Public Awareness of Stroke in Korea
A Population-Based National Survey
Background and Purpose—To date, no large study has been conducted to investigate baseline stroke awareness within a nationally representative sample of the Korean population.
Methods—A total of 1000 residents were randomly sampled according to regional demographic characteristics and were interviewed in person by trained interviewers. Structured, open-ended and close-ended questions were asked to assess stroke awareness.
Results—Among the respondents, 62% reported at least 1 stroke symptom and 56% reported at least 1 risk factor for stroke in open-ended questioning. Multivariate analysis revealed that completion of ≥12 years of education was independently associated with knowledge of symptoms (OR, 1.527; 95% CI, 1.146–2.034) and risk factors (OR, 1.577; 95% CI, 1.175–2.115). Approximately 31% and 33% of respondents, respectively, had some knowledge of thrombolysis and the proper action (call emergency medical services). Compared with subjects aged 20 to 39 years, those aged 40 to 59 years were more knowledgeable about thrombolysis (OR, 1.433; 95% CI, 1.045–1.964) and proper action (OR, 2.291; 95% CI, 1.646–3.188). The major source of information about stroke was television (59%), and the most reliable source was the respondents' physicians (55%). Among respondents 20 to 39 years of age, the Internet (37%) was the second greatest source of information.
Conclusions—Stroke awareness was suboptimal in Korea, especially among younger citizens and those with less education. To improve their knowledge, physicians should exert greater efforts to educate the public about stroke using mass media and the Internet.
Korea is one of the most rapidly aging countries in the world, and the incidence of stroke in Korea is increasing. Although the number of stroke-related deaths has been decreasing in recent years, stroke is still the leading cause of death in Korea.1 However, stroke can be prevented with aggressive control of risk factors, and ischemic stroke symptoms can be reversed with thrombolysis.2 Therefore, stroke awareness in the general public is important for prevention of strokes and provision of proper treatment.
Many researchers in developed and developing countries have studied stroke awareness, and a lack of knowledge of stroke symptoms and risk factors has been documented.3–8 In Korea, several studies have addressed stroke awareness in the general population; however, these studies were only conducted in limited areas.7–9 In this study, we aimed to assess stroke awareness in a nationally representative sample and to identify factors associated with stroke-related knowledge.
A total of 1000 people were interviewed; the sampling error for the survey was ±3.1% at the 95% CI. To ensure that our data were reasonably representative, we conducted random sampling of participants in public spaces (including train stations, bus stations, department stores, and public parks) in proportion to the total number of residents in several demographic categories based on the 2005 census (online-only Supplemental Table 1; http://stroke.ahajournals.org). Fourteen trained interviewers conducted in-person interviews in Korean, and telephone numbers were collected to monitor survey quality. Participation was limited to adults of at least 20 years of age, and consent was obtained before the survey. No public campaigns or educational efforts were launched before or during the study. The Institutional Review Board of the Seoul National University Hospital approved the study. A questionnaire was developed for assessment of stroke awareness that contained 5 sections (stroke definition, stroke symptoms and risk factors, stroke treatment, information sources, and demographic factors). These sections are described in detail in the online-only Supplemental Methods.
Numbers and proportions are presented to describe baseline characteristics. The χ2 test was used for assessment of univariate relationships between various factors, and one-way analysis of variance with the Tukey post hoc test was performed to compare mean correct responses. Using multivariable logistic regression analysis, we investigated the effects of demographics and a respondent's personal risk factors on stroke awareness (knowledge of stroke definition, symptoms, risk factors, thrombolysis, and proper action). Explanatory variables, as identified by univariate analysis at P<0.2, were used in the model. All significance tests were 2-tailed, and differences were considered statistically significant at P<0.05. SPSS Version 12.0 for Windows (SPSS, Inc) was used for data analysis.
To obtain 1000 completed questionnaires, a total of 3960 people were contacted. The response rate was 25.3%. The mean age was 42.8±14.1 years, and participants ranged from 20 to 81 years of age. Demographic characteristics of the respondents are shown in the online-only Supplemental Table 2.
