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(Stroke. 1997;28:1871-1875.)
© 1997 American Heart Association, Inc.

Articles

Patients' Awareness of Stroke Signs, Symptoms, and Risk Factors

Rashmi Kothari, MD; Laura Sauerbeck, RN, BSN; Edward Jauch, MD, MS; Joseph Broderick, MD; Thomas Brott, MD; Jane Khoury, MS; Tiepu Liu, MD, DrPH

From the Departments of Emergency Medicine (R.K., E.J., T.L.), Neurology (L.S., J.B., T.B), and Environmental Health (J.K.), University of Cincinnati (Ohio) Medical Center.

Correspondence to Rashmi Kothari, MD, Department of Emergency Medicine, University of Cincinnati, PO Box 670769, Cincinnati, OH 45267-0769. E-mail rashmikant.kothari{at}uc.edu

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose We sought to determine knowledge at the time of symptom onset regarding the signs, symptoms, and risk factors of stroke in patients presenting to the emergency department with potential stroke.

Methods Patients admitted from the emergency department with possible stroke were identified prospectively. A standardized, structured interview with open-ended questions was performed within 48 hours of symptom onset to assess patients' knowledge base concerning stroke signs, symptoms, and risk factors.

Results Of the 174 eligible patients, 163 patients were able to respond to the interview questions. Of these 163 patients, 39% (63) did not know a single sign or symptom of stroke. Unilateral weakness (26%) and numbness (22%) were the most frequently noted symptoms. Patients aged 65 years were less likely to know a sign or symptom of stroke than those aged <65 years (percentage not knowing a single sign or symptom, 47% versus 28%, P=.016). Similarly, 43% of patients did not know a single risk factor for stroke. The elderly were less likely to know a risk factor than their younger counterparts.

Conclusions Almost 40% of patients admitted with a possible stroke did not know the signs, symptoms, or risk factor of a stroke. Further public education is needed to increase awareness of the warning signs and risk factors of stroke.

Key Words: health education • risk factors • stroke, acute

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Recombinant tissue plasminogen activator has been shown to improve neurological outcome if given within 3 hours of symptom onset in patients with acute ischemic stroke.¹ Delay to presentation continues to be the primary cause of patient exclusion from interventional thrombolytic stroke trials.² Investigators stress the need for early symptom recognition and intervention if thrombolytic therapy is to be effective.¹ As in myocardial infarction, delays from symptom onset to decision to seek medical attention are the most significant causes of delay in patients with stroke.^{3 4} Recent educational campaigns have focused on educating the general public regarding the signs, symptoms, and risk factors of cerebrovascular disease in the hopes of improving early recognition, reducing time to treatment, and reducing the risk of stroke. Designing effective future programs relies on an accurate assessment of a population's prior knowledge base. The goal of this prospective study was to determine baseline knowledge regarding the signs, symptoms, and risk factors of stroke in patients presenting to the emergency department (ED) with this disease.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This was a prospective study of patients admitted to the hospital with an ED diagnosis of stroke. Patients were recruited from a university hospital and three community hospitals. This protocol was approved by Institutional Review Boards at all four hospitals. We identified patients by reviewing the ED admission logs and contacting the neurologists' offices on a daily basis. Inclusion criteria consisted of an ED admission for stroke, transient ischemic attack, intracerebral hemorrhage, or subarachnoid hemorrhage. Patients who were unable to participate due to speech difficulties or an impaired mental status were excluded from analysis. The study was explained to the patient and/or the legal guardian by a study investigator, and informed consent was obtained. To minimize in-hospital stroke education, an attempt was made to interview all patients as soon after their admission as possible (preferably within 12 hours, but no later than 48 hours after admission). A standardized, structured interview with open-ended questions was conducted by one of two stroke research nurses on a sample of patients.

Information regarding patients' knowledge of the signs, symptoms, and risk factors for stroke and heart disease were obtained from the patient. Demographic characteristics, time from symptom onset to ED arrival, past medical history, and baseline neurological examination results were obtained from their medical record.

