Assessment of Knowledge and attitude towards Stroke among the UAE population during the COVID-19 pandemic: A cross-sectional study

Introduction

According to the World Health Organization, stroke is the ‘incoming epidemic of the 21^st century’, which is unsurprising considering that it accounted for 12.2 million incident cases, 101 million prevalent cases, 143 million disability-adjusted life-years lost, and 6.6 million deaths in 2019.¹ The United Arab Emirates (UAE) was reported to be among the three countries within the Middle East and North Africa region with the highest prevalence of stroke in 2019.² Alarmingly in 2022, it was reported by the Ministry of Health and prevention that 50% of stroke patients were under the age of 45 as opposed to the global incidence of 80% over the age of 65.³ Despite significant medical advancements, morbidity and mortality from stroke remain high.^4–6 It is associated with a high burden of healthcare costs, upwards of US$ 721 billion estimated in 2017.⁷ Furthermore, the absolute number of strokes is expected to rise due to the worldwide aging phenomenon. Also, the high prevalence of comorbidities such as hypertension, congenital heart disease, previous stroke, and diabetes is associated with increased risk for all types of stroke.^8,9

Knowledge and awareness play an essential part in the early detection of chronic conditions such as stroke. The World Health Organization has recognized the importance of driving efforts toward increasing knowledge about disease conditions and risk factors. Epidemiological studies have shown that higher health literacy positively relates to preventive measures, especially against chronic non-communicable diseases.^10,11 The level of knowledge can affect people’s attitudes and practices; on the other hand, negative attitudes and practices could increase the risk of disease and subsequent morbidity and mortality. Regarding stroke, early identification of symptoms, appropriate and timely management can positively influence individuals’ outcomes.¹²

Stroke is a multifactorial condition; the most significant risk drivers include hypertension, high body mass index, dyslipidemia, diabetes, smoking, and a family history of stroke.^13,14 Analysis of reports pertaining to the COVID pandemic had shed light on the fact that COVID infection raised the risk of stroke by more than two times.¹⁵ Also, another study has demonstrated that COVID-19 associated ischaemic strokes tend to be more severe and can lead to death compared to non-infected stroke patients.¹⁶ ACE receptors, where the COVID virus binds to gain intracellular entry, is expressed in many cells, including epithelial and endothelial cells, which trigger an immediate immunological activation that can lead to hypercoagulability and thrombosis. Multisystem thrombosis, including ischemic stroke, has been associated with severe COVID-19 infection. The pathogenesis is further compounded, given that the fibrinolytic pathway ceases operation. While the pathogenesis of COVID-19-related neurovascular events is not yet clear, some major pathogenic mechanisms have been put forth. These include innate system hyperinflammation, endothelial dysfunction, and disruption of the renin-angiotensin-aldosterone system, hence impacting blood flow, oxidative stress and excessive platelet aggregation.¹⁷

Furthermore, COVID vaccination was associated with both ischemic stroke and vaccine-induced immune thrombotic thrombocytopenia¹⁸; and cerebral venous thrombosis.¹⁹ The vaccine's most adverse side effect is vaccine-induced immune thrombocytopenia and thrombosis (VITT), also known as thrombosis with thrombocytopenia syndrome. This immune-mediated condition is caused by the development of pathological anti-platelet factor 4 (PF4) antibodies following vaccination against COVID-19, which leads to intense activation of platelets and the coagulation system. The subsequent clinical syndrome includes life-threatening thrombosis and secondary haemorrhage.²⁰

Despite effective therapies for stroke, only a small proportion of patients receive medications due to delayed presentation.²¹ However, many strokes are preventable, suggesting that prevention strategies should be at the forefront of stroke management with primary and secondary prevention measures that target the risk factors.²² Factors influencing the management of stroke include awareness of stroke signs and symptoms, awareness of the importance of early management, educational level, distance from the hospital, and past history of stroke.^23,24

Identifying baseline stroke knowledge in the general population is crucial to developing effective, targeted, and appropriate health promotion programs for stroke prevention. There is limited data on people’s knowledge and attitudes towards stroke in the UAE. In 2019, a knowledge survey study pertaining to stroke was conducted in Sharjah city, UAE.²⁵ It was reported that most participants had low to average knowledge levels.²⁵ Given the increased risk of stroke in COVID patients and the scarcity of data regarding stroke, we aimed to assess the general public knowledge and attitudes on stroke and stroke risk factors across the entire UAE during the COVID pandemic.

Methods

Results

Knowledge on stroke

The mean (SD) knowledge score was 13.66 (5.31) and ranged from 2 to 24. Table 2 presents the responses regarding knowledge of stroke. Around (82%) of the study participants knew the brain was the organ affected by stroke, 41.8% knew that a stroke could be recurrent, and 63.2% knew that a stroke could be prevented. On the other hand, many participants (83.2%) knew that stroke affects the patients’ daily lives and activities.

Table 2. Participant responses to questions on stroke knowledge (n = 500).

