(Stroke. 1997;28:1165-1169.)
© 1997 American Heart Association, Inc.
Articles |
Perspectives of Stroke in Persons Living in Seoul, South Korea
A Survey of 1000 Subjects
From the Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea.
Correspondence to Jong S. Kim, MD, Department of Neurology, Asan Medical Center, Song-Pa PO Box 145, Seoul 138-600, South Korea.
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Abstract |
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Background and Purpose The aim of the present study was to investigate the perspectives of stroke in persons who live in Seoul, South Korea, a country which is unique in that the social and political status of traditional (herbal) medicine is equal to that of western (modern) medicine.
Methods We randomly selected 1000 persons living in Seoul, South Korea, and performed open-ended telephone interviews regarding stroke risk factors, symptoms, and the choice of treatment for stroke. We also asked whether the subjects would prefer to visit western-medicine doctors or traditional-medicine doctors if they developed stroke.
Results Twenty-nine percent of the interviewees responded correctly that the most important risk factor for stroke is hypertension. However, other major factors, such as cigarette smoking, diabetes mellitus, and heart disease, were greatly underappreciated, while less important risk factors such as hyperlipidemia/obesity, stress, and exposure to coldness were overappreciated. Also, although 65% of the subjects correctly identified paresis as the most important symptom of stroke, tremor was indicated incorrectly as an important symptom of stroke. Regarding the choice of treatment, only 46% responded that visiting a hospital is the most important method of treatment, whereas a significant percentage of the subjects responded that they would prefer herbal medicine and other traditional methods of treatment. Generally, the older and less educated the subjects, the more they prefer to depend on traditional medicine.
Conclusions These data show that perspectives of stroke are heavily influenced by the presence of traditional medicine in Korea, especially in older and less educated persons. This perspective significantly deviates from the scientific concept regarding the etiology, symptoms, and treatment of stroke. Current science-based health education is urgently needed in this country.
Key Words: cerebrovascular disorders • health education • medicine, herbal • risk factors • South Korea
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Introduction |
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South Korea is a rapidly developing country, and its gross national product currently is ranked as the 11th largest in the world. However, regarding stroke mortality, it still retains major problems. The mortality from stroke was recorded as 85.8 per 100 000 deaths in 1994,1 which was considerably higher than that reported in the United States, Canada, and Mexico.2 Furthermore, in Korea, the mortality from hypertension was recorded as 26.2%1 ; of these cases, however, a significant number would have been classified as stroke had they been accurately reported.3 It thus is highly likely that the mortality from stroke in Korea is actually higher than was reported. Moreover, in Korea, unlike other developed countries,4 5 6 declining stroke mortality has not been clearly observed until recently, especially in women.1 The high stroke mortality, despite Korea's relatively large economic share in the world, could be due to prevalent risk factors for stroke, inadequate treatment (or prevention) of stroke, or both. In a recent national survey, however, the prevalence of hypertension (blood pressure
160/95 mm Hg) in
Korea was 12.4%, which in fact was lower than that reported in the
United States and most western European countries.7 On the
other hand, evidence suggests that hypertension is less well
controlled, cigarette smoking more prevalent (especially in
men),8 and salt intake is higher9 in this
country than in its western counterparts. All these data suggest that
the concept of a healthy lifestyle has not been substantially
established in Koreans. One thing that should be considered in this regard is the strong presence of traditional (herbal) medicine in this country. Korea is unique in that the status of its traditional medicine is equal to that of western (modern) medicine, socially and politically. There are many herbal-medicine hospitals, universities teaching herbal medicine, and strong organization for herbal medicine proponents. Information on herbal medicine is broadcast daily in the same way as western medical knowledge. For a long time, traditional medicine has emphasized its role in the treatment of stroke, among other diseases. However, the concept of the disease is quite different in many ways from that held by western medicine. Generally, the disease state is considered mainly as a destruction of harmonious components of soul and body. Stroke is considered to be caused either by weak internal strength (so-called Kee) invaded by strong external "bad wind" or by excessive internal "fire," such as anger, fatigue, heavy drinking, or dietary problems. Both can violate the harmonious negative-positive balance of the self, which eventually leads to stroke.10
Thus, Koreans are under the influence of both traditional and western medicine, and their perspective of stroke is likely to be confused. In this study, we attempted to determine the perspectives of stroke in persons living in Seoul, South Korea, and how much they are influenced by the presence of traditional medicine.
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Subjects and Methods |
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Seoul, the capital city of South Korea, has 25 prefectures. We serially numbered each prefecture according to the Korean alphabet and selected 8, those with numbers divisible by 3 (ie, prefectures 3, 6, 9, 12, 15, 18, 21, and 24). For each prefecture, we randomly opened that telephone book and selected the telephone number at the 10th line from the top on the selected page. In this way, we randomly chose 1000 people and interviewed them by telephone. The interview was done by pretrained nurses working in the Department of Neurology, Asan Medical Center, between August 10 and August 20, 1996. Excluded were subjects who were (1) <20 years or >80 years of age, (2) not permanent residents in Seoul, or (3) reluctant to be interviewed. If a chosen subject was excluded, we repeated the selection from the telephone book, taking the telephone number at the 11th line of the same page.
