Stroke Awareness Among Georgia Adults: Epidemiology and Considerations Regarding Measurement.

ABSTRACT

Background. To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke.

Methods. Adults in Georgia were studied with a random digit dial telephone survey.

Results. Answering an unaided question, 39% of 602 respondents named [greater than or equal to]1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family.

Conclusions. Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.

To REDUCE the impact of stroke in Georgia, an effort is being organized by clinicians, government officials, public health organizations, and stroke survivors to raise public awareness of the warning signs of stroke, its risk factors, and the need to call 911 immediately when a stroke is suspected. [1] These efforts are supported by studies showing that patients with acute ischemic stroke benefit from thrombolytic therapy if it is given within 3 hours and that stroke patients often delay presentation more than 3 hours. [2-4] Also, people may be underestimating their risk for having a stroke. A study of patients from family medical practices in North Carolina reported that among patients with an above average risk for stroke, only 11% perceived their risk to be more than average; and a study of a pool of diverse populations with increased stroke risk showed that only 41% acknowledged they had an increased risk for stroke. [5,6]

Few population-based studies of stroke awareness have been published, and we know of none from Georgia. To design an effective campaign and establish a baseline assessment for evaluating the impact of stroke reduction efforts, we conducted a statewide survey of adults in Georgia. The objectives were to assess knowledge of stroke warning signs, stroke risk factors, and what should be done if a person is having a stroke, and to estimate the burden of stroke among Georgia adults and their family members.

METHODS

Study Design and Population

This study was a stratified cross-sectional telephone survey. The questionnaire and sampling methodology were based on American Stroke Association recommendations. [7] Modifications included increasing the sample size and broadening eligibility to include nonmetropolitan residents and adults less than 50 years old.

The state was divided into two strata: (1) the Atlanta metropolitan area, which consists of Cobb, DeKalb, Fulton, and Gwinnett counties, and (2) the remaining 155 counties. For each stratum, randomly generated telephone numbers were purchased from a private vendor (Survey Sampling Inc, Fairfield, Conn). Noninstitutionalized adults 18 years of age living in Georgia were eligible for participation. At each household contacted, the eligible adult with the most recent birthday was selected for participation. The target sample size was 400 interviews for the Atlanta area and 200 interviews for the remainder of the state. The Atlanta area was oversampled because initially the interventions were to be focused on that region. Because results were similar for both strata, they were combined in the analysis. In accordance with American Stroke Association recommendations, the sample was evenly divided between men and women. The study protocol was approved by the human subjects review boards of the Centers for Disease Co ntrol and Prevention and the Georgia Department of Human Resources.

Data Collection

Interviews were conducted by telephone using a standard questionnaire, and verbal consent was obtained from all participants. Participants were asked about the signs and symptoms of stroke, stroke risk factors, and sources of information on stroke treatment; what should be done if someone is having a stroke; whether strokes can be prevented; whether strokes can be treated by emergency care; and whether the interviewee or a family member had ever had a stroke. Participants were also asked their race, ethnicity, sex, education, and income.

Interviews were conducted by the Applied Research Center at Georgia State University (Atlanta) from March 30 to May 8,1999. Interviewing was conducted on weekdays from 10:00 AM to 9:15 PM, Saturdays from 11 AM to 7 PM, and Sundays from 10 AM to 6 PM. No upper limit was placed on the number of calls to a particular phone number before a final disposition was assigned, and potential respondents who initially declined to be interviewed were called once more to try to complete the interview.

Analysis

Responses to open-ended questions were coded into categorical responses independently by two of us (A.K.R. and M.R.F), and discrepancies were resolved by all three of us. An urban county of residence was defined as a metropolitan county (as classified by the US Department of Agriculture), and rural was defined as a non-metropolitan county. [8]

Unless otherwise stated, responses were weighted to adjust for probabilities of selecting households within strata and sampling subjects within each household. Poststratification weights based on US Census Bureau estimates were used to make the weighted sample approximate the distribution of Georgia adults [greater than or equal to]18 years of age by stratum, sex, race, and age. [9,10] Weighted proportions and 95% confidence intervals (CIs) were estimated using SUDAAN software version 7.5 (Research Triangle Institute, Research Triangle Park, NC) to account for the sampling design.