	Response = yes N (%)
What organ of the body is affected by stroke? Brain	413 (82.60)
Stroke is preventable	316 (63.20)
A person can have a stroke more than once	209 (41.80)
Stroke affects daily activities	416 (83.20)
Stroke is preventable if treated early	373 (74.60)

Figure 1 presents positive (yes) responses to questions on the signs and symptoms of a stroke. More than half of the participants correctly identified confusion (64.6%), numbness (64.4%), and trouble walking (58.8%). Less than half could identify trouble seeing (49.2%), vomiting (21.2%), headache (46.8%), and fever (10.6%) as signs of a stroke. Approximately (23%) of the participants incorrectly identified a nose bleed as a sign of stroke.

Figure 1. Distribution of knowledge of stroke signs and symptoms among survey participants (n = 500).

The Y axis represents percentages of positive (yes) responses. (*) on x-axis label indicate incorrect sign/symptom of stroke.

Figure 2 presents positive (yes) responses to questions on stroke risk factors. More than half of the participants correctly identified smoking (63.2%), lack of exercise (51.8%), high blood pressure (69%), heart disease (53.6%), high cholesterol (50.4%), being overweight/obese (54.2%), and stress (56.4%). Fewer than half knew about a family history of stroke (46%), diabetes (34.6%), an unhealthy diet (43 %), atrial fibrillation (24.2%), and 8% incorrectly identified cough as a risk factor for stroke.

Figure 2. Distribution of knowledge of stroke risk factors among survey participants (n = 500).

The Y axis represents percentages of positive (yes) responses. (*) on x-axis label indicates incorrect risk factor of stroke.

Discussion

The present study was conducted to assess the knowledge and attitudes towards stroke in a general population sample in the UAE during the COVID-19 pandemic. Generally, we identified suboptimal knowledge and attitudes toward stroke. Attitudes toward stroke prevention seemed suboptimal for preventive measures; many knew about hypertension, and less than two-thirds knew about blood glucose control. The sources of information were also varied and underutilized, especially healthcare providers.

Generally, and to the best of our knowledge, studies from the Middle East have reported suboptimal levels of knowledge of stroke. Most of the studies from the Middle East have reported inadequate knowledge regarding stroke risk factors and warning symptoms^{29–32,34–36}; on the other hand, only a few studies have reported an adequate level of awareness.^37–39 Similarly, studies from different parts of the world have reported an inadequate understanding of stroke in the general population.^40,41

More than half of our study participants were aged 18 to 25. There have been few previous studies on stroke awareness among adolescents and young adults. Studies from Nepal have reported knowledge of stroke in the younger demographics.^42,43 Participants reported knowing someone with a stroke which could have contributed to better understanding.⁴³ However, many participants did not recognize stroke as a brain disease.⁴³ Similarly, some studies in western countries have shown inconsistent awareness of this aspect.^44,45 In the Nepalese studies, many identified hypertension, alcohol, and smoking as risk factors. However, few could identify all risk factors together. Many believed that stroke could present with sudden weakness or numbness of limbs, and less than half were able to identify three or more symptoms of a stroke. More than two-thirds of participants believed stroke could be treated, and more than four-fifth believed stroke could be prevented.⁴³ Many said they would take patients to the hospital and that they would need immediate medical treatment.

Pradhan et al. reported better knowledge among male participants⁴²; however, Thapa et al. reported that gender was not associated with knowledge of risk factors or warning signs.⁴³ Similar to Thapa et al. study,⁴³ in our study, gender was not a determinant of either knowledge or attitudes. Nevertheless, several studies have reported differences in knowledge scores by gender; females possessed better knowledge^46–48 which perhaps could be related to the fact that women experience more strokes⁴⁹ or knew someone with a stroke in the capacity of a caregiver.⁵⁰ Furthermore, a review has reported better knowledge of stroke warning signs in women compared with men⁵¹; women tended to know more evidence-based stroke risk factors than men, which could be attributed to a more proactive health-seeking approach in women; stroke knowledge also appeared to be related to the country of study origin, age, education, and medical history.

In comparison, a recent study from the USA among adolescents reported that stroke knowledge was relatively inadequate.⁵² Approximately half knew that stroke occurs in the brain, two-thirds said they would call emergency services, and about half were aware of the acronym FAST (face, arms, speech, time). The knowledge of stroke symptoms and risk factors was generally low, with no difference in scores according to gender in similarity to our findings. Furthermore, a surrogate marker of socioeconomic status, the parental education level, was used to assess the contribution to stroke knowledge; no relationship between survey scores and the father’s level of education was seen, but there was a significant association between survey scores and the mother’s level of education. Also, limited knowledge of cerebrovascular disease was observed among teenagers in Spain, hence the need for integrating topics related to neurovascular disease within the school curriculum.⁵³

A community-based study from India, where stroke is a leading cause of morbidity and mortality, reported that participants knew the basic connotations of stroke and paralysis. However, knowledge about red flags and stroke risk factors was inadequate.⁴¹ Signs and symptoms identified were paralysis and loss of consciousness, but there was a lack of awareness of headache, vomiting, and fits. Participants were well aware of hypertension as a risk factor but less for diabetes and smoking. Hypertension was one of the most frequently recognized risk factors, as in another study from Iran.⁵² In comparison, a survey in South Korea reported better awareness about stroke; hypertension was the most common risk factor identified, and paresis was the most commonly reported symptom. Around two-thirds were able to identify one or more symptoms⁵⁴; in contrast, in our study, half of the participants identified five symptoms (results not tabulated).