We used open-ended questions rather than a structured format to direct the subjects' responses, partly because we were not able to anticipate the diverse responses of the subjects and partly because we wished to avoid possible bias that may result from directing spontaneous responses. We also identified ourselves only after the completion of the interview to eliminate the bias. We systematically interviewed the subjects regarding the following: (1) age, sex, education level, past history of stroke, and family history of stroke; (2) what they believe is the most important etiology/risk factor for stroke; (3) what they believe is the most important symptom/sign of stroke; (4) what they believe would be their choice of treatment if they developed stroke; (5) which doctor they would prefer to visit if they developed stroke, western or traditional; and (6) what is the most important source of their knowledge regarding stroke.
All data were collected and analyzed with Student's
t test and 
2 with the use of SAS
software (version 6.0).
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Results |
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The subjects comprised 1000 residents (400 men and 600 women) of Seoul. Their demographic characteristics are summarized in Table 1
. Ages were stratified as 20 to 39, 40 to 59, and 60 to
79 years; education level was categorized as follows: low, no education
or primary school graduate; medium, middle or high school graduate; and
high, college graduate. Men had a significantly higher education level
(P<.05) and higher age (P<.001) than women.
Eighteen subjects had a past history of stroke, and 115 had a family
member who had suffered stroke. The important etiology (or risk
factors) for stroke perceived by persons living in Seoul is summarized
in Table 2. The most frequently referenced risk factor
was hypertension, which was followed by
hyperlipidemia/obesity, stress, circulation problems,
and so on. Hyperlipidemia/obesity was categorized as a
single entity because most of the subjects seemed to use the words
"excessive fat," "obesity," and
"hyperlipidemia" interchangeably. Answers that
were inappropriate or irrelevant were categorized as "others,"
which included cloudiness of blood, air pollution, insomnia, etc.
Regarding the most important symptom of stroke, paresis was referenced
most frequently (n=595, of whom 149 responded "hemiparesis" and
others responded just "paresis") and was followed by tremor, gait
disturbance, altered consciousness, etc (Table 3). "Others" included emaciation, anosmia, skin
change, etc. The method of treatment after the occurrence of stroke is
summarized in Table 4. Although visiting a hospital is
the most frequently referenced method, traditional ways of treating an
emergent disease, such as cutting the fingertips or ingesting
traditional emergent herb pills, were not infrequently recorded.
When asked their preference, 462 and 455 subjects responded that they
would visit western and traditional doctors, respectively, if they
developed stroke. Finally, regarding the source of knowledge about
stroke, media broadcasting was most often referenced (Table 5).
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We then attempted to see whether education level, age, or sex has any relationship with the method of the emergent treatment of stroke, as well as preference for western versus traditional medicine.
As shown in Figs 1 and 2, the more the
subjects were educated, the more they preferred to visit western
doctors and the less they chose to use traditional methods
(P=.001). On the other hand, the less educated, the more
they tended to rely on traditional medicine, cutting their fingertips
or ingesting emergent herb pills (P=.001). Age also affected
their behavior in that the older subjects more often preferred to use
traditional methods of treating stroke (Fig 3) and visit
an herbal-medicine doctor (Fig 4) when compared with
young persons (P=.001). There were no significant behavioral
differences between sexes.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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This is to our knowledge the first report that investigated the conceptual or behavioral aspects of stroke in subjects influenced by both western and traditional medicine. The use of an open-ended questionnaire seems to have resulted in a relatively high occurrence of irrelevant answers (recorded as "others" in the Tables), a possibly imperfect categorization of each item, and a variable number of subjects who responded "I do not know." Despite these limitations, our data provided a unique opportunity to understand the perspectives of stroke in Seoul residents.
Understanding vascular risk factors and appropriate control of them is
very important in the prevention of stroke in a given society.
Hypertension is the single most important risk factor for stroke, not
only in western countries but also in Korea.11 Its
relative risk has been shown to be 4 to 5.12 13 It has
also been shown that cigarette smoking, heart disease, and diabetes
mellitus are major risk factors for stroke, with their relative risks
ranging from 1.5 to 3, 5 to 7, and 1.5 to 3,
respectively.13 14 15 In our study, nearly 30% of the
responders appropriately recognized hypertension as the most important
risk factor. However, other major risk factors, such as cigarette
smoking, diabetes mellitus, and heart disease, were greatly
underappreciated, as shown in Table 2
. This may reflect the
methodological bias in our study, since we asked for only the most
important risk factor but not the second or third. However, considering
the other less important risk factors occupying the status between
hypertension and the above-mentioned major risk factors, it is likely
that the major risk factors other than hypertension were truly
underappreciated by the population living in Seoul.
