Knowledge and awareness of stroke in the United Arab Emirates: a cross-sectional study of the general population

Introduction

Stroke is a major cause of mortality, morbidity and a leading cause of disability worldwide. The incidence of stroke increases in parallel to age, the prevalence of chronic cardiovascular disease and unhealthy lifestyle.^1,2 Stroke is a health condition that describes a disruption of the blood supply to the brain and thus has devastating health consequences resulting from oxygen starvation and brain cellular damage.³ This damage might lead to paralysis, speech and communication problems, cognitive and memory problems, and death.⁴

According to World Stroke Organization, stroke has already become a worldwide epidemic and the prevalence rate of stroke reaching around 13.7 million people by the year 2021, and approximately 40% of them are going to die because of the stroke. The data also urged for action as the statistics indicate a rise to 6.7 million expected annual deaths if no actions were taken.^5,6

Prevention is a key to reducing the burden of stroke, with joint efforts required at the individual and community levels. People’s knowledge and stroke awareness are essential for primary stroke prevention and timely access to stroke treatments, including acute reperfusion therapies (such as thrombolysis and mechanical thrombectomy). However, a lack of awareness of stroke among population in many countries has been highlighted.^7–10 Generally, knowledge of risk factors and warning signs in the general population is consistently inadequate or poor.^11,12

The UAE is a fast growing developing country where the last country report on the population number reaching nearly ten million.¹³ In addition, the UAE is a youth country where 65% of the people are between (25-54 years old).¹⁴ There has been about a 40-times increased in country’s population in the past four decades, plus the disparity in education, beliefs, and cultural practices has posed many challenges for shaping population-based public health strategies.^15,16 The increased population has also been associated with an increase prevalence of several non-communicable diseases such as diabetes, asthma, cardiovascular diseases, and cancer.^17–19 However, stroke is considered among the top killer diseases in the country. It is located just behind the ischemic heart diseases and road injuries, where the number of deaths between 1990–2019 has changed by 105%.²⁰

Although there were several calls from national media and practitioners regarding the importance of enhancing awareness among residents in the UAE regarding stroke, only a few available published data have been assessed the awareness level and knowledge among residents in the UAE.²⁰ In a recent study carried out by a group of researchers in one city (the emirate of Sharjah) to assess the knowledge of the stroke among adult residents, data revealed that around 25% of people were misdescribed the disease.²¹ Another study that evaluated the knowledge of stroke in the Gulf Cooperation Council (GCC) confirmed a poor level of knowledge among GCC communities and urged stroke educational campaigns.²²

There are multifactorial aspects of importance in this study. The high prevalence of the disease, the level of stroke knowledge of the public in the country, the level of ignorance of symptoms among the people, and the scarcity of data available for healthcare professionals and health strategists that may help develop programs to increase stroke awareness among the population including rapid response when faced with a case of stroke, which may also help focus on people with poor knowledge of stroke. The current study aimed to assess stroke knowledge among the general population in the UAE and determine the factors associated with stroke awareness.

Methods

Results

Stroke knowledge of the participants

Many respondents (70.8%) recognized the brain as the primary organ affected by a stroke. In comparison, less than half (42.9%) perceived it as a preventable disease (Figure 1A). As for early stroke symptoms, only 21.3% of participants were able to recognize all symptoms of a stroke. The most often recognized symptoms were sudden difficulty speaking/understanding speech (78.0%), loss of consciousness/fainting (73.8%) and sudden dizziness (71.4%) (Figure 1B). When asked about possible risk factors, only 22.2% of participants were able to identify all stroke risk factors. The most three frequently identified risk factors were high blood pressure (90.3%), stress (79.3%) and old age (68.1%) (Figure 1C). Most participants (77.4%) and (75.6%) reported that stroke might lead to functional/movement problem and cognitive/memory problems, respectively. In addition, many participants (70.2%) reported that stroke might lead to long-term disability (Figure 1D).

Figure 1. Knowledge of the participants (n = 545) about [A] Stroke, [B] Risk factors related to stroke, [C] Early symptoms of stroke, and [D] Consequences of stroke.

