Stroke is a leading cause of long-term disability and the fifth leading cause of death in Israel.1 According to the National Acute Stroke Israeli registry, between years the 2004 and 2010, a decrease in mean age of stroke patients was observed.2 Between 2004 and 2010, the percentage of people younger than 50 years among hospitalized patients with ischemic stroke and intracerebral hemorrhage in Israel increased from 10% to 19.8%, whereas the percentage of transient ischemic attack patients decreased from 14% to 11.7%.3,4 According to the Israeli National Health Interview Survey (INHIS), a substantial increase in self-reported prevalence of hypertension among adults 21 to 44 years old has occurred from 2003–2004 to 2007–2010.5,6 Increasing prevalence of hypertension, a major risk factor for stroke, may result in increasing risk of stroke. Previously, Yang et al7 demonstrated that hypertension was associated with the perceived risk for stroke among community residents in Western urban China. Evaluating the level of stroke knowledge in the general population is important as a basis for planning stroke preventive strategies.
Successful identification of early signs of stroke has been associated with early hospital arrival, which is essential for active treatment of stroke.8 In the United Kingdom, arrival time shortened and rates of emergency medical services utilization improved following implementation of the FAST (Face-Arm-Speech-Time) public stroke awareness education campaign.9
Data on gender differences in stroke knowledge are inconsistent: whereas some studies have shown better knowledge in women,10,11 others reported no substantial differences by gender.12 Associations between knowledge of stroke and age have been inconsistent: poorer knowledge was found in an elderly Irish population,13 young Korean adults (20–39 years of age) had poor knowledge of stroke warning signs compared with older age groups,14 and knowledge of stroke risk factors and warning signs was not associated with age in an Italian adult population.15 The current study aims to assess the level of stroke knowledge among the Jewish adult population in Israel and to study potential differences in stroke knowledge by age group and gender.
The study, approved by the Tel Aviv University ethics committee, was conducted at the Nursing Department of Tel Aviv University. The study included 1137 Jewish Israelis 18 years or older with no history of stroke recruited as a convenience sample from the different geographic areas of the country. Only participants with a sufficient level of Hebrew to complete the interview were included. A short explanation regarding the purpose of the study was given to the participants and signed informed consent was obtained.
Data were collected during predefined data collection periods in 2010–2015, each period lasting about 2 months. Personal interviews were conducted by registered nurses, students in the master in nursing program, who were trained by the authors for this purpose. The structured questionnaire, previously used in a telephone survey on stroke knowledge in the Israeli population,16 was adapted for personal interviews conducted by registered nurses. The interview structured form was reviewed and tested for validity by 3 researchers whose main research area is stroke.
The questionnaire included open questions on knowledge of stroke and its causes, stroke warning signs, stroke risk factors, primary and secondary stroke prevention, first action in identification of stroke occurrence, and demographic characteristics. Questions were supposed to be comprehensible to the interviewed who was able to understand ordinary native speech and carry on an exchange of ideas. Participants were encouraged to ask the interviewer if the question was unclear. During the training meetings, a list of possible answers expected from participants with different levels of knowledge for each item was supplied to the interviewers, to assist them to correctly report the responses.
Definition of Acceptable Total Level of Stroke Knowledge
Previously, Hickey et al13 defined knowledge of stroke risk factors and signs as being able to correctly state 2 or more risk factors and 2 or more stroke signs. Similarly, in the current study, correctly answering to at least 2 questions on knowledge about stroke risk factors and how to control them as well as at least 2 correct answers about stroke signs and what to do when a first sign is evident were defined as a sufficient level of total knowledge about stroke.