For instance, hyperlipidemia/obesity was referenced second most frequently. Actually, this is at best a minor risk factor for stroke, especially in Korea, where fat ingestion is much lower than in the United States. In Far Eastern countries, where primary intracerebral hemorrhage is relatively common,11 it has even been suggested that a low level of blood cholesterol may predispose subjects to develop hemorrhagic stroke.16 17 The overappreciation of hyperlipidemia/obesity as a cause of stroke may be an indiscriminate influence from western society, where coronary heart disease and atherosclerotic cerebral infarction are prevalent and control of hypercholesterolemia is advised.15 18 However, it can also be an influence from traditional medicine, where fat-containing food (especially pork and chicken) is considered a poor diet for stroke patients and is strictly avoided regardless of the subject's blood level of cholesterol. Likewise, the frequently referenced etiologies of stress and circulation problems also reflect the influence from traditional medicine, where inharmonious organization of body and soul has been emphasized as a cause of stroke.10 19 Of particular interest in this respect was that coldness or cold wind was ranked as a relatively important risk factor for stroke. Although cold weather is indeed related to frequent occurrence of stroke,20 21 22 coldness itself has never been considered as a major risk factor in western literature. On the other hand, traditional medicine has taught that coldness, especially cold wind, should be avoided to prevent stroke. It is noteworthy that the Chinese character Poong, which is nearly equivalent to "stroke," actually means "wind."
Regarding symptoms of stroke, similar considerations hold true. Sixty percent of the subjects correctly responded that paresis is a main symptom of stroke. However, tremor, which is far from a major symptom of stroke but is often taught to be a symptom of Poong by traditional medicine practitioners, was referenced second most frequently. Similarly, facial palsy was referenced relatively frequently in our study, although facial paresis without hemiparesis is actually rare in stroke. In traditional medicine, deviation of the lip has been frequently cited as a symptom of stroke, and it is probably true that the traditional concept of Poong includes Bell's palsy.10 Thus, our results show that the perception of etiology and symptom of stroke is heavily influenced by the presence of traditional medicine in Korea.
Early presentation to a hospital should be very important in the management of acute stroke, considering the importance of early vital care and the short therapeutic time window for thrombolysis.23 In the present study, however, only 46% of subjects responded that visiting a hospital is the way to deal with stroke. On the other hand, traditional medicine and traditional treatment methods (such as cutting the fingertips, ingesting emergent herb pills, etc) were still popular, and the preference regarding western versus traditional doctors was generally similar in our study. We also found that the older and less educated the subjects, the more they depend on herbal medicine and other traditional treatment methods. However, it remains unknown what percentage of patients actually visit traditional-medicine doctors after stroke in Korea. In the People's Republic of China, where traditional medicine is also prevalent, approximately one third of the patients were not admitted to a hospital and are sometimes treated with traditional medicine.19 The preference for traditional medicine and traditional methods of stroke management in persons of stroke age in Korea illustrates that a sizable portion of patients are not examined and treated by modern medicine. Indeed, self-management or treatment with traditional medicine before a hospital visit was shown to be one of the main reasons why patients are not admitted to a hospital early enough in this country.24 However, our study showed that younger persons prefer to use modern medicine, suggesting that behavior regarding stroke management is shifting to the western style. Finally, our study showed that major sources of knowledge concerning stroke were media broadcasting and immediate neighborhood. In Korea, the information on both traditional and western medicine is broadcast in the same way; the message received by the people is frequently confused. In this regard, the result of our study is not unexpected. The fact that only 18 subjects responded that they got information regarding stroke from school illustrates that formal education from school has been inadequate in this country.
In conclusion, the perspectives of stroke in persons living in Seoul deviate from science-based knowledge and are heavily influenced by the presence of traditional medicine. From this study alone we cannot clarify whether the mixed perception of this important disorder has any role in the high mortality of stroke in Korea; however, we think it does. The different methods of stroke management as perceived by the population may prevent stroke victims from receiving the most appropriate and science-based management of their illness. More importantly, the confused concept of stroke in our people may make it difficult for them to maintain clear-cut guidelines regarding the prevention of stroke. For instance, with this confused perception in mind, subjects may easily disregard the importance of quitting smoking but may at the same time obsessively try to avoid fatty foods regardless of their blood lipid level. Thus, our results emphasize that proper and science-based health education, either through school education or public media, is urgently needed in Korea and should include information on risk factors, warning symptoms, and adequate management of stroke.
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Acknowledgments |
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We gratefully acknowledge that Dr S.I. Lee helped us in designing the study and that the nurses in our department generously devoted their time for this project.
Received February 5, 1997; revision received March 26, 1997; accepted March 26, 1997.
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