Factors Associated with Knowledge and Awareness of Stroke Among the Jordanian Population: A Cross-Sectional Study

Introduction

Stroke is the second cause of death worldwide, with approximately 11% of total deaths and is the leading cause of serious and permanent disability (WHO, 2020, Katan, 2018). Moreover, in the past decades, the prevalence of stroke has increased more in developing countries than in developed countries (Feigin et al., 2009, Roth et al., 2020). For instance, stroke represents a major cause of disability and death in the last three decades in Jordan as a large Middle Eastern country. This surge has been linked to the prevalence of behavioral risk factors such as smoking, insufficient physical activity, and an unhealthy diet (Vos et al., 2020, Ministry of Health, 2020).

Primary prevention of cerebrovascular accidents is essential to minimize stroke occurrence. It is achieved through different means, focusing on identifying associated risk factors, initiating prophylactic measures, and increasing patient awareness. Educational programs directed towards the community are among the best preventive measures; thus, an accurate assessment of comprehensive knowledge of stroke and its associated trigger factors is needed (Sug Yoon et al., 2001, Trobbiani et al., 2013, Hatzitolios et al., 2014, Morren and Salgado, 2013, Pandian et al., 2005). In addition to improving the patients’ quality of life, knowledge will prevent healthcare professionals from being overwhelmed when stroke cases present to the emergency room at an early stage (Awad and Al-Nafisi, 2014). It is worth noting that 80% of stroke cases are preventable if necessary precautions and actions are taken (Vincent-Onabajo et al., 2015).

Globally, there is a lack of knowledge about stroke modifiable risk factors as unhealthy behaviors, obesity, smoking, and uncontrolled chronic diseases (Medeiros et al., 2012, Boehme et al., 2017, Farrag et al., 2018). The accurate identification of stroke early symptoms is critical for quick and efficient medical interventions and the reduction of neuro-deficit complications as well as mortality (Müller-Nordhorn et al., 2006, Stroebele et al., 2011a). Hence, in Low-Middle Income and developing countries, there is always a question about the public's understanding of stroke’s risk factors and related issues in terms of the condition’s risk, morbidity and mortality (Stroebele et al., 2011c, Romero et al., 2008). Therefore, it is important to screen public characteristics and traits regarding lifestyle, behavior (O'Donnell et al., 2016), educational level, smoking habits (Hosseininezhad et al., 2017), and socioeconomic status (Hawkes et al., 2015, Hosseininezhad et al., 2017).

Since stroke risk factors (i.e., history of hypertension or/and diabetes) are identifiable in individuals with low socioeconomic status, past medical history is also essential to be investigated. Educational level, personal history of smoking, and high-income status have been associated with increased stroke knowledge (Ramírez-Moreno et al., 2016). Gender is another factor to consider, as findings are contradictory. Indeed, several studies reported that women are more likely to present non-traditional stroke warning signs, develop stroke, and go late to the emergency department compared to males (Lisabeth et al., 2009, Mandelzweig et al., 2006, Roger et al., 2012); oppositely, others showed that women recognize all the five traditional warning signs and quickly call the emergency department (Focht et al., 2014).

Although the assessment of knowledge study deems simple, the outcomes of such research segment positively impact the design and implementation of highly effective interventions based on accurate population-based data. The study will provide an overall insight towards importance of raising the level of knowledge and awareness towards stroke to minimize stroke development, to prevent stroke recurrence, and ensure early patient presentation. Yet, no nationwide study has been conducted in Jordan to assess the public awareness towards stroke. This study aims to highlight public’ gaps in knowledge and to reveal practice-related misconceptions in Jordan as a Middle-Eastern Developing country.

Methods

Results

Stroke knowledge

The sample showed a satisfactory overall level of knowledge about stroke (Figure 1 and Table 2). Nearly 95% of the participants mentioned that the brain is the primary organ of the body affected by stroke and 81% were aware of its possible prevention. In the question about risk factors, 92.1% believed that high blood pressure is the most common risk factor of stroke, followed by psychosocial stress (90.1%) and dyslipidemia (86%), Figure 2. The most identified warning signs were “Sudden difficulty in speaking or understanding speech” as 92.3% and “Sudden weakness/numbness/tingling” as 88%, Figure 3.

Figure 1. Assessment of stroke knowledge.