Descriptive and comparative statistical analyses were performed with the use of the statistical program SAS. Means, standard deviations, medians, and ranges were presented for continuous variables. Fisher's exact and ² tests were performed to compare differences in knowledge base between groups. The Wilcoxon test was used to compare differences in ED arrival times among groups.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Of the 174 eligible patients, 163 were able to respond to the interview questions, and these constitute the study population (Table 1). The study population included 38 patients who, although noted to have an altered mental status or to be aphasic on their ED record, were able to complete the interview. The demographic profile of the study population is similar to that of the city of Cincinnati in terms of race and sex, but a smaller proportion of the study population completed high school compared with the city population (42% versus 70%, P<.001), and 68% had an annual income of less than $10 000 (annual per capita income for the city of Cincinnati=$15 354).

View this table: [in this window] [in a new window]   Table 1. Patient Demographics (n=163)

Of the 163 patients, 22 (14%) had a final hospital discharge diagnosis other than stroke. Data from these 22 patients were included in the analysis of the knowledge base of signs, symptoms, and risk factors for stroke but were not included in analysis of presenting signs and symptoms. These nonstroke diagnoses included dizziness/ataxia (4), seizure (4), dysarthria not otherwise specified (NOS) (2), numbness NOS, syncope, migraine headache, anxiety, subdural hematoma, visual disturbances NOS, hepatic encephalopathy, alcoholic amnesic syndrome, acute poliomyelitis, soft tissue pain NOS, dementia, and other brain condition NOS. These nonstroke patients were similar to those with a final diagnosis of stroke in terms of age, race, and sex.

Signs and Symptoms
Of the 163 potential stroke patients, 58 (36%) thought they might be having a stroke before ED arrival. Of the 88 patients who were asked, "What part of the body is injured during a stroke?" 43 (49%) realized that a stroke was due to an injury to the brain. When asked to name the signs and symptoms of a stroke, 63 (39%) of the 163 patients could not identify a single sign or symptom of stroke. There was no difference in this variable between those with a final hospital discharge diagnosis of stroke (56 of 141, 40%) versus nonstroke (7 of 22, 32%) (P=.38). As might be expected, those who were able to name the signs and symptoms of a stroke were more likely to know they were having a stroke at onset (44 of 100, 44%) than those who knew no warning signs (14 of 63, 22%) (P=.005). Our patient population was equally lacking in knowledge of the warning signs of a heart attack. Forty-one percent of patients did not know the warning signs of a heart attack. Those who knew the symptoms of a heart attack were significantly more likely to know the symptoms of a stroke (75% versus 42%, P<.001).

Patients aged 65 years or older, the group at most risk, were less likely to know the signs and symptoms of a stroke than those under age 65 years (percentage not knowing a single sign or symptom, 47% versus 28%, P=.016; Fig 1). There was no significant difference in terms of race, sex, education, income, or final discharge diagnosis of stroke between those who did not know any warning signs for stroke and those that knew one or more. Among stroke patients, those with right hemispheric findings were more likely to know a sign or symptom of a stroke than those with left hemispheric findings, but the difference was not significant (percentage knowing a sign or symptom, 65% versus 49%, P=.1).

View larger version (72K): [in this window] [in a new window]   Figure 1. Number of signs and symptoms known by patients admitted with a diagnosis of stroke aged 65 years versus those aged <65 years.

Unilateral weakness, numbness, and speech abnormality were the most common symptoms recognized as warning signs of stroke by our study population (Table 2). Among patients with a final diagnosis of stroke (n=141), unilateral weakness was the most common initial symptom at stroke onset noted by the patient (Table 3). Those patients with unilateral weakness as a presenting symptom were no more likely to identify unilateral weakness as a sign or symptom of a stroke than those who did not have this finding. Interestingly, when asked to recall all the signs and symptoms that they had, difficulty walking was the most frequently reported (49 of 141, 35%).

View this table: [in this window] [in a new window]   Table 2. Patients' Knowledge Base Regarding the Signs and Symptoms of Stroke

View this table: [in this window] [in a new window]   Table 3. Signs and Symptom of Patients With Final Diagnosis of Stroke or Transient Ischemic Attack (n=141)

Risk Factors
The patients' knowledge base regarding the risk factors for stroke was no better than that for the signs and symptoms. Seventy patients (43%) did not know a single risk factor for stroke (Table 4). Only 43 (26%) could identify more than one risk factor. Hypertension was the most commonly identified risk factor. However, even in the 124 patients with a history of hypertension, only 39 (31%) identified hypertension as a risk factor. Again, those patients aged 65 years or older were significantly less likely to know a risk factor for stroke than those younger than 65 years (percentage not knowing a single risk factor, 58% versus 24%, P=.001). There was no significant difference in terms of race, sex, education, income, or final discharge diagnosis of stroke between those who did not know any risk factors for stroke and those who knew at least one risk factor.

