Schneider AT, Pancioli AM, Khoury JC, Rademacher E, Tuchfarber A, Miller R, Woo D, Kissela B, Broderick JP. Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke. JAMA. 2003;289(3):343-346. doi:10.1001/jama.289.3.343
Author Affiliations: Departments of Neurology (Drs Schneider, Woo, Kissela, and Broderick and Ms Miller), Emergency Medicine (Dr Pancioli), Environmental Health (Ms Khoury), and Institute for Policy Research (Drs Rademacher and Tuchfarber), University of Cincinnati, Cincinnati, Ohio.
Context Poor public knowledge of stroke warning signs and risk factors limits
effective stroke intervention and prevention.
Objective To examine temporal trends in public knowledge of stroke warning signs
and risk factors.
Design and Setting Population-based random-digit telephone survey conducted in July-November
2000 among individuals in the greater Cincinnati, Ohio, region.
Participants A total of 2173 survey respondents (69% response rate) were randomly
identified based on their demographic similarities to the ischemic stroke
population with regard to age, race, and sex.
Main Outcome Measures Spontaneous recall of at least 1 important stroke warning sign and 1
established stroke risk factor in comparison with findings from the same survey
Results In 2000, 70% of respondents correctly named at least 1 established stroke
warning sign vs 57% in 1995 (P<.001), and 72%
correctly named at least 1 established stroke risk factor vs 68% in 1995.
Groups of individuals with the highest risk and incidence of stroke, such
as persons at least 75 years old, blacks, and men, were the least knowledgeable
about warning signs and risk factors. Television was the most frequently cited
source of knowledge, 32% in 2000 vs 24% in 1995 (P<.001).
Conclusions Public knowledge of stroke warning signs within the greater Cincinnati
region has significantly improved from 1995 to 2000, although knowledge of
stroke risk factors did not improve significantly during the same time period.
Public education efforts must continue and should focus on groups at the highest
risk of stroke.
The inability of patients and bystanders to recognize stroke symptoms
and to quickly access the emergency medical system are the largest barriers
to effective acute stroke therapy.1- 9 Previous
surveys have shown that knowledge of stroke warning signs among persons who
have had a stroke and the general public is poor, with only 39% to 61% able
to name at least 1 stroke warning sign.10- 13 Knowledge
of stroke risk factors is also limited, with only 57% to 76% able to name
at least 1 stroke risk factor.11,12 In
1998, we reported results of a 1995 survey of public knowledge of stroke warning
signs and risk factors.10 The current observational
study, using the same methods and survey instrument within the same population,
evaluates public knowledge of stroke warning signs and risk factors in 2000
and examines changes over the 5-year period.
The study population was defined as all residents in a 5-county region
around Cincinnati, Ohio. This population is similar to the United States in
terms of age, sex, proportion of blacks, education level, and economic status.14
This study was designed to ensure a random selection of potential respondents
who approximately matched the demographic characteristics (age, race, and
sex) of patients with ischemic stroke. We used random-digit selection of telephone
numbers and random-respondent selection within a household. Details of this
method have been previously described.10 Since
97.8% of households in Cincinnati reported having telephone service in 2000,
only a small proportion of the population would have been omitted from this
The 64 professional telephone interviewers of the University of Cincinnati
Institute for Policy Research who administered the survey were monitored for
quality and comparability. The supervisor randomly monitored 20% of the interviews
by using special telephone lines or direct computer screen viewing.
To ensure that the demographic characteristics of the respondents approximated
those of the ischemic stroke population, we created a demographic table that
contained the desired number of respondents in each of the demographic categories
of age, race, and sex. To maintain consistency, the age, race, and sex demographics
were determined by the same method used in 1995.10 We
interviewed only those respondents whose demographic characteristics matched
an unfilled category.
The survey instrument consisted of 29 questions divided into 3 sections.