Table 2. Number of risk factors, early symptoms and consequences identified by the participants.

Variables (n = 573)		Frequency (%)	Cumulative, Frequency (%)
Number of correct responses in the general knowledge	Less than two	4 (0.7)	4 (0.7)
	Two	7 (1.2)	11 (1.9)
	Three	63 (11)	74 (12.9)
	Four	236 (41.2)	310 (54.1)
	Five	263 (45.9)	573 (100)
Number of risk factors identified	Zero	11 (1.9)	11 (1.9)
	One	1 (0.2)	12 (2.1)
	Two	14 (2.4)	26 (4.5)
	Three	17 (3)	43 (7.5)
	Four	23 (4)	66 (11.5)
	Five	28 (4.9)	94 (16.4)
	Six	48 (8.4)	142 (24.8)
	Seven	42 (7.3)	184 (32.1)
	Eight	79 (13.8)	263 (45.9)
	Nine	97 (16.9)	360 (62.8)
	Ten	213 (37.2)	573 (100)
Number of early symptoms identified	Zero	26 (4.5)	26 (4.5)
	One	7 (1.2)	33 (5.8)
	Two	24 (4.2)	57 (9.9)
	Three	23 (4)	80 (14)
	Four	52 (9.1)	132 (23)
	Five	106 (18.5)	238 (41.5)
	Six	129 (22.5)	367 (64)
	Seven	206 (36)	573 (100)
Number of consequences identified	Zero	11 (1.9)	11 (1.9)
	One	12 (2.1)	23 (4)
	Two	15 (2.6)	38 (6.6)
	Three	53 (9.2)	91 (15.9)
	Four	123 (21.5)	214 (37.3)
	Five	359 (62.7)	573 (100)

Figure 2. Identification of stroke risk factors.

Figure 3. Awareness of stroke early symptoms.

Internet/social media was the primary source of information about stroke as described by 24.4% of the respondents, followed by healthcare professionals as reported by 20.9% and family/relatives as 15.2%, Figure 4.

Figure 4. Evaluation of sources of information about stroke.

Multivariable analysis

When considering the identification of at least a risk factor as the dependent variable, the multivariable analysis showed that those residing in rural areas were less likely to identify a risk factor than those living in urban areas (OR = 0.2, p-value of 0.011).

The participant's ability to identify at least one early symptom of stroke as the dependent variable, university compared to the scholar level of education had significantly higher odds (OR = 3.4, p-value of 0.023), and diabetes was inversely associated with early symptoms identification (OR = 0.2, p-value of 0.008).

When considering the identification of at least one consequence of stroke as the dependent variable, females versus males and those with medium income versus low income had significantly higher odds (OR of 6.6 and 4.1 respectively). Moreover, residents of rural areas were less likely to identify stroke consequences compared to urban residents (OR = 0.1, p-value of 0.005).

Concerning the response to stroke symptoms (by taking the patient to the hospital) as the dependent variable, university compared to scholar level of education and employed versus unemployed had significantly higher odds (OR of 2.5 and 1.8 respectively) whereas, having diabetes was associated with lower odds compared to no diabetes history (OR = 0.4) (Table 5, Figure 5).

Table 5. Multivariate analysis.

Variables (n = 573)	β (SE)	OR (95% CI)	P-value
Risk factor(s) identified (≥1)
Gender (female versus male*)	1.1 (0.6)	2.9 (0.8-10.2)	0.098
Residence area (rural versus urban*)	−1.5 (0.6)	0.2 (0.060-0.697)	0.011
Employment status (employed versus unemployed*)	1.2 (0.6)	3.4 (0.9-12.6)	0.062
Early symptom(s) identified (≥1)
Educational level (university versus scholar*)	1.2 (0.5)	3.4 (1.1-9.8)	0.023
Residence area (rural versus urban*)	−0.8 (0.4)	0.4 (0.1-1.04)	0.063
Diabetes (yes versus no*)	−1.4 (0.5)	0.2 (0.07-0.68)	0.008
Obesity (yes versus no*)	1.3 (0.7)	3.7 (0.8-17.2)	0.093
Consequence(s) identified (≥1)
Gender (female versus male*)	1.8 (0.7)	6.6 (1.6-26.9)	0.008
Residence area (rural versus urban*)	−1.8 (0.6)	0.1 (0.04-0.5)	0.005
Income level (medium versus low*)	1.4 (0.6)	4.1 (1.04-15.7)	0.043
Income level high versus low*)	1.7 (1.1)	5.5 (0.58-52.03)	0.137
Taking a patient to a hospital
Educational level (university versus school*)	0.9 (0.4)	2.5 (1.1-5.5)	0.030
Employment status (employed versus unemployed*)	0.6 (0.2)	1.8 (1.1-3.1)	0.028
Diabetes (yes versus no*)	−0.9 (−0.3)	0.4 (0.18-0.85)	0.018

Figure 5. Knolwedge, attitude, and reactions of the participants towards stroke.

