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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 134-139

Awareness of stroke, its warning signs, and risk factors in the community: A study from the urban population of Benin City, Nigeria


1 Neurology Unit, Department of Medicine, Central Hospital, Benin City, Nigeria
2 Neurology Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Submission17-Jan-2018
Date of Acceptance11-Jul-2018
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Francis Ehidiamen Odiase
Neurology unit, Department of Medicine, University of Benin Teaching Hospital, Benin City
Nigeria
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DOI: 10.4103/smj.smj_4_18

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  Abstract 


Background: Stroke is increasingly a major cause of mortality and morbidity in Nigeria. Studies in Nigeria regarding public awareness of stroke are few and mainly hospital based. Objectives: This study was designed to assess the level of public awareness of stroke, its warning signs, and risk factors in the urban population of Benin City, Nigeria. Materials and Methods: This was a cross-sectional study carried out in Benin City, Edo State, Nigeria. Participants were recruited randomly in public places and interviewed face to face with a questionnaire to determine their demographics, knowledge of stroke, its warning signs, and risk factor with source of information on stroke. Data analysis was with the Statistical Package for the Social Science (SPSS) version 21with a level of significance of P < 0.05. Results: Five hundred and twenty-five respondents were recruited with a median age of 42 (12.1) years. The most identified risk factor for stroke and warning sign for stroke by respondents were hypertension (93.2%) and sudden-onset loss of speech (77.3%), respectively. Faith-based settings (39.5%) were the most common sources of information about stroke while hospital settings accounted for only 12.1%. The awareness of stroke campaign 9.97 (confidence interval [CI], 5.75–17.3, P≤ 0.001) and awareness that the brain is involved in stroke 7.51 (CI, 4.11–13.72, P≤ 0.001) were significantly associated with identifying at least one warning sign of stroke. Conclusion: Awareness of stroke, its risk factors, and warning signs is good in this urban community of Benin, but the major sources of information are from faith-based settings. It is recommended that efforts should be sustained at continuous health education campaigns, and it is hoped that other avenues of information, mass media, and hospital settings should be optimized to ensure robust knowledge about stroke.

Keywords: Risk factors, stroke, warning signs


How to cite this article:
Kayode-Iyasere E, Odiase FE. Awareness of stroke, its warning signs, and risk factors in the community: A study from the urban population of Benin City, Nigeria. Sahel Med J 2019;22:134-9

How to cite this URL:
Kayode-Iyasere E, Odiase FE. Awareness of stroke, its warning signs, and risk factors in the community: A study from the urban population of Benin City, Nigeria. Sahel Med J [serial online] 2019 [cited 2019 Oct 13];22:134-9. Available from: http://www.smjonline.org/text.asp?2019/22/3/134/267896




  Introduction Top


Stroke is a global epidemic that threatens lives, health, and quality of life.[1] According to the World Health Organization, stroke is the second leading cause of mortality accounting for approximately 4.6 million deaths annually.[2] Every 6 s, someone somewhere will die of stroke. Stroke is responsible for more deaths annually than those attributed to AIDS, tuberculosis, and malaria combined, yet stroke remains a silent epidemic.[1] Thus, stroke is a disease of grave public health concerns, with huge financial, economic, and social consequences.[3]

Stroke to an extent is a preventable neurological disease, as many of the established modifiable risk factors for stroke including hypertension, high cholesterol, diabetes, heart disease, and smoking can be prevented either through healthy lifestyle modification or by medications.[4] Studies have shown that lack of recognition of stroke warning signs is an important cause of delayed arrival to the hospital after a stroke.[5],[6] Thus, health professionals and the public awareness of stroke risk factors and warning signs are the first steps to action in the control of the disease.

The current prevalence of stroke in Nigeria is 1.14/1000, while the 30-day case fatality rate is as high as 40%.[7] Strokes is a huge burden in Nigeria and places a major financial burden on the people and the inadequate health care resources in the country.

]The high prevalence of stroke in Nigeria may be attributed to poor public community awareness of the disease. Studies in Nigeria regarding public awareness of stroke are few and are mainly hospital based.[8],[9],[10],[11] In a country with a high stroke burden like Nigeria, there is an urgent need to access public awareness of the disease. It is with this background that this study was designed to access the level of public awareness of stroke, its warning signs, and risk factors in an urban population in Nigeria, as this would help provide the basis and direction of the relevant health education on the subject, for those at risk and the public in general. It will also provide the platform for our health-care providers and policy-makers to deliver to the populace better health-care packages that emphasize that “prevention is better and cheaper than cure.”


  Materials and Methods Top


This was a cross-sectional study which was carried out in Benin City, Edo State, Nigeria, with an estimated population of 1.5 million people between March and July 2017.

The study was conducted using a pretested questionnaire, with participants recruited randomly in public places including churches, marketplaces, shopping malls, restaurants, and motor parks.

The interview was done by the authors and four assistants, in a face-to-face manner after a verbal consent from each participant. This study was approved by the Research and Ethics Committee, Central Hospital Benin City on May 2, 2018 (Reference number A736/15).