Only 21.1% of the respondents believed they do not have good knowledge about stroke and its effects. However, the majority of the participants (82.7%) were curious to have more information related to stroke, including symptoms, emergency signs and responses when facing someone with a stroke attack and the consequences of the stroke. In addition, the majority of participants (94.9%) believed that the role of the family is essential in providing care to a patient with stroke at an early stage. In addition, more than half of the participants (54.7%) believed that stroke disease could make patients’ lives unhappy.

The most common sources of stroke-related information reported by participants were internet/social media (53.6%), followed by healthcare professionals (38.5%) and family/relatives (31.4%) (Figure 2).

Figure 2. Participants’ Sources of information about stroke.

Discussion

A study to assess stroke knowledge among the general UAE population was conducted. More than half of the participants were female and employed. The majority were less than 50 years old and had a university bachelor’s degree or higher. Good general knowledge of stroke was reported in more than two-thirds of the participants. However, just over 20% of the participants recognized all of the symptoms of stroke and were able to identify all of the stroke risk factors.

In 2019, a study by Karkout et al. reported an average to low level of knowledge about stroke among the adult population in the UAE.²¹ Although the majority of our study participants could identify the brain as a typical stroke-affected organ, they were unable to recognize all symptoms and risk factors associated with stroke. However, they identified at least four symptoms, five risk factors, and three-stroke consequences. Visual issues and severe headaches were the least detected signs and symptoms of stroke in the Karkout et al. study.²¹ At the same time, African American race, female gender, and advanced age were the least identified risk factors for stroke.²¹ Because more than half of the study population identified all information, risk factors, symptoms, and consequences related to stroke, our stroke health literacy outcome measures are higher than similar literature.^28–31

In our study, 99.8% of participants identified at least one risk factor related to stroke. In comparison, previous studies have reported 98.1% among 573 participants in Jordan,⁹ 85.4% among 5391 participants in first study in Lebanon,¹⁰ and 97.8% among 551 participants in the second study in Lebanon,³² 76.2% among 822 participants in Australia,²⁸ 76.2% among 609 participants in Iraq,³³ 59.6% among 2,884 participants in Spain,³⁴ and 8.6% among 4,671 participants in Benin of West Africa.³⁵ Conversely, other previous studies have demonstrated poor knowledge of stroke risk factors and symptoms in the general population.^7,36,37 High blood pressure, hyperglycemia, obesity, renal dysfunction, and hyperlipidemia are all risk factors for stroke, according to the American Heart Association’s latest update for 2021, with a further (47%) attributed to behavioral risk factors like sedentary behavior, smoking, and an unhealthy diet.³⁸ With percentages reaching 50%, hypertension, psychological stress, old age, hypercholesterolemia, smoking, heart disease, physical inactivity, and obesity were the most recognized risk factors for stroke in our study. Unlike a previous Sharjah study in 2019, which found that hypertension (87.0%), hypercholesterolemia (72.6%), obesity (62.3%), and hyperglycemia (59.2%) were the most commonly identified risk factors in the study.²¹ This demonstrates a more confident tendency among our study participants to recognize stroke risk factors. Furthermore, participants in several studies conducted in Jordan, Saudi Arabia, Lebanon, Iraq, and Morocco reported that hypertension and stress were main risk factors for stroke, at different levels.^{9,10,32,33,39,40} Diabetes Mellitus was somewhat less recognized by our study participants, despite being one of the most frequent modifiable risk factors for stroke (49.7%). This finding has been observed in other investigations in Jordan, Iraq and Morocco.^9,33,40