View this table: [in this window] [in a new window]   Table 4. Patients' Knowledge Base of Stroke Risk Factors

When asked what their primary source of stroke information, 41% could not recall or did not know. Among those that could recall, having friends and family who had strokes was the most common primary source of stroke information (Fig 2). Only 2% of patients reported that their physician was their primary source of information regarding stroke.

View larger version (48K): [in this window] [in a new window]   Figure 2. Primary source of information regarding signs, symptoms, and risk factors for stroke in patients admitted with a potential stroke.

Time to ED Presentation
For those patients with a time of onset recorded in the ED (n=125), the median time to presentation was 6.2 hours (range, 0 to 342.8 hours; interquartile range, 19.5). Of these 125 patients, 44 (35%) presented promptly to the ED (within 3 hours of symptom onset). Interestingly, level of stroke knowledge had no notable impact on prompt ED arrival. There was no significant difference in ED arrival within 3 hours between those who knew a sign, symptom, or risk factor of stroke and those who did not (P>.05). Those transported to the hospital by 911 were more likely to arrive to the ED within 3 hours of symptom onset than those transported by private car (47% versus 19%, P=.001). There was no difference in 911 use between those who knew they were having a stroke and those who did not.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In light of recent Food and Drug Administration approval of tissue plasminogen activator in the treatment of acute ischemic stroke, there has been a concerted effort to educate the general public about stroke. The American Heart Association, the National Stroke Association, the National Institute of Neurological Disorders and Stroke, and other major health organizations have emphasized educating the public regarding the signs, symptoms, and risk factors for stroke. These organizations have used various media including television, video, newsprint, educational pamphlets, and health seminars to disseminate their message. To date, though, there is very little information regarding the preexisting knowledge base of stroke patients regarding these issues. Collecting baseline data about patients' stroke knowledge can help these organizations to determine the effectiveness of their programs and to adjust them to target specific populations and emphasize particular facts.

Despite current educational campaigns, public knowledge regarding the signs, symptoms, and risk factors of stroke is inadequate. Previous surveys of the general public suggest that up to 27% of the adult population do not know a single sign or symptom of a stroke and up to 25% do not know a single risk factor.^{5 6} This number is even larger in those patients who have actually had a stroke. Immediately after having an acute stroke, 43% of our acute stroke patients did not know a single sign or symptom of a stroke. In our study the lack of information appeared to be related to age, with older patients (those patients at highest risk for stroke) the least knowledgeable. Williams et al⁷ found that 62% of their stroke patients did not know the signs of a stroke. They did not report on the relationship between stroke knowledge base and age or other demographic factors. In our study the elderly were almost 70% (odds ratio=1.68) less likely to be able to recall a sign or symptom of a stroke and almost 2.5 times (odds ratio=2.4) less likely to recall a risk factor than their younger counterparts. This lack of stroke knowledge was independent of race, sex, income or level of education.

Educational programs regarding stroke warning signs list signs and symptoms of stroke. These lists often include weakness, numbness, speech abnormalities, dizziness, and loss of vision, with equal emphasis on each. Research suggests that short, simple, and repetitive messages that focus on two to three points are the most effective.⁸ With stroke, the message should focus on a few, easily identifiable, common symptoms that are specific for stroke. The stroke databases have reported that hemiparesis, paresthesia, and speech abnormalities are the most common neurological abnormalities occurring in patients with ischemic stroke.^{9 10} Similar results were found in our study. Although "weakness (unilateral)" was the most commonly recognized symptom of stroke in our population, only 26% of our patients noted it. Similarly, in a telephone survey of the Greater Cincinnati Metropolitan Area, only 15% of the general public reported "weakness" and only 6% reported "one-sided weakness" as a sign of stroke.⁵ Thus, the initial message should communicate that "the sudden onset of one-sided weakness, numbness, or problems speaking may mean you are having a stroke."

