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

Background: Despite significant advancements in healthcare, the burden of stroke continues to rise in the developed world, especially during the COVID-19 pandemic. Association between COVID-19 infection and stroke is well established. Factors identified for the delay in presentation and management include a lack of awareness regarding stroke. We aimed to assess the general public knowledge and attitudes on stroke and stroke risk factors in the United Arab Emirates during the COVID-19 pandemic. Methods: A cross-sectional study was conducted between September 2021 and January 2022 among adults≥ 18 years old. Participants completed a self-administered questionnaire on sociodemographic characteristics and stroke knowledge and attitudes. Knowledge and attitude scores were calculated based on the number of correct responses. Linear regression analysis was performed to determine the factors related to knowledge and attitude towards stroke. Results: Of the 500 respondents, 69.4% were females, 53.4% were aged between 18 and 25, and nearly half were students (48.4%). The mean knowledge score was 13.66 (range 2-24). Hypertension (69%), smoking (63.2%), stress (56.4%) obesity/overweight (54.4%), and heart disease (53.6%) were identified as risk factors. Overall, the knowledge of signs/symptoms was suboptimal. The mean attitude score was 4.41 (range, 1-6); 70.2% would call an ambulance if someone were having a stroke. A monthly income of 11,000-50,000 AED and being a student were associated with positive knowledge. Being a non-health worker and lacking access to electronic media sources were associated with worse attitudes. Conclusion: Overall, we identified poor knowledge and suboptimal attitudes toward stroke. These findings reflect the need for effective public health approaches to improve stroke awareness, knowledge, and attitudes for effective prevention in the community. Presently, this is of utmost necessity, given the increased occurrence of stroke and its severity among COVID-19 patients.


Introduction
5][6] It is associated with a high burden of healthcare costs, upwards of US $ 721 billion estimated in 2017. 7Furthermore, 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. 8,9owledge 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. 10,11The 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. 12roke is a multifactorial condition; the most significant risk drivers include hypertension, high body mass index, dyslipidemia, diabetes, smoking, and a family history of stroke. 13,14Analysis 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. 15Also, 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. 16ACE 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. 17rthermore, COVID vaccination was associated with both ischemic stroke and vaccine-induced immune thrombotic thrombocytopenia 18 ; and cerebral venous thrombosis. 19The 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. 20spite effective therapies for stroke, only a small proportion of patients receive medications due to delayed presentation. 21However, 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. 22Factors 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. 23,24VISED Amendments from Version 1 The following has been added to the manuscript per the reviewer's suggestion and recommendation.In the introduction section, in-depth information regarding the pathogenesis of COVID-19-induced stroke and the vaccine-induced immune thrombocytopenia and thrombosis process was included.In the methods section, the questionnaire's content about the knowledge and attitude domains, data collection process and mode circulation of the questionnaire was clarified.Importantly, Bloom's modified cut-off point criteria utilized to determine good/poor knowledge and negative/positive attitude was included.The relationship between COVID-19 and stroke knowledge was discussed at length in the discussion section.Furthermore, plausible reasons for the inadequacy of knowledge observed among the participants were put forth.Future research avenues were also included.
Any further responses from the reviewers can be found at the end of the article 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. 25Given 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.

Ethical considerations
The study received the required ethical approval from the research ethics commission (REC) at Al Ain University (AAU-REC-B3, September 2021).

Study population and sample size
This was a cross-sectional study among 500 subjects ≥ 18 years and from the general public in Abu Dhabi, Dubai, Sharjah, Ajman, and other UAE cities.The study was conducted from September 2021 to January 2022 i.e. during the COVID-19 period.Subjects who fulfilled the inclusion criteria and were willing to participate in this study.The sample size was chosen with an assumed prevalence of hypertension, the most significant risk factor for stroke, 52% 26 also via using a Raosoft sample size calculator, 27 a confidence limit of 5%, and a 95% confidence interval estimate of the proportion.A minimum sample size of 384 was needed.The study included both locals (Emiratis) and expats (residents).
Inclusion and exclusion criteria UAE residents (> 2 years living in the UAE) regardless of their nationality, over the age of 18 years and consented (on the questionnaire by ticking the agreement option) to participate were included in this study.Participants who lived < 2-years in the UAE or did not consent to participate were excluded.