The questionnaire had five sections to determine the following:

  1. Demographic data – Sex, age, ethnicity, occupation, religion, and education
  2. Knowledge about stroke – Have you heard of the condition called stroke? Are you aware of any campaign to promote stroke awareness? Your source of information on stroke?
  3. Which of the following options is evidence that a stroke has occurred. (Stroke symptoms, stroke warning symptoms, and stroke warning signs have been used interchangeably in several studies to refer to the presence of sudden onset of speech problems, sudden onset of face, arm, and leg weakness or numbness, sudden onset of headache, sudden onset loss of vision, and sudden onset dizziness, loss of balance, or coordination, based on the listing by the American Stroke Association and the National Institute of Neurological Disorders and Stroke [3],[10],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]). In addition to above, respondents were also presented with four wrong options including sudden-onset fainting, sudden-onset double vision, sudden-onset chest pain, and sudden-onset breathlessness. Identification of at least one warning sign for stroke was regarded as being aware of stroke
  4. Question about which part of the body is affected in stroke was presented as an open-ended question. Mention of the brain was taken as correct knowledge of organ involved in stroke
  5. Knowledge of risk factors included six correct options (hypertension, high cholesterol, obesity, excessive alcohol ingestion, diabetes mellitus, and smoking). Recognition of one or two risk factors was regarded as being aware of stroke risk factors.


Descriptive and comparative statistical analyses were performed using SPSS version 21, Inc, Chicago, Illinois. Means, standard deviation, medians, and interquartile range were presented for continuous variable, with comparison using the two-tailed t-test statistics. Categorical data were presented as frequency and percentages, with comparison based on the Chi-square test. Univariate analysis was performed to detect associations between the knowledge of stroke risk factors and warning signs and various independent parameters including gender, educational status, age, having heard about the word stroke, awareness of brain as organ affected in stroke and awareness of stroke campaign, and source of information. Variables reaching statistical significance in the univariate analysis were included in the final logistic regression model with the result being presented as odds ratios and confidence intervals (CIs). Statistical significance was assigned at the level P < 0.05.


  Results Top


There were 525 respondents with 156 males (29.7%). The mean ages of the male and female respondents were 40.7 (13.8) and 42.4 (11.1) years, respectively, while the overall mean age was 42.0 (12.1) years. The ethnic groups of respondents were comprised the Binis 197 (37.5%), the Ishans 94 (17.9%), the Ibos 85 (16.2%), the Etsakos 75 (14.3%), the Yorubas 14 (2.7%), and the Hausas 4 (0.8%). Majority, i.e. 348 (66.3%) were civil servants, 99 (18.9%) were self-employed, 46 (8.7%) were unemployed, while 32 (6.1%) were retired. Four hundred and ninety-six (94.5%) of the respondents were Christians while 13 (2.5%) were Moslems. Over 50% of respondents had tertiary level of education, while 27 (5.1%) had no formal education [Table 1].
Table 1: Sociodemographic characteristics of participants

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Majority, i.e. 511 (97.3%) of participants have heard of the word stroke, while 247 (48.3%) have heard of the campaign to promote stroke awareness. The highest sources of information about stroke for respondents were from church conventions, 202 (39.5%), whereas only 62 (12.1%) were from hospital/health seminars. Only 198 (38.7%) of respondents were able to identify the brain as the organ involved in stroke. One warning sign was correctly identified by 455 (89.0%), while 481 (94.1%) of the participants correctly identified one risk factor for stroke. The most common warning sign identified was sudden onset of speech problem 397 (77.3%), followed by sudden onset of arm and leg weakness 382 (74.8%), while about 20% of respondents had considered chest pain as a warning sign of stroke [Table 2].
Table 2: Participants response to stroke awareness questions

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The most identified risk factors for stroke by participants was hypertension 476 (93.2%), and this was followed by high cholesterol 376 (73.6%), obesity 343 (67.1%), alcohol 324 (63.4%), diabetes mellitus 296 (57.9%), and smoking 288 (56.4%) [Table 2].

There was no association between gender of respondents and their awareness of at least one risk factor for stroke (P = 0.589) and their ability to identify at least one warning sign of stroke (P = 0.06). The multiple logistic regression analysis showed that awareness of stroke campaign 9.97 (CI, 5.75–17.3, P≤ 0.001) and awareness that the brain is involved in stroke 7.51 (CI, 4.11–13.72, P≤ 0.001) were significantly associated with the ability to identify at least one warning sign of stroke after adjusting other variables [Table 3] and [Table 4].
Table 3: Association between gender and stroke knowledge

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Table 4: Variables in the final logistic regression for awareness of warning sign