“Thrombosis, arterial embolism, clot/blood clot inside the brain or haemorrhage/bleeding in the brain” were considered correct answers to the question “What is a stroke?” The answer to this question was not accounted to the total knowledge about stroke. The question “To your knowledge, what are the signs of stroke?” examined the awareness of stroke warning signs. Knowledge of stroke warning signs was defined as identifying 2 or more early signs (sudden numbness on 1 side of the body, weakness or paralysis on 1 side of the body, loss of balance or coordination or trouble walking, dizziness, confusion, speech difficulties, vision disturbances, and severe headache). The question “To your knowledge, what are the most important risk factors for stroke, in other words, who is at risk for a stroke?” examined the awareness of stroke risk factors. Knowledge of stroke risk factors was defined as identifying 2 or more of the following risk factors: hypertension, high cholesterol, smoking, obesity, diabetes, heart disease, sedentary lifestyle, family history of stroke, poor diet, old age, and previous stroke.17 “Call an ambulance” was the only correct answer to the question “If someone around you showed signs of stroke, what would you do first?” Knowledge about stroke prevention was evaluated by a question regarding actions aimed at preventing stroke: “What can be done to reduce the risk of stroke?” Sufficient knowledge about stroke prevention was reported when the participant answered at least 2 of the following: taking medications for hypertension, keeping a healthy diet, increasing physical activity, quitting smoking, losing weight, taking medications for dyslipidemia, using antiplatelet medicines when recommended, and controlling diabetes. The question “Would you like to learn more about the disease and how to avoid it? If so, through by which means?” examined the respondent’s interest in stroke education and the preferable method of learning. The answer to this question was not accounted to the total knowledge about stroke.
The distribution of continuous variables was presented as mean and SD. For categorical variables, number of participants and percentages were shown. Differences between men and women in demographic and clinical characteristics and in level of knowledge about stroke were analyzed using the X2 or the Fisher exact test for categorical variables. All tests were 2 sided, and a P value of less than 5% was considered statistically significant. Data were analyzed using SPSS Statistics for Windows, Version 21.0 (IBM Corp, Armonk, New York).
In total, 1137 Jewish Israelis, 457 (40.2%) men and 680 (59.8%) women, were included in this study. Distribution of age was as follows: 493 (43.4%) younger than 45 years, 541 (47.6%) 45 to 64 years, and 102 (9%) older than 64 years; 1 (0.1%) did not report age.
Characteristics of participants are shown in Table 1. The mean (SD) age was 46.7 (13.8) years (median, 47 years; range, 68 years; min–max, 18–86 years). Current smoking (P = .026), history of acute myocardial infarction (P = .002), and dyslipidemia (P = .038) were more common among men than women.
Knowledge and Awareness of Stroke
Findings on knowledge and awareness of stroke are presented in Table 2 and Table (Supplemental Digital Content 1, http://links.lww.com/JCN/A36).
Knowledge of Stroke and Its Causes
Thrombosis, arterial embolism, and hemorrhage in the brain were recognized as causes of stroke by 77.3% of men aged 45 to 64 years versus 61.3% of men younger than 45 years (P = .002). Knowledge of stroke and its causes was demonstrated by 82.1% of women aged 45 to 64 years versus 72.4% of women younger than 45 years (P = .014).
Awareness of Stroke Warning Signs
The participants were asked to provide a list of signs or symptoms of stroke with which they were familiar. The proportion of women reporting no knowledge of stroke warning signs was lowest in the 45 to 64 years age group (P = .02). The proportion of those who identified loss of balance or coordination or sudden trouble walking as a symptom increased with age in both genders (P < .05 for both). In both genders, the percentage of those who identified dizziness as a stroke warning sign was higher among participants aged 45 to 64 years, compared with those younger than 45 years (P = .045 for men and P < .001 for women).
Awareness of Stroke Risk Factors
The proportion of participants who identified hypertension as a risk factor for stroke increased with age among men and women (P < .001 for both). Among men, identifying high cholesterol as a risk factor for stroke was associated with increased age (P < .001). In women, the percentage of those identifying high cholesterol as a risk factor for stroke was higher among those aged 45 to 64 years than among those younger than 45 years (P = .002). Among women, identifying old age as a risk factor for stroke was associated with younger age (P < .001).
First Actions Required in Presence of Signs of Stroke
Among men, 71.1% of those aged 45 to 64 years reported that they would call an ambulance if they or someone else showed signs of stroke, compared with 57.4% of those older than 64 years (P = .055).