The first section contained open-ended questions designed to challenge respondents
to spontaneously demonstrate their knowledge. Respondents were asked to name
up to 3 stroke warning signs, then 3 stroke risk factors, and finally 3 sources
of information about stroke. Those listing fewer than 3 were encouraged to
complete the list. The second section contained questions designed to assess
the prevalence of stroke risk factors. These questions were identical to questions
used in the Third National Health and Nutrition Examination Survey.15 The third section contained questions regarding demographics
and level of education. This questionnaire was identical to our 199510 survey. The study was approved by the University
of Cincinnati Medical Center Institutional Review Board. A copy of the questionnaire
is available on request from the authors.
Respondents' knowledge of important warning signs of stroke was assessed
with signs established by several national organizations (American Stroke
Association,16 National Stroke Association,17 and National Institute of Neurological Disorders
and Stroke18), which list the following as
important warning signs of stroke in their educational materials: (1) sudden
numbness or weakness of the face, arm, or leg, especially on one side of the
body; (2) sudden confusion or trouble speaking or understanding speech; (3)
sudden trouble seeing in one or both eyes; (4) sudden trouble walking, dizziness,
or loss of balance or coordination; and (5) sudden severe headache with no
known cause. Knowledge of risk factors was assessed using the following established
risk factors19- 26:
hypertension, smoking, heart disease, diabetes, transient ischemic attack
or prior stroke, heavy alcohol use, and hypercholesterolemia.
Descriptive and comparative statistical analyses were performed using
SAS statistical software (SAS Institute, Cary, NC). The χ2 test
was used to assess the univariate relationship between each risk factor or
warning sign and age, race, and sex. The effects of demographics and the presence
of risk factors on the respondents' knowledge were evaluated using multivariable
logistic regression modeling. Variables considered in the modeling included
age, race, sex, level of education, and self-reported risk factors of hypertension,
hypercholesterolemia, diabetes, prior stroke or transient ischemic attack,
prior heart attack, cigarette use, alcohol use, and use of nonsteroidal anti-inflammatory
medication. Interactions between the demographic variables and self-reported
risk factors were also considered in the model. Comparison of the demographics
and risk factors between 1995 and 2000 were performed using χ2 except
for age where a t test was used. Comparisons of knowledge
between 1995 and 2000 were made using multiple logistic regression.
Between July 13 and November 21, 2000, a total of 25 056 households
were called. Of 3151 persons identified as demographically eligible to participate,
826 (26.2%) did not complete the interview due to language barriers, illness,
or unavailability despite multiple callbacks during the study period; another
152 (4.8%) refused. The remaining 2173 (69%) respondents completed telephone
interviews. Due to the nature of the survey, demographics of the nonresponders
are not known.
The mean (SD) age was 61 (17.3) years (range, 18-95 years), 26% were
black, 61% were female, and 50% had more than a high school education (Table 1). Blacks had higher rates of hypertension
(55% vs 42%) and diabetes (23% vs 16%) than whites. Whites had higher rates
of ever smoking than blacks; however, 67% of whites who had ever smoked had
quit vs 49% of blacks who had ever smoked.
The warning signs, regardless of correctness, named by at least 5% of
the respondents are shown in Table 2.
When using only established warning signs as correct responses, 70% of respondents
correctly gave at least 1 stroke warning sign (Figure 1).
The perceived stroke risk factors reported by at least 5% of respondents
are shown in Table 2. Respondents
with a specific self-reported risk factor were more likely to name that as
a stroke risk factor than those without that risk factor. For example, of
those with hypertension, 61% named hypertension as a stroke risk factor vs
43% without a history of hypertension (P<.001).
This was also the case with those who ever smoked, had diabetes, and had hypercholesterolemia.
Overall, 72% named at least 1 correct established stroke risk factor (Figure 1).
Age was significantly associated with stroke knowledge, with those at
least 75 years old and younger than 35 years having less knowledge. Table 3 lists the independent factors significantly
associated with knowledge of at least 1 established stroke warning sign and
The most frequently cited sources of knowledge about stroke were those
of mass media, including television (32%), magazines (24%), and newspapers
(22%). Other responses named by at least 5% of respondents included physicians
(20%), family member with stroke (19%), medical books (9%), friend with stroke
(7%), and "word of mouth" (5%).