In the analysis of factors related to stroke warning sign awareness, "awareness" was defined as the ability to name spontaneously [greater than or equal to]1 of the following 5 signs: weakness or numbness, loss of vision, speech difficulty, headache, and dizziness or unsteadiness. Associations were evaluated with odds ratios (ORs), 95% CIs, and P values obtained from unweighted logistic regression models using SAS software version 6.12 (SAS Institute Inc, Cary, NC). Adjusted ORs were estimated with a model containing all factors studied (race, sex, age, education, income, county type [urban or rural], and personal or family history of stroke), and multilevel variables were coded using dummy variables. To evaluate the dose-response relationship between multilevel variables and stroke awareness, a model containing all factors studied was created in which multilevel variables were coded as continuous variables. An [alpha] level of .05 was used to evaluate statistical significance.

RESULTS

Enrollment

Of 2,064 telephone numbers screened, 805 were excluded because the number was disconnected or for a business (n = 650), the number was never called because the target sample size was reached (n = 130), no eligible resident was living at the household (n = 16), or all attempts resulted in no answer or a busy signal (n = 9). For the remaining 1,259 telephone numbers, 602 respondents gave an interview, 137 respondents refused, and 520 telephone numbers did not yield an interview for other reasons, such as respondent unavailability or communication barrier. Thus, the cooperation rate was 81.5% (602/739), and the overall response rate was 47.8% (602/1,259). The median age of respondents was 41 years (range, 18 to 99 years). Distributions of the demographic characteristics of respondents (Table 1) were similar to estimates from the US Census Bureau and the Georgia Behavioral Risk Factor Surveillance System (BRFSS). [10,11]

Awareness of Stroke Warning Signs

When asked, "Would you recognize any signs or symptoms in a person having a stroke," 55.5% of respondents answered affirmatively. However, when subsequently asked the open-ended question "What are the signs or symptoms of a person having a stroke? Try to tell me as many as you can," only 38.5% (95% CI; 32.6%-44.4%) named [greater than or equal to]1 of the 5 warning signs. The proportions of respondents who could name exactly 1, 2, 3, and 4 warning signs were 21.6%, 11.7%, 5.1%, and 0.1%, respectively (Figure). No respondent named all 5 stroke warning signs. The most commonly named signs not related to stroke were trouble breathing (10.0%), chest pain (6.9%), and seizure (1.1%).

In contrast to relatively low levels of awareness when measured by an open-ended question, a much greater proportion of respondents recognized stroke warning signs when they were read from a list (Table 2). Almost all respondents (99.5%) identified [greater than or equal to]1 stroke warning sign, and more than half (54.9%) identified all 5 warning signs (Figure). Similarly, a greater proportion of respondents identified signs not relating to stroke: arm pain (65.9%), chest pain (58.0%), and joint pain (32.0%).

A logistic regression analysis with a model containing race, sex, age, education, income, county type, and personal and family history of stroke revealed that only age, education, and family history of stroke were significantly associated with knowledge of [greater than or equal to]1 stroke warning sign (Table 3). For both age and education, there was a dose-response relationship with knowledge of [greater than or equal to]1 stroke warning sign (P value for trend for age = .0001; P value for trend for education = .003).

Knowing What Should Be Done

Most respondents (69.8%) stated they would call 911 if someone were having a stroke.

Among those who did not give the "best" answer of calling 911, most responses still indicated that stroke was considered a medical emergency: go to hospital (8.7%), call doctor (4.0%), call for help (3.7%), call emergency number or ambulance (3.3%), go to doctor (2.6%), call hospital (1.8%), or seek medical attention (0.9%). Only 5.1% of respondents did not know what to do or gave a response indicating that stroke was not a medical emergency. Similarly, 94.4% of respondents agreed with the statement, "I would call emergency services if I or someone I was with experienced signs or symptoms of a stroke."

Knowledge About Stroke Prevention and Treatment

Most respondents (83.8%) agreed that "a person can reduce his or her risk of having a stroke." The proportion of respondents who identified stroke risk factors from a list of factors ranged from 68.5% (diabetes) to 96.8% (a previous stroke) (Table 4). With the exception of stress (94.5%), factors that are not true risk factors were not commonly identified as risk factors: cancer (26.2%), arthritis (15.4%), and poor eyesight (14.4%).

Most respondents (78.2%) agreed that "there are emergency treatments for stroke," and 27.5% had heard or read something about a stroke treatment in the past year. In the latter group, the most common sources of information were television (44.3%), newspapers (28.0%), hospitals (19.4%), brochures/flyers/posters (15.7%), word of mouth (11.2%), and newsletters (11.0%).

