of warning signs³⁴.

Studies from other countries also documented a poor knowledge of participants towards stroke warning signs. A survey from Northwest Ethiopia and Zaragoza reported 72.3% and 63.5%, respectively^33,21 and 71.2% could not identify warning signs from Iran.³² Whereas from Ethiopia, only 20.26% did not know at least one warning sign of a stroke²³, and from Italy, 43.5% of participants could list >1 warning sign.³⁰

Our study's most common warning signs were 'confusion and slurred speech identified by 17.0%, and 'sudden numbness or weakness of one side of the body was identified by only one participant (.05%). Whereas, most subjects in other countries identified ' Sudden numbness or tingling sensation' as the most common warning sign of stroke, identified by 68.7% in Italy³⁰, 62.6% in another part of Ethiopia²³ and 66.73% in Spain, followed by 'speech/language disturbance (58.98%)³², 35.97% and 15.2% participants in Northwest Ethiopia and Iran respectively.^33,32 Nearly or more than two-thirds of Assam (64.1%) identified sudden problems with walking and loss of balance²⁹and from New Delhi identified sudden numbness/weakness of legs (68.9%) and arms (68.4%).²⁸

Immediate response to acute stroke:

In our study, all participants stated that they would seek medical attention, take patients to a hospital within 72 hours after giving first aid, and call an ambulance to shift the patient to the hospital's emergency unit. In comparison, more than half of subjects (53.2%) from Kerala and 30.6% from North India would call to ambulance 108 emergency services^35,17 and 30.6% reported that they would take the patient to the hospital immediately, and only a few reported (4.6%) that they would not do anything²⁷. Study findings from Spain (26.46%), Italy (59%), and Iran (59%) reported that they would immediately seek assistance and would call ambulance/emergency medical services in the event of a stroke^22,32-33.

Our study participants were unsure about the timeline/window period of thrombolytic therapy (0-4.5 hours) and its importance. In comparison, very few participants in New Delhi (11.2% including stroke survivals and high-risk patients) and 21.43% in North India knew about the golden period (within three hours)/correct window period of thrombolytic therapy.^{28, 27}In contrast study conducted by Koushal et al reported 73% of stroke patients and 77% high risk patients were aware that stroke treatment should be started within 3 hours³⁴.

Further, no one was aware of stroke facility hospitals and thrombolytic treatment in the current study. In a study from Italy, 26.2% of participants and from Iran, only 1.1% participants were aware of thrombolytic therapy (tPA) as a first-line drug for stroke treatment.^30,32

Association with socio-demographics and clinical variables:

In the current study, no statistically significant association was observed between knowledge of stroke risk factors and warning signs with socio-demographic and clinical variables. Similar findings were reported by Raul et al. (2020) except with the source of information.²² In contrast, other studies reported a significant association between participants' knowledge of stroke risk factors with the culture²¹, young age^21,23,33, lower education level, and having sufficient monthly income³³, a higher education level^23,36, with the advanced age^32,36, and with a higher socioeconomic position (SEP)³⁷.

CONCLUSIONS:

Most patients have better knowledge about risk factors. Still, they lack warning signs and immediate response to stroke irrespective of their socioeconomic, clinical, and source of receiving stroke-related information. Therefore, the public needs to educate about stroke using intensive educational strategies. The hospital must galvanize the effort to disseminate stroke-related information by displaying/distributing printed leaflets or pamphlets during the waiting time to the public visiting OPD. Nursing staff must organize and conduct education sessions in OPD. Further community-based stroke awareness studies are required to identify ongoing community-based strategies to enhance their knowledge.

CONFLICT OF INTEREST:

The author declares no conflict of interest.

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Received on 26.10.2021 Modified on 31.01.2022

Int. J. Nur. Edu. and Research. 2022; 10(4):385-391.

DOI: 10.52711/2454-2660.2022.00087