Stroke is the fourth most common cause of death in developed countries1 and a leading cause of acquired disability in adults.2 When thrombolytic treatment is delivered within 3 hours of ischemic stroke onset (and up to 4.5 hours in certain patients), the risk of acquired disability is reduced, and the probability of a favorable outcome is increased.3 However, less than 7% of patients with ischemic stroke receive thrombolytic treatment, primarily because most patients reach the hospital after the required time window.4,5 One of the factors contributing to out-of-hospital delay is incorrect interpretation of symptoms.6 Awareness of stroke risk factors and warning signs has been shown to have a considerable impact on early arrival at the hospital.7 In addition, delayed presentation at the hospital has been shown to be more common among ethnic minorities in the United States,8 and differences between minority groups have been reported. For example, Mexican Americans were less likely than non-Hispanic whites to arrive by emergency medical services following the onset of stroke symptoms, contributing to longer out-of-hospital delay.9 Similarly, associations between delay in seeking medical treatment (≥3 hours from stroke onset) and black ethnicity were found in South London, England.10
Israel has a multiethnic population with 2 major ethnic groups, Jews and Arabs. The Jewish population (75% of Israel’s population) is heterogeneous in terms of ethnicity, genetics, and lifestyle. Following the establishment of the State of Israel in 1948, Jews immigrated to Israel from different parts of the world. After the collapse of the Soviet Union in the early 1990s, a massive wave of Jewish immigration from the Former Soviet Union (FSU) to Israel occurred, consisting of more than 1 million new immigrants.11 At present, immigrants from the FSU (IFSUs) comprise a substantial proportion of the Israeli Jewish population. Previous studies have examined rates of different health conditions among IFSUs.12–14 The rates of self-reported age-specific prevalence of ischemic heart disease and hypertension among IFSUs are much higher than commonly observed in Western countries.12 Immigrants from the FSU have a significantly higher body mass index and lower reports of a “good” health status compared with the native Israeli population.13 Moreover, an analysis of risk factors for stroke showed a significant trend toward a high prevalence of ischemic heart disease, atrial fibrillation, obesity, carotid artery stenosis, and peripheral vascular disease among immigrant compared with nonimmigrant Jews in Israel.15
Poor public knowledge of stroke symptoms is one of the factors affecting delays in presentation to an emergency room.16 The aim of the current study was to examine stroke awareness and knowledge among veteran residents (VRs) compared with IFSUs.
Design and Setting
The study was conducted at the Nursing Department of Tel Aviv University from 2010 to 2014. The authors trained 62 registered nurses, students in the Master of Arts in Nursing program, to conduct the interviews. The participants were recruited by snowball method from among the interviewers’ friends and family members. Because the students lived in different cities, all areas of Israel were represented in the present study. The sample contained 2 subgroups: VRs, people born in Israel or who had immigrated to Israel before 1989, and IFSUs, people born in the FSU who had immigrated to Israel beginning from 1989. The study’s inclusion criteria were age 40 years or older and a sufficient level of Hebrew comprehension. The multiple-choice questions were based on a telephone questionnaire used previously by Tanne et al17 and adapted for personal interviews. The questionnaire included data on demographic characteristics, as well as knowledge of stroke and its causes, stroke warning signs, risk factors, and primary prevention. Level of knowledge of stroke warning signs was tested by examining the number of correct signs or symptoms of stroke (from 0 to 3) provided by the respondents.
The study was approved by the Tel Aviv University ethics committee. A short explanation regarding the purpose of the study was given to the participants, and signed informed consent was obtained.
The distribution of continuous variables was presented as mean ± SD, and percentages were shown for categorical variables. Differences between VR and IFSU respondents in demographic and clinical characteristics and level of knowledge about stroke were analyzed using the χ2 test for categorical variables, the Student t test for continuous variables, and the Mann-Whitney U test for ordinal variables. In order to measure the predictive contribution of education and income to the number of stroke signs identified by the respondents, an ordinal regression analysis was performed. All analyses were performed using SPSS (version 21; SPSS Inc, Chicago, Illinois).
A total of 643 Israelis, 420 (65.3%) VRs, and 223 (34.7%) IFSUs, 40 years or older with no history of stroke, were interviewed. Of these, 40.7% were men, and the mean age was 52.6 (SD, 9.3) years. The mean age was higher for IFSUs than for VRs (53.9 [SD, 10.6] years and 51.3 [SD, 8.0] years, respectively; P < .001). Religiosity, categorized as level of religious activity, dedication, and belief, was higher among VRs than among IFSUs (P < .001). Compared with VRs, IFSUs were more likely to report previous myocardial infarction (P = .022), hypertension (P < .001), and diabetes (P = .012). Immigrants from the Former Soviet Union, more than VRs, reported performing physical activity, such as 30 minutes or more of brisk walking, cycling, or athletics, at least twice a week (P < .001) (Table 1).
Knowledge and Awareness of Stroke
Findings on knowledge and awareness of stroke are presented in Table 2.