Discussion

Public health literacy is a strong asset for a healthier community. As of August 2020, The U.S. Department of Health and Human Services (HHS) released Healthy People 2030, introducing an updated definition of personal health literacy as “the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others,” while organizational health literacy describes the degree to which organizations equitably enable individuals to pursue personal health literacy (Services, 2020, Ancker et al., 2020). This study describes the levels of knowledge and awareness related to stroke among individuals from the general Jordanian population.

Although Karasneh et al., mentioned in their study that Jordanians have an inadequate level of health literacy, most of the participants in our study expressed good knowledge regarding stroke (Karasneh et al., 2020). Particularly being related to the brain, not contagious, not old-age specific, not hereditary, and being preventable. Additionally, most participants identified at least one risk factor, one consequence, and one symptom related to stroke. Compared to similar literature (Sug Yoon et al., 2001, Pancioli et al., 1998, Croquelois and Bogousslavsky, 2006, Reeves et al., 2008), our outcome measures of stroke health literacy are higher, mainly that all knowledge, risk factors, symptoms, and consequences related to stroke were identified by more than 50% of the study sample.

In our study, 98.1% of participants identified at least one risk factor related to stroke. In comparison, previous studies have reported 85.4% among 390 participants in Lebanon (Khalil and Lahoud, 2020), 76.2% among 822 participants in Australia (Sug Yoon et al., 2001), and 59.6% among 2884 participants in Spain (Segura et al., 2003). Conversely, other previous studies have demonstrated poor knowledge of stroke risk factors and symptoms in the general population (Jones et al., 2010, Stroebele et al., 2011b, Nicol and Thrift, 2005). According to the latest 2021 update from the American Heart Association, risk factors related to stroke are high blood pressure, hyperglycemia, obesity, renal dysfunction, and hyperlipidemia, in addition to 47% being attributed to behavioral risk factors such as sedentary lifestyle, smoking, and an unhealthy diet (Alonso et al., 2021). At the same time, 30% were attributed to air pollution worldwide (Collaborators and Ärnlöv, 2020). Most identified risk factors related to stroke in our study were hypertension, psychological stress, hypercholesterolemia, smoking, and obesity, with percentages exceeding 80%. Unlike a previous 2014 Jordanian study of 1854 participants, which reported getting older (58.8%), previous stroke (56.6%), and hypertension (56.0%) as most commonly identified risk factors in their study (Madae’en et al., 2013). This shows a more confident trend in identifying risk factors related to stroke among our study participants. Moreover, hypertension (48.2%), followed by stress (43.1%), were identified as risk factors among participants in a study from Lebanon (43.1%) (Khalil and Lahoud, 2020). Similarly, among 469 participants in a study from Morocco, hypertension (55.7%), followed by stress (48.8%), were identified as risk factors for stroke (Kharbach et al., 2020b). Despite being one of the most common modifiable risk factors for stroke, Diabetes Mellitus was relatively less identifiable by our study participants (68.4%). This finding has been reported elsewhere in previous studies (Kharbach et al., 2020a).

Also, participants in our study expressed a higher percentage recalling at least one stroke symptom (95.5%) compared to studies in Portugal (74.2%) (Duque et al., 2015), Norway (70.7%) (Sundseth et al., 2014), Oman (68.0%) (Al Shafaee et al., 2006), Korea (65%) (Kim and Yoon, 1997), and Lebanon (68.2%) (Khalil and Lahoud, 2020). Similarly, in a previous 2014 study from Jordan, (87.3%) of participants identified at least one sign and symptom related to stroke, which is still relatively high. (Madae’en et al., 2013). Sudden difficulty speaking or understanding speech was the most frequently reported stroke symptom in our study (92.3%) compared to a previous study in Jordan (85.1%) (Madae’en et al., 2013), and Australia (14.2%) (Sug Yoon et al., 2001), and Ireland (54%) (Hickey et al., 2009). However, sudden weakening of one side of the body was reported as relatively the most prevalent stroke symptom, as among Omani (65 %) (Al Shafaee et al., 2006) and Nigerian (24.4%) populations (Wahab et al., 2008).