The course of action in the event of a stroke was assessed with a single-response
open-ended question. Most respondents (75%) indicated they would activate
911/emergency services. Only 1% answered that they would wait to see if symptoms
Compared with the baseline characteristics of 1995 respondents, the
2000 respondents were younger (mean age, 61 vs 63 years [P<.01]), more highly educated (50% reporting at least some college
vs 41% [P<.001]), and had higher prevalence of
diabetes (16% vs 14% [P = .02]) and hypercholesterolemia
(38% vs 32% [P<.001]).
A significantly higher number of respondents correctly named at least
1 established warning sign in the 2000 survey compared with 1995 after controlling
for age, education, and hypercholesterolemia (70% vs 57%; P<.001) (Figure 1). No
statistically significant difference was seen regarding knowledge of at least
1 stroke risk factor between 2000 and 1995 (72% vs 68%). However, a significantly
higher number of year 2000 respondents named 2 or more stroke risk factors
than in 1995 (32% vs 25% [P<.001]).
Methods of mass media were the most commonly cited source of knowledge
in both survey years. There was a significant increase in television cited
as the primary source between 1995 and 2000 (24% vs 32% [P<.001]). There was no significant difference regarding physicians
being cited as the source of knowledge. A family member having a stroke as
the source of knowledge was cited more frequently by year 2000 respondents
compared with 1995 (19% vs 12% [P<.001]).
Public knowledge of stroke warning signs significantly improved in the
Greater Cincinnati/Northern Kentucky region between 1995 and 2000, while knowledge
of risk factors remained relatively constant. Although public knowledge of
stroke has increased, significant gaps continue to exist, with lack of knowledge
most apparent in the elderly, blacks, and men—groups that have higher
incidence rates of stroke.27- 30 Continued
and intensified educational efforts to promote knowledge of stroke, particularly
among high-risk groups, are needed by policymakers, as well as local and national
Most respondents reported they would use 911/emergency services if they
identified themselves or someone else as having a stroke. However, this may
represent an overestimate given the nature of this survey. Recognition of
possible stroke does not necessarily lead to the proper course of action.
In a study of 152 patients seeking emergency department care for strokelike
symptoms, median delay in hospital arrival was less in cases where a witness
recognized the seriousness of the symptoms.1 Public
education promoting awareness of the seriousness of stroke, the urgency of
stroke evaluation, and the narrow therapeutic time window may lead toward
changes in behavior.
Mass media, especially television, was reported to be the source of
stroke knowledge for most respondents, although physicians were reported as
the primary source of information by 20%. Of patients recalling being informed
by their physician that they are at increased risk of stroke, only 26% acknowledged
that they have increased stroke risk.27 Multiple
strategies to reenforce knowledge may be useful. This approach should include
verbal, written, and other visual information, and repeated educational encounters.
Since television is the most frequently cited source of knowledge, it should
be strongly considered in campaigns promoting public knowledge of stroke warning
signs and risk factors.
Limitations of our study include the inability to determine whether
knowledge leads to changes in behavior such as risk factor modification and
rapid seeking of medical attention in the event of stroke symptoms. We did
not assess knowledge of available stroke treatment or the urgency of acute
stroke evaluation. We also do not know whether the knowledge of the nonresponders
(31%) was greater or less than that of the survey participants.
Improvement in knowledge of stroke warning signs over 5 years in our
regional population occurred without any specific educational intervention
as part of our study. However, tissue plasminogen activator (TPA), the first
Food and Drug Administration–approved treatment for acute ischemic stroke,
became available for use in 1996 with accompanying media coverage that has
continued. We have documented 91 episodes, encompassing 59 days, of stroke-related
coverage in our local and national television, radio, and print media between
1995 and 2000. These stories, many of which included information concerning
stroke warning signs and the approval of TPA for acute stroke, are a potential
explanation for the improved stroke knowledge in the region. Yet, we do not
know if our local media coverage is representative of the United States as
a whole. If educational efforts in our community are greater than efforts
elsewhere, then the call to action regarding stroke education is even more
In summary, some improvement in stroke knowledge over the 5-year period
was observed, but gaps exist, especially in those at the highest stroke risk.
The modest progress that has occurred thus far should act as an incentive
to what can be further achieved by redoubled, organized, and focused efforts
to educate the public about stroke.