Burden of Stroke

Overall, 5.9% (95% CI, 1.9%-10.0%) of respondents reported having had a stroke. Nearly half of all respondents (47.8% [95% CI, 41.8%-53.9%]) reported that someone else in their family had had a stroke.

DISCUSSION

This survey shows a limited awareness of stroke warning signs among Georgia adults and also highlights difficulties in measuring stroke awareness with commonly used questions. While virtually all respondents could recognize at least 1 sign when read from a list and more than half could recognize all 5 of the major stroke warning signs, only 39% of respondents could spontaneously name at least 1 sign and none could name all 5.

Intuitively, one suspects that awareness is overestimated by the aided question and underestimated by the unaided question. In fact, neither question simulates the reality of needing to make a spontaneous connection between a stroke sign and a stroke. The aided question suggests the unlikely scenario in which a person having a stroke says, "My right arm feels weak. Do you think I'm having a stroke?" In contrast, the unaided question measures only knowledge that can be spontaneously recalled, which may not be required when a sign is observed or a symptom described. Perhaps a "partially aided" question would more closely approximate the situation in which a person needs to recognize a potential stroke (eg, "A person tells you 'I've just noticed my arm feels numb.' What would you do? What do you think this person's problem is?").

Given these limitations, we defined awareness conservatively by using results from an unaided question. For designing and evaluating interventions to improve stroke recognition and reduce delays in seeking treatment, such a definition decreases the likelihood of incorrectly concluding a population has "adequate" awareness.

Another drawback to the study was its limited response rate, which may have been a source of selection bias. However, even if nonrespondents had considerably greater knowledge of stroke than study participants, overall stroke awareness would still be low enough to warrant public health action. Nonresponse also might have biased the OR estimates for the predictors of stroke knowledge; however, this scenario seems unlikely because to be a confounder, nonresponse would have to be associated with both the predictor and stroke knowledge.

Results from this study reflect knowledge levels that are lower than those shown by other published surveys. Surveys from Cincinnati showed that 57% of adults with a demographic profile of stroke patients and 61% of patients with an emergency department diagnosis of stroke could name at least 1 sign; also, in a survey from North Carolina in which patients more than 55 years old were recruited at primary care medical practices, 75% could name at least 1 sign. [12-14] Differences between our findings and those of other surveys may be explained by selection bias (as described), different study populations, the broader presence of stroke therapy trials, and greater efforts to promote stroke awareness. [13]

When using data to decide which groups deserve extra attention from a stroke awareness campaign, one strategy is to focus on groups with relatively lower stroke awareness. Such a strategy is supported by the observation that, at least in one setting, most stroke-related calls to activate emergency medical services were made by family members, paid caregivers, and co-workers--not stroke patients themselves. [15] Although we found that adults who are younger ([less than]30 years), not college graduates, or lacking a family history of stroke have relatively less knowledge of stroke warning signs, we believe overall awareness levels are so low that all Georgia adults should be considered "at risk." Another strategy for setting priorities is to focus efforts on groups with an increased risk of dying of stroke. State mortality statistics show that these high-risk groups are blacks and older people. [16]

Most Georgia adults recognize that strokes are emergencies. Nearly 70% of adults report they would call 911 if someone were having a stroke, and an additional 25% would seek medical attention. Since not being transported by ambulance is a risk factor for delayed transport of stroke patients to a hospital, it is important to educate or remind Georgia adults to call 911 if someone appears to be having a stroke. [3,4]

Most Georgia adults agree that people can reduce their risk of a stroke, and a large proportion of adults can recognize risk factors from a list. While these results reflect some knowledge of stroke prevention, other studies have shown an increasing prevalence of risk factors, such as smoking, obesity, and physical inactivity. [17] Thus, recognition of stroke risk factors does not appear to translate into healthy lifestyles for many Georgia adults.

By self-report, nearly 6% of Georgia adults (1 of 17) have had a stroke, and almost half of adult Georgians have a family member who has had a stroke. This first statistic is 3 times higher than results obtained from the Georgia BRFSS (K. E. Powell, MD, MPH, written communication, Georgia Department of Human Resources, September 1999). In the BRFSS, however, the question was "Has a doctor ever told you that you had any of the following?" (a list of health conditions follows that includes stroke), while in the present survey, the question was, "Have you ever had a stroke?" A validation study of this latter question showed a sensitivity of 95% and a specificity of 96%. [18] Perhaps the lower stroke prevalence from the BRFSS reflects the requirement that a physician mention the stroke.