Regarding their attitude toward stroke, participants in our study were encouraged to go to a hospital as soon as possible after a stroke is identified (89.0%), like a previous study that emphasized the need for immediate medical care for stroke patients (Khalil and Lahoud, 2020). Among 400 participants in an earlier study from Oman, 73% of participants reported they would immediately go to the hospital emergency if they suspected a stroke (Al Shafaee et al., 2006). However, percentages from international studies may vary, with only 47% claiming they would go to a hospital if they were suspicious of a stroke (Jones et al., 2010). Adequate knowledge about risk factors, symptoms, and consequences related to stroke in our study could be attributed to the younger age and high level of education of the participants.

Our study findings showed that the female gender was attributed to better knowledge about stroke consequences than males, with no gender-specific difference in knowledge about risk factors and symptoms related to stroke. In a systematic review until 2008, the female gender was attributed to the better overall understanding of risk factors and symptoms related to stroke (Stroebele et al., 2011b). Another study explained the male gender as a predictor of enhanced knowledge (Wahab et al., 2008). Whether there are gender-specific variations in knowledge remains controversial and would need further in-depth causality assessments, as previous studies provide no consistent gender correlations in favor of such differences about stroke’s risk factors, symptoms, or consequences (Park et al., 2006, Koçer et al., 2006, Pontes-Neto et al., 2008). Nevertheless, women tend to be more knowledgeable, express greater interest in health topics, and even spend more time seeking information than men do (Horch and Wirz, 2005).

Moreover, our results revealed that living in an urban area was significantly associated with better awareness of stroke risk factors and consequences; this could be attributed to better access to information resources and health services than rural ones (Joubert et al., 2008). Similar findings were revealed by Alluqmani in Saudi Arabia, as they also recommended for comprehensive investigation for stroke awareness, including large samples in rural populations (Alluqmani et al., 2021). In addition, participants who were well educated, employed, or diagnosed with diabetes in our study expressed willingness to promptly take a patient to hospital if they were suspicious of a stroke, which is somewhat expected, as better knowledge of consequences of a stroke would warrant prompt care. Furthermore, employment can warrant accessibility to seek medical help through insurance. While for diabetic patients, this might be attributed to their better knowledge of their disease status and consequences, as they often visit a healthcare provider for chronic medical care (Bogoshi, 2003, Chukwuocha et al., 2018).

Concerning stroke information resources, no particular resource was regarded as major by the participants in our study, but rather relatively, the internet and social media (24.4%) were the most frequently used resource of information, followed by healthcare professionals (20.9%), and family or relatives (15.2%). This is rather alarming since publicly available health information across social media might not be evidence-based and often misinterpreted by the general public (Suarez-Lledo and Alvarez-Galvez, 2021, Waszak et al., 2018). Although a similar study was previously conducted in Jordan by Madae’en et al. (2013), which assessed the level of knowledge and awareness toward stroke among the general Jordanian population, this study did not evaluate the factors that exert an influential effect on stroke. Thus, our study provided insight into both the level of knowledge and awareness toward stroke and the factors associated with it.

Conclusion

The general Jordanian population expresses good overall personal health literacy about risk factors, symptoms, and consequences related to stroke. Higher education levels, living in an urban residential area, and being employed were attributed to better knowledge about various aspects of the stroke. Through structured, reliable, evidence-based, and accessible health awareness resources, organizational health literacy is warranted to target individuals with inadequate personal health literacy related to stroke among the Jordanian population. Further nationwide studies could affirm more representative findings to the general Jordanian population.

Data availability

Open Science Framework. Assessment of Knowledge, Awareness of Stroke, and the Factors Associated with Among Jordanian Population: A Cross-Sectional Study. DOI: https://doi.org/10.17605/OSF.IO/QZTV3.

This project contains the following data.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Authors' contributions

All authors were involved in all parts of the study and manuscript preparation, including literature search, study design, analysis of data, manuscript preparation, and review of the manuscript.