In our study, knowledge and attitudes toward stroke did not differ by age category. Nevertheless, previous studies have consistently shown that different age groups were differently associated with knowledge and attitudes towards stroke.^32,52,55,56 In our study, being a student was associated with positive knowledge scores and a non-healthcare worker with poorer attitudes. Similar to our findings, a study from Saudi did not report that attitudes differed by gender.⁵⁷ Moreover, some studies have reported that knowledge differed with academic level, and higher education was a predictor of better knowledge.^52,58–60 Similarly, a recent European review reported that a higher socioeconomic position was associated with better knowledge of stroke risk factors and warning signs.⁶¹ A review from the UK reported a good awareness of red flags of unilateral weakness and speech disturbance; however, the first point of contact mentioned was a general practitioner rather than emergency services.⁶² In our study, a little over two-thirds said they would call an ambulance, and this finding is not very different from the Middle East.³⁵

We observed that inadequate knowledge was significantly associated with not having heard of stroke, not knowing someone with a stroke, and not receiving stroke-related information from either a healthcare provider or electronic media. Note that the study was conducted during the COVID-19 when there was a nationwide extended lockdown. Hence, the lack of stroke knowledge and awareness could be due to the public limited access to healthcare providers or due to the limited healthcare provider-led educational campaigns during the quarantine period. Also, the lack of use of electronic media by the participants could have contributed to the public’s gap in knowledge. Hence, overall, the lack of accessibility to healthcare providers and perhaps also to electronic media could have resulted in poor stroke awareness and knowledge. Stroke inadequate knowledge is of great concern given that ischemic stroke is a well-documented side effect of COVID-19. In a US study, it was observed that 46.35% of imaging confirmed ischemic stroke patients had COVID-19.⁶³ Also, the incidence of stroke in COVID-19 patients ranged between 0.9% to 3.3% in several large retrospective studies. Also, higher mortality was reported in patients with COVID-19 who have ischemic stroke compared to control ischemic stroke patients. Furthermore, ischemic stroke was shown to develop in COVID-19 patients with or without co-morbidities.⁶⁴ Hence, stroke knowledge-based educational campaigns provided and led by health care personnel are of utmost importance during the pandemic.

It is reassuring to see that despite studies reporting inadequate understanding of stroke, there was a positive attitude toward calling an emergency in case a person displayed signs or symptoms of stroke,^65,66 while others are reporting taking the patient to the hospital.⁶⁷ In our study, being a non-health care worker was associated with poorer attitudes. Hence efforts should be made to reach out to different sectors and address gaps in knowledge and attitudes towards stroke. Moreover, electronic media campaigns could play an important role in raising public awareness and improving attitudes by employing a variety of social media platforms and types of messages.

Some of the strengths of this study are as follows: First, the study is one of the few studies that comprehensively quantify knowledge and practices and would help identify common knowledge gaps in the UAE population. Second, the study was conducted on a representative sample of the general population comprising of diverse backgrounds and provided a projection of the knowledge and attitudes in the community. Third, we used a validated and reliable questionnaire to collect responses. Lastly, we had a large sample size and a reasonable response rate, allowing us to conduct analyses with good statistical power to detect associations.

There are some limitations, however: The self-reported nature of specific measures such as income may lead to misclassification bias of the independent variables in the study. Moreover, self-reporting of information may be biased by overestimating or underestimating actual attitudes related to stroke. Next, as with studies of observational nature, it can be challenging to draw definite conclusions about causality and temporal relationships; hence we need further research with more robust study designs and pre-post interventional studies to assess the impact on knowledge and attitudes towards stroke in the community. Also, some of the respondents did not answer the questions if they were either working or studying in the healthcare field or not. While the study was conducted in several UAE major urban cities, rural cities participants were not represented. Finally, the age distribution of participants in our study was mostly young people/students and hence does not reflect the age distributed in the general population in the UAE. Bias in data collection may produce this problem. Nonetheless, we believe that the impact of this bias on the validity of the findings may not be significant.

The future direction of the study can focus on conducting a cross-sectional study to assess the stroke knowledge and attitude among COVID-19-infected individuals and COVID-19 vaccine recipients, a significant risk group highly susceptible to stroke occurrence. Also, it is of interest to assess if stroke incidence dropped post-COVID-19 period.

Conclusions

The present study showed a general inadequacy of knowledge regarding stroke and suboptimal attitudes towards someone presenting with stroke signs and symptoms. The community should be familiarized with the “FAST” acronym to recognize a stroke and access appropriate services as soon as possible. There is an urgent need for widespread educational interventions regarding stroke risk factors, especially among non-medical professions, and involving healthcare providers to address the growing burden of stroke worldwide, especially in the era of Covid-19, which increases the risk of stroke via infection and post-vaccination.