In conclusion, results from this statewide survey add to the growing body of evidence that stroke awareness in the general population is low and that action to improve stroke awareness is urgently needed. In Georgia, and most likely in the United States as a whole, education campaigns should be directed to the general public. Extra effort should be focused on young adults ([less than]30 years) and those who are not college graduates because these groups have lower awareness levels, and on blacks and the elderly because stroke mortality disproportionately affects these groups. When possible, stoke messages should be communicated via mass media, such as television and newspapers, and in hospital settings. The impact of public education alone may be limited; therefore complementary strategies, such as educational campaigns directed toward physicians and paramedics, should also be implemented to reduce treatment delays. [19,20] Regarding the measurement of stoke awareness, interventions can be planned and evalua ted with surveys using unaided questions, but further work is needed toward developing and validating "partially aided" questions that approximate more closely the situation in which a person must identify a potential stroke.

References

(1.) Rowe AK: Stroke in Georgia: defining the problem and finding solutions. Georgia Epidemiol Rep 1999; 15:1-3

(2.) National Institute of Neurologic Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581-1587

(3.) Wester P, Radberg J, Lundgren B, et al: Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Stroke 1999; 30:40-48

(4.) Williams LS, Bruno A, Rouch D, et al: Stroke patients' knowledge of stroke: influence on time to presentation. Stroke 1997; 28:912-915

(5.) Kreuter MW, Strecher VJ: Changing inaccurate perceptions of health risk: results from a randomized trial. Health Psychol 1995; 14:56-63

(6.) Samsa GP, Cohen SJ, Goldstein LB, et al: Knowledge of risk among patients at increased risk for stroke. Stroke 1997; 28:916-921

(7.) American Stroke Association, a Division of American Heart Association: Metro Stroke Task Force Handbook. 1998

(8.) US Department of Agriculture: Economic Research Service's 1989 revised county topology for Georgia. Available at: http://www.econ.ag.gov/epubs/other/typolog/TYP89GA.txt. Accessed September 22, 1999

(9.) Lee ES, Forthofer RN, Lorimer RJ: Analyzing Complex Survey Data. Newbury Park, NY, Sage Publications Inc, 1989

(10.) US census Bureau: Population Estimates for counties by Age, Race, Sex, and Hispanic Origin. Available at: http://www.census.gov/population/estimates/county/casrh/casrhl3.txt. Accessed September 16,1999

(11.) Centers for Disease Control and Prevention: Behavioral Risk Factor Surveillance System. Available at: http://www2.cdc.gov/nccdphp/brfss/index.asp. Accessed January 17, 2000

(12.) Pancioli AM, BroderickJ, Kothari R, et al: Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998; 279:1288-1292

(13.) Kothari R, Sauerbeck L, Jauch E, et al: Patients' awareness of stroke signs, symptoms, and risk factors. Stroke 1997; 28:1871-1875

(14.) Goldstein LB, Gradison M: Stroke-related knowledge among patients with access to medical care in the stroke belt. J Stroke Cerebrovasc Dis 1999; 8:349-352

(15.) Wein TH, Staub L, Felberg R, et al: Activation of emergency medical services for acute stroke in a nonurban population. The TLL Temple Foundation Stroke Project. Stroke 2000; 31:1925-1928

(16.) Rowe AK, Dignam TA, Fox P, et al: The 1998 Georgia stroke report. Georgia Department of Human Resources, Division of Public Health, and the American Heart Association, SE Affiliate; 1998. Publication No. 98DPH.23HW

(17.) Rowe AK, Powell KE, Hall V: The 1999 Georgia State of the Heart Report. Georgia Department of Human Resources, Division of Public Health, Cardiovascular Health Section, and the American Heart Association, SE Affiliate; 1999. Publication No. DPH99.3HW

(18.) O'Mahony PG, Dobson R, Rodgers H, et al: validation of a population screening questionnaire to assess prevalence of stroke. Stroke 1995; 26:1334-1337

(19.) Castaldo JE, Nelson JJ, Reed JF, et al: The delay in reporting symptoms of carotid artery stenosis in an at-risk population. Arch Neurol 1997; 54:1267-1271

(20.) Alberts MJ, Perry A, Dawson DV, et al: Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke 1992; 23:352-356