Awareness of the Possibility of Preventing Stroke
Among men, the percentage of those not aware of the possibility of stroke prevention decreased with age (P = .016). In women, a higher percentage of those not aware of how to prevent stroke was evident among participants younger than 45 years than among women aged 45 to 64 years (P = .002). Use of medications for hypertension as a strategy for stroke prevention was associated with increased age (P < .001). The proportion of women who identified medications for hypertension as a stroke prevention measure was higher for those ages 45 to 64 years (19.4%) than among those younger than 45 years (40.9%) (P < .001). Identification of medications for dyslipidemia, antiplatelet drugs, and diabetes control as ways of preventing stroke was accompanied by an increase in age among men (P = .003, P = .001, and P = .043, respectively).
Interest in Stroke Education and the Preferable Method of Learning
Fourteen percent of the entire sample were not interested in receiving any information on stroke. For those who were interested (86%), Internet sites and TV programs were the preferable means for receiving information. The percentage of those whose preferable method of learning was Internet sites (among both men and women) declined with age (P < .001 for both genders).
Stroke knowledge among different age groups was similar in both genders.
The current study found that Israeli Jewish adult men and women younger than 45 years demonstrated the lowest knowledge of stroke cause and were less likely to identify at least 2 stroke risk factors, compared with older participants. Women younger than 45 years were less likely to identify at least 2 stroke warning signs and at least 2 stroke prevention strategies. No difference in total stroke knowledge was found between men and women.
Differences Between Age Groups
Knowledge of the Correct Cause of Stroke
The highest rate of correct answers was found in the 45 to 64 years age group, similarly to findings of Hickey et al13 regarding Irish adults. Likewise, Korean adults aged 40 to 59 years were more likely to know the definition of stroke.14 Stroke is a leading cause of long-term disability and the fifth leading cause of death in Israel,1 with the mean (SD) age of patients with acute stroke in 2010 being 69.5 (14.1) years.2 Therefore, we expected that individuals older than 64 years would demonstrate higher knowledge of stroke causes, owing to more common stroke occurrence in the immediate circle of members of this group. A possible explanation of the higher knowledge of stroke causes among participants aged 45 to 64 years may be connected to the occurrence of stroke among their parents and older relatives. As Grant et al18 found, family members of stroke survivors seek information on stroke diagnosis, prognosis, complications, and predicted recovery. This data searching also exposes them to knowledge of stroke causes.
Awareness of Stroke Warning Signs
In both genders, scores for knowledge of at least 2 stroke warning signs were lower in the younger than 45 years age group, compared with the 45 to 64 years and older than 64 years groups, and this difference was statistically significant among women. These results are similar to those reported by Madsen et al,11 who demonstrated that American women aged 18 to 34 years were more likely to have less knowledge of stroke warning signs than did women aged 35 to 54 years. Moreover, the results are similar to those reported by Kim et al,14 who found that Korean adults aged 20 to 39 years identified hemiparesis significantly less frequently than did participants from older age groups.
The lower knowledge of stroke warning signs among younger participants in the current study might be connected to the fact that strokes in young adults are reported as being uncommon, comprising 10% to 15% of all stroke patients.19 Therefore, stroke is less familiar to young adults and perceived as irrelevant to them. However, because recent studies have reported an increased incidence of stroke in young adults,20,21 primary prevention and improving knowledge of stroke warning signs in younger adults are crucial.19
Awareness of Stroke Risk Factors
We found that knowledge of stroke risk factors in both genders was significantly lower among those younger than 45 years than among older groups. The results are similar to those previously reported by Kim et al,14 regarding poor stroke knowledge among Korean adults aged 20 to 39 years. Likewise, Hickey et al13 reported that Irish adults younger than 45 years were unlikely to be able to specify 2 or more stroke risk factors. The possible explanation for lower knowledge of stroke risk factors among younger participants in the current study might be related to an optimistic bias regarding participants’ own risk of undergoing a stroke. Similarly, Masiero et al22 reported that young adults showed an optimistic bias related to cardiovascular diseases, which was linked to behavioral patterns such as tobacco smoking and alcohol consumption. Young people might ignore data and information about stroke and therefore have lower stroke risk factor knowledge because they believe that a stroke would not occur at young age.