With regard to stroke symptoms, participants in our study expressed a high percentage recalling at least one stroke symptom (89.9%) compared to studies in Jordan (95.5%),⁹ Iraq (76.2%),³³ Portugal (74.2%),⁴¹ Norway (70.7%),⁴² Canada (69.5%),⁴³ Oman (68.0%),⁴⁴ Korea (65%),⁴⁵ Lebanon (68.2%),¹⁰ and Benin of west Africa (4.9%).³⁵ In contrast to our study, only (23%) of participants in a prior 2007 study among GCC countries, including the UAE, identified at least one sign or symptom connected to stroke, which is still a low percentage.²² Sudden difficulty speaking or understanding speech was the most frequently reported stroke symptom in our study (78.0%) with same symptom reported in previous studies in Jordan (92.3%),⁹ Iraq (88.0%),³³ China (65.2%),⁴⁶ Saudi Arabia (63.8%),³⁹ Ireland (54%),¹¹ and Australia (14.2%).²⁸ However, in Omani (65%) and Nigerian (24.4%) populations, sudden weakness on one side of the body was the most prevalent stroke symptom were reported.^44,47

In terms of their attitudes toward stroke, less than half of the participants in our study (23.9%) were encouraged to go to a hospital as soon as possible after a stroke was detected, with no strong correlation to their socio-demographic characteristics. In a recent large study in China involving 3,051 adults, this phenomenon of paradoxical behavior toward seeking immediate medical help was recognized, with around (25%) of participants who recognized at least one of the stroke symptoms in the stroke action scenario not indicating that they would call an ambulance.⁴⁶ Nevertheless, previous studies emphasized the need for immediate medical care for stroke patients.^35,43,48,49 In Oman, 73% of participants reported they would immediately go to the hospital emergency if they suspected a stroke.⁴⁴ However, percentages from international studies may vary, with only 47% claiming they would go to a hospital if they were suspicious of a stroke.⁵⁰ In a previous study in Jordan using the same evaluation measure, participants who were well educated, employed, or diagnosed with diabetes expressed a readiness to take a patient to the hospital as soon as possible if they suspected a stroke.⁹ Such discrepancies necessitate a more in-depth examination to address knowledge gaps in our study population. It is self-evident that a greater understanding of the implications of a stroke would necessitate timely treatment.

Until 2008, a systematic analysis linked the female gender to a superior overall understanding of stroke risk factors and symptoms.³⁶ In our study, adequate knowledge about risk factors was not attributed significantly to any socio-demographic characteristics, but learning about stroke symptoms was attributed significantly to female gender and advanced education while learning about consequences of stroke was attributed significantly to female gender and nationality of participants. In another study, the male gender was found to be a predictor of increased knowledge.⁴⁷ Previous research has found no consistent gender correlations in favor of such differences in knowledge of stroke’s risk factors, symptoms, or consequences, so whether there are gender-specific variations in knowledge remains debatable and would require further in-depth causality analyses.^49,51,52 On the other hand, women are more knowledgeable, show a greater interest in health issues, and spend more time looking for information than men.⁵³

In terms of stroke information resources, the internet and social media were regarded as the most relied on among participants, followed by healthcare professionals and family and/or relatives. However, in studies in Jordan and Iraq, the sequence of the sources of information are similar but the percentages of participants are different.^9,34 This is concerning since publicly available health information on social media may not be evidence-based and is frequently misunderstood by the general public.^40,54,55

Finally, although the levels of awareness and knowledge related to stroke and risk factors among the people of the UAE were high compared with many studies among people in the region and the world, these levels were still not sufficient. Practically, many of the risk factors associated with stroke are relatively high among the people in the UAE such as smoking, diabetes, cardiovascular diseases, non-healthy lifestyle.^56–59 Therefore, organizational health literacy is needed to target individuals with inadequate personal health knowledge related to stroke among the UAE population through systematic, credible, evidence-based, and accessible health awareness tools. Further research on a national scale could confirm more representative findings of the UAE population.

Conclusions

Although the general UAE population has a moderate to high level of personal health literacy when it comes to stroke risk factors, symptoms, and consequences, recognition of all stroke symptoms, risk factors, and consequences were low, and there is still a gap between recognizing a stroke-related event and taking immediate action. Better knowledge of many stroke elements was associated with higher education levels and the female gender.

Additional studies at the national level could confirm results that are more representative of the general UAE population. More work is needed to raise awareness among people in the UAE through a structured, reliable, evidence-based and accessible health awareness program to target all people in the UAE especially individuals who do not have sufficient knowledge regarding stroke.