The discrepancy in stroke knowledge between the general public and actual stroke patients may be due to differences in study populations or may be due to cognitive deficits of the acute brain insult in the latter population. In our sample 11 patients were so severely afflicted that they could not complete the interview. Another 38 patients were noted to have altered mental status or aphasia on arrival to the ED but were alert enough at the time of interview to complete the survey. There was a trend toward patients with right hemispheric findings being better able to recall symptoms of stroke than those with left hemispheric findings (P=.1). A larger sample size could find differences in stroke knowledge based on stroke subtype or location. Important determinants of what a patient does at stroke onset may be dependent on what they are able to recall at the time of their stroke rather than what they knew before their stroke. This further emphasizes the need for a simple and consistent educational message that can be easily remembered.

Educational efforts aimed at the general public have focused on early recognition of stroke warning signs in the hopes of reducing time to ED evaluation. We found that those patients who recognized that they might be having a stroke did not arrive at the ED any sooner than those who did not recognize they were having a stroke. This may be due to the fact that the patient did not perceive their condition as an "emergency" or due to their choice of initial medical contact. The Gallup Poll of the general public found that 90% of respondents would seek medical attention if they experienced symptoms of a stroke. However, whom they would contact varied greatly. Of the 750 respondents, only 43% reported that they would call 911 if they thought they were having a stroke. Twenty-six percent of respondents would contact their primary physician, and 11% would go directly to the ED. Williams et al⁷ found that ambulance transport was independently associated with early arrival. Barsan et al³ found that patients who initially contacted 911 arrived to the hospital almost 3 hours sooner than those who contacted their private physician first or those who came directly to the ED by private car. Similarly, in our study those patients who used 911 were more likely to arrive at the hospital within 3 hours of symptom onset than those who arrived by private car (47% versus 19%, P<.001). Unfortunately, patients who thought they were having a stroke before their arrival at the hospital were no more likely to use 911 than those who did not know they were having a stroke. Educational campaigns must not only stress the symptoms of stroke but also the proper response: "If you are having any of the symptoms of a stroke, call 911 immediately!"

Subsequent educational messages may need to be varied based on the audiences' demographics. The elderly need greater emphasis on the symptoms of stroke. However, there may be differences based on other factors such as race. Blacks consistently had less knowledge regarding signs and symptoms than whites (Table 2) but had a somewhat similar level of knowledge regarding stroke risk factors. This suggests that we may be reaching that population in regard to risk factors education but not in regard to signs and symptoms.

Medical professionals must play a greater role in educating the public about stroke. Currently, only 2% of patients viewed their physicians as their primary source of stroke knowledge. Patients with stroke risk factors can be identified by their private family physician. The patient and their families could be educated by the physician or nursing staff regarding ways to modify their stroke risk factors, the symptoms of a stroke, and the appropriate response if they are having the symptoms of a stroke. This education can be done in person or by video and print materials that are already available through various health organizations. A similar approach could be implemented by pharmacies dispensing medications for hypertension, diabetes, and other illnesses associated with stroke.

The majority of patients rely on personal or family history as their primary source of stroke knowledge. These interpersonal contacts can be a very effective means of disseminating medical information.^{8 11 12} Ensuring the retention of simple and accurate information regarding cerebrovascular disease in patients and families as they go through stroke rehabilitation may be an effective means of disseminating this information to the general public.

In conclusion, almost 40% of patients admitted from the ED with a diagnosis of stroke did not know a single sign or symptom of stroke, and a similar number did not know a single risk factor. Despite the fact that the elderly have a higher incidence of stroke in the general population, in this study population the elderly (aged 65 years) were significantly less knowledgeable about stroke than their younger counterparts. Further public education is needed to increase the awareness of the signs, symptoms, and risk factors for stroke and should be focused especially on high-risk patients such as the elderly and patients with a history of hypertension.

	Acknowledgments

 
This study was supported by a Young Investigators Award from the American Heart Association, Ohio Affiliate (SW-93944-YI). In addition, we would like to thank Drs Scott Becker, James Farrell, Scott Heath, John Kelly, Todd Perkins, and Karen Thalinger for their assistance in this project

Received June 9, 1997; revision received July 23, 1997; accepted July 24, 1997.

	References

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