TABLE 1. Respondent Demographics (Unweighted Analysis)
Characteristic                         No. (%)
Female sex                          304/601 (50.6)
Race
 White                              402/596 (67.5)
 Black                              165/596 (27.7)
 Other                               29/596  (4.9)
Age (yrs)
 18-29                              132/588 (22.5)
 30-44                              211/588 (35.9)
 45-64                              155/588
 [greater than or equal to]65        90/588 (15.3)
Income
 [less than]$20,000                  63/602 (10.5)
 $20,000-$34,999                    127/602 (21.1)
 $35,000-$49,999                     70/602 (11.6)
 $50,000-$74,999                     46/602 (7.6)
 [greater than or equal to]$75,000   47/602 (7.8)
 Not reported                       249/602 (41.4)
Education
 Did not graduate high school        82/598 (13.7)
 High school graduate               143/598 (23.9)
 Some college                       206/598 (34.5)
 College graduate                   167/598 (27.9)
County of residence
 Urban                              513/602 (85.2)
 Rural                               89/602 (14.8)
TABLE 2. Awareness of Stroke Warning Signs Among Georgia Adults,
as Measured by 2 Types of Questions (Weighted Analysis)
                         Sign Mentioned in Response to an
                               Open-Ended Question
Sign or Symptom                      Percent                95% CI
Weakness or numbness                  24.4                 18.7-30.0
Loss of vision                         5.0                  2.7-7.3
Speech difficulty                     14.3                 10.1-18.4
Headache                               7.5                  4.2-10.7
Dizziness, unsteadiness                9.7                  6.4-12.9
                         Sign Identified From a List Read
                                  to Respondent
Sign or Symptom                      Percent                95% CI
Weakness or numbness                   94.8                92.6-97.0
Loss of vision                         77.0                71.7-82.3
Speech difficulty                      93.3                90.7-95.9
Headache                               76.9                71.6-82.2
Dizziness, unsteadiness                89.5                85.9-93.2
CI = Confidence interval.
TABLE 3. Factors Associated With Knowledge of at Least 1 Stroke
Warning Sign as Assessed With an Unaided Question
                                 Knowledge of [greater than or
                                        equal to]1 Sign
                                           Percent *
Age (yrs)
   18-29                                     26.7
   30-44                                     38.2
   45-64                                     47.3
   [greater than or equal to]65              47.4
Education
   Not high school graduate                  31.0
   High school graduate                      30.5
   Some college                              39.1
   College graduate                          53.2
Family history of stroke
   No                                        32.9
   Yes                                       44.8
                                              Adjusted
                                  95% CI    Odds Ratio +  95% CI
Age (yrs)
   18-29                         15.6-37.8    Referent       -
   30-44                         28.9-47.5      1.8       1.0-3.0
   45-64                         34.3-60.2      2.8       1.6-4.9
   [greater than or equal to]65  34.0-60.7      2.7       1.4-5.2
Education
   Not high school graduate      17.5-44.5    Referent       -
   High school graduate          20.2-40.8      1.9       1.0-3.7
   Some college                  29.2-49.0      2.1       1.1-3.9
   College graduate              40.6-65.8      3.1       1.6-6.0
Family history of stroke
   No                            25.5-40.4    Referent       -
   Yes                           35.5-54.1      1.7       1.2-2.5
CI = Confidence interval.
(*) Weighted percentage.
(+) Estimates from an unweighted logistic regression model
adjusting for sex, race, income, county type (urban or rural),
and personal history of stroke.
TABLE 4. Awareness of Stroke Risk Factors Among Georgia Adults As
Assessed With an Aided Question (Weighted Analysis)
      Risk Factor     Percent   95% CI
Previous stroke        96.8    94.7-98.8
High blood pressure    96.1    93.6-98.6
Overweight             93.0    90.1-95.9
High cholesterol       89.5    85.7-93.4
Sedentary life-style   89.2    85.4-92.9
Smoking                89.0    85.8-92.1
Heart disease          86.4    82.0-90.7
Heavy alcohol use      83.0    77.9-88.1
Diabetes               68.5    63.0-74.0
CI = Confidence interval.

[Graph omitted]

KEY POINTS

* Most respondents (78.2%) agreed that emergency treatments for stroke exist.

* Some respondents (27.5%) had heard or read something about a stroke treatment in the past year, usually through television (44.3%), newspapers (28.0%), hospitals (19.4%), brochures/flyers/posters (15.7%), word of mouth (11.2%), and newsletters (11.0%).

* Overall, 5.9% (95% CI, 1.9%-10.0%) of those surveyed reported having had a stroke.

* Nearly half of the people (47.8%; 95% CI, 41 .8%-53.9%) said someone in their family had suffered a stroke.

* Education programs should be directed to the general public.