Knowledge of Stroke Symptoms and Risk Factors
Recognition of stroke symptoms and risk factors in the open-ended survey questions are shown in Table 1. The most commonly identified stroke symptom was paresis (44%). When stratifying identification of symptoms by age group, hemiparesis was identified significantly less frequently among participants 20 to 39 years of age than in the other groups. Hypertension (31%) was the most commonly listed risk factor followed by heavy drinking (23%) and smoking (21%). When the listed symptoms and risk factors were stratified by education, completion of ≥12 years of education generally correlated with greater knowledge. However, we did not find any difference when stratifying by residence population (online-only Supplemental Table 3).
A total of 615 (62%) respondents listed ≥1 symptom, and 561 (56%) respondents listed ≥1 risk factor. The mean (SD) number of correctly listed symptoms was 1.1 (1.0), and the mean number of correctly listed risk factors was 1.3 (1.3). In multivariable logistic regression analysis, completion of ≥12 years of education corresponded with better knowledge of stroke symptoms and risk factors (Table 2).
Knowledge of Thrombolysis and Response to Stroke Symptoms
Of the participants, 305 (31%) had knowledge of thrombolysis. A total of 937 (94%) respondents stated that they would visit the general hospital if they experienced stroke symptoms; however, only 325 (33%) subjects chose the proper action of calling emergency medical services. Multivariable logistic regression analysis for those two factors showed that the older age groups, when compared with participants 20 to 39 years of age, tended to have better knowledge about thrombolysis and proper action on symptom presentation (Table 3).
Sources of Information About Stroke
The most common source of information about stroke identified by respondents was television (59%) followed by newspapers/magazines (33%; online-only Supplemental Table 4). However, the Internet (37%) was the second most commonly reported source for 20 to 39 years of age. Few subjects, especially among the younger participants, cited their physicians as a source of information. However, physicians were cited as the most reliable source of information (55%) followed by television (34%) and then educational health programs (25%).
This study was the first national survey to investigate stroke awareness in the general Korean public using in person interviews. It is representative because participants were randomly selected based on regional demographic characteristics, and selection bias was minimized. Therefore, our study may contain unique information about the Korean population.
Awareness of stroke symptoms and risk factors was significantly higher among participants with more education. Although education level was high among 20 to 39 years of age (online-only Supplemental Table 5), this group did not have more knowledge than older age groups. These findings may be associated with the fact that older adults have more risk factors and visit the hospital regularly and thus receive more information from their physicians. Considering that awareness of stroke in bystanders has been shown to reduce prehospital delays in Korea,9 educational strategies focused on younger people are necessary.
If more people understand that stroke treatments can reverse symptoms, decisions after symptom occurrence could possibly occur more quickly.10 Therefore, knowledge of thrombolysis and the proper actions after the appearance of stroke symptoms are important. In our study, 31% of respondents were familiar with thrombolysis, and 33% stated that using emergency medical services transportation is the correct action. Although the rate of familiarity with thrombolysis was higher than in a previous report,6 there is great potential for improvements in overall knowledge among Korean residents. Multivariate analysis showed that adults aged 20 to 39 years consistently demonstrated poor knowledge. The lack of knowledge in younger respondents was an interesting finding, and educational efforts should be directed at these individuals.
An important limitation of our study is that the response rate was only 25.3%. The low response rate may have been due to numerous contacts with elderly and poorly educated subjects who chose not to participate. As a result, overestimation of the population's knowledge about stroke is a possibility that should be considered when generalizing these results. However, we believe that older subjects and those with low literacy may provide unclear data and limited information.
In addition to knowledge about stroke symptoms and risk factors, an understanding of the time-sensitive nature of stroke treatments is essential. In our study, we made the important observation that the younger generation had less knowledge of proper stroke treatments. Development of educational strategies should take into consideration the findings that the younger generation tended to obtain information from the Internet and that the most reliable source of information is physicians. After sufficiently educating the general public, a national survey using the same methods should be repeated to evaluate stroke awareness.
Sources of Funding
This study was supported by grants from the Korea Health 21 R&D Project, Ministry of Health and Welfare, Republic of Korea (A060171).
The online-only Data Supplement is available at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.111.638460/-/DC1.
- Received September 26, 2011.
- Revision received October 25, 2011.
- Accepted October 31, 2011.
- © 2011 American Heart Association, Inc.
Korea National Statistical Office. Annual Report on the Cause of Death Statistics. 2008.
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