Knowledge of Stroke and Its Causes
Of all respondents, 11.4% of VRs and 9.9% of IFSUs answered that they had not heard about stroke or had heard but did not know what it was. Thrombosis, arterial embolism, or hemorrhage in the brain were recognized as causes of stroke by 80.0% of VRs and by 83.4% of IFSUs (P = .3). Stroke was described as a “psychiatric illness” by 1.3% of IFSUs respondents compared with none of VR respondents (P = .02).
Awareness of Stroke Warning Signs
The respondents were requested to provide 3 signs or symptoms of stroke with which they were familiar. The mean number of stroke warning signs reported by IFSUs (2.1) was slightly higher but statistically significant than that reported by VRs (2.0) (P = .031). Dizziness was reported as a stroke warning sign by 8.4% of VR respondents compared with 13.7% of IFSUs (P = .037). Sudden chest or arm pain was wrongly reported as a stroke warning sign by 5.5% of VR respondents compared with 1.8% of IFSUs (P = .03). Spearman correlation analysis demonstrated that education (r = 0.194, P < .001), income (r = 0.183, P = .001), and religiosity (r = −0.137, P = .01) were associated with the number of stroke warning signs in VRs, and only education was significantly associated with the number of stroke warning signs in IFSUs (r = 0.149, P = .043). An ordinal logistic regression analysis showed that in VRs, education was associated with the number of stroke warning signs (odds ratio, 1.10; 95% confidence interval, 1.01–1.19; P = .03). Among IFSUs, no significant associations were found between these variables.
Family History of Stroke
When asked whether someone in their own family had had a stroke, 5.5% of VRs reported grandparents with a history of stroke, compared with 10.8% of IFSUs (P = .01).
Awareness of Stroke Risk Factors
Hypertension was the most frequently reported risk factor for stroke (62.8% of IFSUs vs 50.4% of VRs, P = .03). In addition, family history as a recognized risk factor for stroke was reported by 10.0% of VRs compared with 4.9% of IFSUs (P = .03). When asked “If you or someone else showed signs of stroke, what would you do first?”, 70% of VRs and 73.1% of IFSUs (P = .41) answered that they would call an ambulance.
Awareness of the Possibility of Preventing Stroke
When asked about stroke prevention, 6.7% of VR respondents compared with 16.1% of IFSUs (P < .0001) noted that medications for dyslipidemia might prevent stroke.
Interest in Learning About Stroke
Interest in learning about stroke and its prevention was expressed by 87.1% of VRs and 88.3% of IFSUs (P = .66). Eighteen percent of VRs compared with 29.1% of IFSUs (P = .001) noted that they would prefer to learn about stroke from their doctors. Moreover, 11.2% of VRs compared with 19.7% of IFSUs (P = .003) would prefer to learn about stroke from radio programs. Veteran residents more often than IFSUs (15.7% vs 8.1%, P = .006) declared that they would prefer to learn about stroke from brochures provided by professional sources such as stroke associations.
The aim of the current study was to examine stroke awareness and knowledge in VRs compared with IFSUs. We found that IFSUs had a higher prevalence of risk factors for stroke such as previous myocardial infarction, hypertension, and diabetes. In addition, IFSUs had more knowledge of stroke risk factors, warning signs, and strategies for the prevention of stroke.
A higher prevalence of personal risk factors has been reported in previous studies among IFSUs.12–14 Moreover, these findings are consistent with findings from other countries indicating a higher prevalence of modifiable risk factors18–20 and higher rates of disease, such as diabetes21 and acute myocardial infarction,22 among immigrants. Another and perhaps more significant argument is the higher prevalence of cardiovascular risk factors among the population of the present Russian Federation. For example, according to the World Health Organization report on Noncommunicable Diseases Country Profiles, 2014,23 the estimated proportional mortality percentage of all deaths, all ages, both genders) for 2000 to 2012 due to cardiovascular disease in the Russian Federation was 60%, compared with 26% in Israel. Moreover, in 2008, the prevalence of hypertension among citizens of the Russian Federation was 37.8%, compared with 21.2% in Israel. Furthermore, in 2010, a higher prevalence of smoking and alcohol consumption was found in Russia (40% and 15 L/y per capita, respectively), compared with Israel (26.2% and 2.8 L/y per capita, respectively). These data might explain the elevated prevalence of cardiovascular risk factors among IFSUs.
We also found differences between IFSUs and VRs in reported income. Thus, 10.5% of VRs compared with 4.4% of IFSUs reported a low income, whereas 58.2% of VRs compared with 53.5% of IFSUs reported a high income. Differences in self-reported income may be explained by various factors; however, the possible causes of the observed differences are not within the scope of the present study.