Calling an Ambulance When Stroke Signs are Suspected
Rates of the answer “Calling an ambulance” in the presence of stroke sign were lowest in men older than 64 years (57.4%) and highest in women aged 45 to 64 years (76.7%). However, differences between age and gender groups were not statistically significant. The present rates are higher than those previously reported by Hickey et al13: 53.9%, 42.6%, and 30.1% in the younger than 45 years, 45 to 64 years, and older than 64 years age groups, respectively, and by Baldereschi et al (59% of the entire sample).15 Previously, Malek et al23 reported that perception of stroke-like symptoms as an emergency was one of the predictors of calling 911. A possible explanation of the higher than previously reported rates of the answer “Calling an ambulance” might be that most of the participants in the current study perceived stroke as an emergency.
Identifying at Least 2 Possible Actions for Stroke Prevention
A statistically significant difference was found among women, with 50.0% of participants younger than 45 years and 64.2% of those aged 45 to 64 years identifying at least 2 possible actions for stroke prevention. Hong et al24 demonstrated that awareness, treatment, and control of stroke risk factors such as hypertension, readiness to quit smoking among men, hypercholesterolemia, and diabetes mellitus were lower in the 30 to 39 years old group, compared with older age groups. Familiarity with possibilities for preventing stroke may not be perceived as important by young people. Nonetheless, similar to other age groups, around 85% of participants younger than 45 years reported an interest in stroke education. Participants younger than 45 years may have expressed an interest in stroke education having felt during the interview that their stroke knowledge is insufficient.
Interest in Stroke Education and the Preferable Method of Learning
For most of the participants, the preferred means for receiving stroke information were internet sites and TV programs. Because in the current study, lower scores of stroke knowledge were observed among the youngest and oldest participants, this indicates that Internet and TV are preferred pathways for transmission of educational contents about stroke among these age groups.
High scores on knowledge of stroke among participants in the current study might be attributed to a media campaign led in Israel during the last 2 years by the Neeman voluntary association established by stroke patients and their families. The campaign includes information about signs, symptoms, and prevention of stroke.25 However, to provide stroke information and to improve stroke prevention both in men and women, ongoing global and local stroke-prevention campaigns are needed.10
Participants younger than 45 years tended to score lower for total stroke knowledge than participants from other age groups, similarly to young American, Korean, and Irish adults.11,13,14
Young adults might feel that stroke is a disease typical of older ages, and they are “too young” to experience stroke. However, in the last 2 decades in the United States, the incidence rates of stroke increased in patients aged 35 to 55 years.20 In Israel, there is no evidence of substantial increase in the proportion of younger patients among hospitalized stroke.3,4 However, the increase in reported hypertension among Israeli young adults (INHIS-1 and INHIS-2) entails a possible increase in future stroke morbidity.5,6
A previous publication reported that hypertension was associated with the perceived risk for stroke among community residents in Western urban China.7 Educational campaign, including leaflet and booklet distribution, as well as holding lectures improved stroke knowledge among community residents in Japan.26 Our findings suggest that actions aimed at increasing stroke awareness and mass media intervention campaigns, targeting specific subpopulations at increased risk (as young hypertensive patients), are required.
Although the sample in the current study consisted of residents belonging to various communities living in different geographic regions of the country, the use of a convenience sample might have introduced some potential biases. The convenience sampling might produce the underrepresentation or overrepresentation of particular groups within the sample. The present study did not focus on specific subpopulations in Israel, such as immigrants, Muslim or Christian Arabs, or Druses. As a result, the generalizability of the results might be limited. Further studies including representative samples of the Israeli subpopulations are recommended.
The participants in the current study demonstrated high levels of stroke knowledge, compared with previous studies. Participants younger than 45 years showed lower levels of stroke knowledge than older participants did. The highest stroke knowledge was found in the 45 to 64 years age group. Stroke knowledge among different age groups was similar in both genders. Educational campaigns aimed at increasing knowledge of stroke among the general population and targeting the younger population, with a focus on individuals with known stroke risk factors, are recommended.
What’s New and Important
- Among adults with no history of stroke, individuals younger than 45 years showed the lowest scores in stroke knowledge.
- Stroke knowledge among different age groups was similar in both genders.
- Mass media interventions aimed at increasing knowledge of stroke and targeting specific subpopulations are recommended.
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