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  Discussion Top


The study showed that there was a high level of awareness of stroke, its warning signs, and risk factors among the study population better than that described in similar studies in the literature.[12],[13] This high level of awareness of warning signs and risk factors might be motivated by the health consciousness of the people and perhaps from life experiences. In our study, assessment of stroke warning signs and risk factors was performed through a closed-ended questionnaire which may explain the outstanding level of knowledge. The use of a closed-ended questionnaire in identifying stroke warning signs and risk factors may have resulted in an overestimate of the real level of knowledge than if an open-ended questionnaire was used. There is evidence that respondents are better at recognition of warning signs and risk factors than they are at identifying them in response to open-ended (unaided) questions.[14],[23] Awareness in this study was very high in both male and female respondents, with the female gender constituting more than two-third of the respondents. The reasons could be attributed to the fact that the females were more receptive toward accepting our questionnaire; they were more available in public places where recruitment for the study was made. They also form the majority, where public enlightenment campaigns on health issues are being organized. Only 38.7% of those who had knowledge of stroke were able to identify the brain as the organ involved in stroke. This finding is low compared to studies from India with 45.5%[15] and Pakistan 50.8%[24] and even much lower when compared to studies from Brazil 73.4%[16] and Australia 76%.[17]

Sudden onset of speech identified by 77.3% of our respondents was the most common warning sign as in some studies in Ireland who reported a much higher figure 90%[18] and a lower figure from Australia 60.1%[17] but in marked contrast to findings by Wahab et al. 7.6%[11] in a hospital-based study in South-South Nigeria. Furthermore, reports from the United States showed a figure of 8%.[19] Another frequently reported warning sign was sudden onset of arm and leg weakness 74.8%. This finding is comparable with other studies from the United States [19] and Omani [25] where we observed that this was the most identified warning sign. In contrast, only 24.4% of respondents by Wahab et al. were able to recognize unilateral arms and leg weakness as a warning sign, and this was the most common warning sign identified in this study, which was attributed to the fact that in some parts of Nigeria, stroke is described simply as paralysis of the limb on one side of the body. The reason for this difference in the same geographical zone may be attributed to the fact that public enlightenment campaigns on health issues using the various media are more regular and rampant in the urban setting than in the semi-urban/rural setup where the study was carried out. It could also be attributed from our findings that church conventions where a lot of public enlightenment campaigns on health issues are being given are frequently organized in the urban centers, and only a few people from the semi-urban/rural areas usually attend. This inability to identify and respond to stroke warning signs in a semi-urban/rural setting highlights an area of specific need for health promotion intervention. About 58.0% of the respondents were able to identify other warning signs of strokes while 32.1% identified nonstroke warning signs which included sudden-onset chest pain, sudden-onset breathlessness, sudden-onset fainting, and sudden-onset double vision [Table 2].

The most commonly identified risk factor for stroke was hypertension (93.2%). This is similar to observation from Brazil (93.6%).[16] Other studies in which hypertension was the most recognized risk factor for stroke include Ireland (75%),[20] India (45.1%),[15] Cincinnati, Ohio (49%),[19] Pakistan (69.2%).[24] The proportion of respondents who had positive answers for other risk factors such as high cholesterol, obesity, alcohol, diabetes mellitus, and smoking were also much higher compared to other studies.[17],[18],[19] The observed ability to recognize at least one warning sign of stroke was high compared to 77% reported by Pandian et al.[15] and 68% reported by Al Shafaee et al.[25] though these were hospital-based studies. Despite this high level of awareness, studies in Nigeria have reported a general delay in arrival to the hospital following an acute stroke,[26],[27] which means that some gaps in knowledge still exist. Similarly, the observed ability to recognize at least one risk factor for stroke was high compared to 86.9% reported by Aly et al.[24] and 76.2% reported by Sug Yoon et al.[17] The reason why knowledge of stroke risk factors is important is for the population to be aware of their increased risk status and to participate in stroke preventive measures. Majority of stroke risk factors are modifiable, and hence, individual behavioral changes can lead to healthier lifestyles and increased longevity. In fact, studies have shown that increased awareness in patients at high risk for stroke leads to improved compliance with better stroke prevention practices.[28],[29]

The primary sources of information of respondents in this study were from church conventions followed by media, with a small proportion from hospital/health seminars. No doubt faith-based organizations play an important role in caring for the health needs of the people as some of them organize free medical screening and public enlightenment campaigns at such times to attract members to their churches. This free medical screening and public enlightenment campaigns are usually done by doctors, nurses, pharmacist, laboratory scientist, etc., This ensures that the knowledge given to the people is accurate and free from erroneous information. More than 50% of the respondents had tertiary level of education; this might have contributed positively to their choice of answers. Although we did not detect any significant association between level of education and knowledge of stroke, studies have shown a strong association between higher level of education with correct identification of stroke risk factors and warning signs.[15],[17]

From our study, mass media campaign to improve public awareness of stroke was found to be effective in improving knowledge of stroke, its warning signs, and risk factors. This finding is strongly supported by other studies.[10],[21],[22] To date, evidence indicates that stroke awareness campaigns are at least effective in increasing knowledge in the general population.[20] An increasing awareness of stroke, its warning signs, and risk factors, therefore, will translate into reducing the mortality and morbidity associated with stroke.[30]


  Conclusion Top


Although awareness of stroke, its warning signs, and risk factors are well recognized in the population, it is possible that some gaps in knowledge still exist, which may result in delayed arrival to the health facility for prompt treatment. Early recognition of stroke warning signs is the key to maximizing the potential for medical intervention and more favorable stroke outcomes – “time is brain.” It is recommended that increasing efforts should be made to maintain this high level of awareness through continuous health education for more productive outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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