Our findings regarding the higher level of stroke knowledge among IFSUs participants, compared with VRs, do not support previous reports. Lower levels of education and lower socioeconomic status have been reported as factors contributing to poorer health outcomes among ethnic minorities, compared with nonminority populations.24 However, IFSUs have been reported to be highly educated.25 Previous studies have consistently reported lower levels of stroke knowledge among minorities.26,27 In part, the differences between VRs and IFSUs in knowledge of stroke signs might be related to differences in education. This is consistent with previous studies that found a higher level of education is one of the predictors of knowledge about stroke.28,29
Immigrants from the Former Soviet Union were found to have higher levels of stroke knowledge than VRs. Moreover, IFSUs reported engaging in physical activity more frequently than did VRs. According to a model suggested by Osborn et al,30 a causal pathway links health literacy to health status via determinants of self-care, such as disease-related knowledge, self-efficacy, and physical activity. Health literacy is directly related to health knowledge, knowledge to self-efficacy, self-efficacy to physical activity, and physical activity to health status. Further support of this model might follow from an additional study that found significantly lower levels of knowledge about stroke among older people (≥65 years old) who reported no regular physical activity.31 However, evaluation of these reported associations is beyond the scope of the present study.
Knowledge of stroke warning signs was associated with level of religiosity in VRs, but not in IFSUs. Previous studies have shown that spirituality and religious beliefs might affect individuals’ medical decisions and health-seeking behavior.32 Moreover, the spiritual attachment of hypertensive patients with a supreme being increases their expectation of divine healing instead of encouraging adequate adherence to antihypertensive medication.33 It has been shown that culturally targeted educational interventions aimed at increasing health awareness significantly increased the colorectal cancer knowledge of African Americans.34 Culturally targeted educational interventions among various cultural/ethnic groups in Israel might promote stroke knowledge and awareness.
The preferable sources of information about stroke among IFSUs were their doctors, whereas the preference for information from this source among VRs was significantly lower. In the FSU, the doctor-patient relationship was paternalistic.35 According to the paternalistic model, physicians function as patients’ guardians responsible for their patients.36 Moreover, in addition to medical services, doctor-patient relationships in the FSU are often extended to consultations about family and social problems.35 In Israel, the doctor-patient relationship is often based on the shared model, which assumes a 2-way information exchange between doctor and patient.36
In order to improve the identification of stroke warning signs and promote fast seeking of medical help, educational programs for the general population are essential. A recent report showed that a 6-month educational campaign, including flyers, posters, and mass media advertisements including newspaper, radio, and public events, increased stroke knowledge and awareness among the urban population in Northern Germany.37 Moreover, the mass media FAST campaign (Face Arm Speech Time [face drooping, arm weakness, speech difficulty, and time to call 911]) for stroke awareness brought about significant changes in medical treatment-seeking behavior following the onset of stroke symptoms.38
In Israel, the Israel Heart Society runs an educational campaign titled “Atrial Fibrillation and the Risk of Stroke.” The campaign contents are distributed through various social media networks such as YouTube, Facebook, Twitter, and LinkedIn. The contents of the campaign include popular science articles about atrial fibrillation and stroke, short films, and presentations on stroke prevention.
Although the study sample included representatives of both VR and IFSUs communities in different geographical areas of the country, generalizability of the results may be limited as a convenience sample was used. Moreover, the current study consisted of Jewish VRs only and did not include other main ethnic minorities such as Arab VRs. In addition, in the current study, VRs and IFSUs were considered homogeneous populations. However, the Israeli Jewish population has heterogeneous origins. Therefore, the knowledge, perception, and risk factors of stroke among the VR population might be affected by the norms and culture in the country of origin. In addition, the FSU included 15 different republics characterized by cultural differences. As a result, there may be differences in knowledge, perception, and prevalence of risk factors for stroke among the IFSU population, and these should be further studied.
The reasons for the higher rates of chronic diseases and several metabolic risk factors among IFSUs are not entirely clear. Various reasons have been suggested, among them subjective and objective socioeconomic status,39 the known association between immigration and the development of hypertension,19 and differences in the dietary behavior of IFSUs.13 The effect of knowledge and attitudes on behaviors aimed at reducing the prevalence of specific chronic diseases among IFSUs might be an interesting subject for future studies. In addition, the comparison between Arab and Jewish VRs might be an interesting focus for future studies. Future research should also examine knowledge about stroke among immigrant populations in other developed countries.
This study is the first to compare stroke awareness and knowledge in VRs compared with IFSUs in Israel. Veteran residents demonstrated lower levels of stroke knowledge. Educational campaigns aimed at increasing stroke knowledge and awareness of stroke warning signs in Israel’s general population, as well as targeting specific cultural subgroups, are recommended. In addition, the doctor-patient relationship may be a means of spreading information about stroke among the general population. Physicians and other healthcare providers can distribute information on stroke symptoms to their patients.
What’s New and Important
- Immigrants from the Former Soviet Union showed a higher prevalence of risk factors for stroke, such as previous myocardial infarction, hypertension, and diabetes.
- Immigrants from the Former Soviet Union showed a higher knowledge of stroke risk factors, warning signs, and strategies for the prevention of stroke.
- Educational campaigns aimed at increasing stroke knowledge and awareness among Israel’s general population, while targeting specific cultural subgroups, are recommended.
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