Design of questionnaire
The questionnaire was developed after a careful literature review of previous studies utilizing standardized and validated instruments [28][29][30][31][32] and expert feedback.Some questions were included to suit the public within the UAE e.g.city of residence, place of birth.The questionnaire was constructed in Arabic and English.The translation process was via an Authentic Medical Translator who was officially approved to translate English to Arabic (the official language of residents in the UAE).Pretesting of the questionnaire was performed to gather information on its feasibility, and assess time to completion, understandability, and consistency.After pretesting, the survey was conducted online, and the responses were collected in an Excel sheet.
The survey started with a brief introduction that described the study objectives, emphasized the confidentiality of the participants, and informed them that completing the survey represents consent to participate in the study.The survey included socio-demographic questions, twenty-five questions evaluating the knowledge of stroke comprising the organ affected, stroke attributes (preventable or recurrent), effect on daily activities, treatment, prevention, risk factors, and signs and symptoms.Six questions evaluating attitude (the approach) towards preventative measures and actions to take if someone showed signs and symptoms of a stroke.All knowledge and attitude questions had a yes/no answer.Lastly, there was a question about the sources of information.For the 25-item knowledge questions, the score range was 0-25.For attitudes, the score range was 0-6.Each correct statement for knowledge and optimal attitude got a 1; otherwise, 0.
Based on the modified Bloom's cut-off point, a participant who scored ≥80% of the correct knowledge questions (≥20 points out of 25) was considered as having "good/adequate knowledge"; moderate if the score was between 60 and 79%, (≥15-19 out of 25), and poor/inadequate if the score was less than 60% (<15 points out of 25).For attitude, a respondent who scored ≥80% of the correct attitude questions (≥4.8 points out of 6) was considered as having a "good attitude" or moderate/suboptimal attitude if the score was between 60 and 79%, (≥3.6-4.7 out of 6), and poor attitude if the score was less than 60% (<3.6 points out of 6). 33lidation of the study questionnaire The validation test was conducted for the edited questionnaire version.A questionnaire draft was written and sent to a panel of experts for face and content validity in the pharmacy profession at Al-Ain University to test the content validity of the survey.They examined many factors of the questionnaire, including the length, conciseness, language, clarity, time, appropriateness, and bias of questions.Content validation of a questionnaire was aligned with recommendations. 28liability testing of the study questionnaire The reliability test was conducted as a pilot study on 50 students to achieve the most acceptable Cronbach's values.The Cronbach alpha value determined was 0.72.According to Nunnally's criteria, an α ≥ 0.70 should be regarded as an acceptable reliability.Additionally, preliminary pilot testing was carried out to ensure the understandability and practicality of the questionnaire.

Data collection
The online, self-administered survey was randomly distributed via a convenience sampling technique.Data was collected from study participants using Google Forms between September 2021 to January 2022.Participants were briefed about the study's purpose and informed about the study's confidentiality and anonymity policy.Each participant was invited to answer the survey after consent.The questionnaire was self-administered.

Statistical analysis
Data were verified at the end of the survey and before the analysis.The data analysis was performed using the SAS software (version 9.4 SAS Institute, Cary, NC) (alternative; PSPP software; free open source).Respondent's sociodemographic characteristics were stated using descriptive statistics.Means, standard deviations (SD), and proportions were generated to describe the overall sample characteristics (age, gender, occupation, marital status, education, income, country of birth, and comorbidities).Multivariable linear regression modeling was applied to determine the variables associated with stroke-related knowledge and attitude.All associations were considered significant at the alpha level of 0.05.

Demographic characteristics
Table 1 presents the sociodemographic characteristics of the study population.Of the 500 participants who completed the questionnaire, 69.4) were females, 53.4% were aged between 18 and 25, and 59.4% were single.Among the participants, 79.8% were expats.Additionally, roughly half earned AED ≤10,000 (Dirham) per month.Among the study participants, 50.8% had no known comorbid, 9.4% had hypertension, 6.6% had diabetes, 3.4% had cardiovascular disease, and 1.8% had a history of a stroke.Regarding the sources of information about stroke, approximately 50.4% and 40.4% of the study participants reported electronic media and friends, respectively.Fewer than one-third stated a healthcare provider as an

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.
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.

Attitude towards stroke
The mean (SD) score of participants' attitudes towards stroke was 4.41 (1.40) and ranged from 1 to 6. Table 3 presents the participants' attitudes toward stroke development in a person.Over two-thirds (70.2%) of the study participants would call an ambulance if someone showed signs and symptoms of stroke, (12.4%) would take the person to a hospital, and (4.6%) would call a healthcare provider.Regarding stroke prevention, more than two-thirds (67.0%) knew a controlled diet could prevent stroke, many (72.0%)knew control of hypertension was important, and over half (54.6%) knew the importance of the control of blood glucose.Merely 10.2% thought that stroke could not be prevented.

Determinants of stroke knowledge and attitudes
We determined the variables associated with the knowledge and attitudes toward stroke using linear regression analysis.Note that the nine respondents with history of stroke were excluded from analysis and hence the sample size is 491.

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.8][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 Hover, 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 n 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 participants 42 ; however, Thapa et al. reported that gender was not associated with knowledge of risk factors or warning signs. 43Similar 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][47][48] which perhaps could be related to the fact that women experience more strokes 49 or knew someone with a stroke in the capacity of a caregiver. 50Furthermore, a review has reported better knowledge of stroke warning signs in women compared with men 51 ; 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. 52Approximately 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. 53community-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. 41Signs 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. 52In 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 symptoms 54 ; 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. 32,52,55,56In 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. 579][60] Similarly, a recent European review reported that a higher socioeconomic position was associated with better knowledge of stroke risk factors and warning signs. 61A 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. 62In 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 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. 63Also, 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. 64Hence, 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. 67In 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.

Contribution to the field statement
The burden of stroke and its associated DALYs necessitates the evaluation of stroke KAP in the community.Especially in the Middle East, where despite the advances in stroke management, we continue to see a substantial stroke burden.As suggested by previous literature, knowledge and attitudes towards stroke may influence stroke prevention and outcome, and is a cornerstone of the WHO's efforts toward increasing chronic disease literacy.In the UAE, literature is scarce about the level of knowledge of stroke in the community.Currently, this assessment is of outmost importance given the association of COIVD infection with stroke.Therefore, we aimed to conduct this study in a representative sample of the general population.Our study revealed suboptimal knowledge and suboptimal attitudes towards stroke, consistent with some studies in other parts of the region.We recommend that such findings be the base for educational awareness efforts among the general population and high-risk individuals in the community.This could improve stroke outcomes and encourage the adoption of healthy behaviors in all risk profile groups.
Keywords: Need to be alphabetically arranged Stroke is generally considered to occur in elderly people.However, in this research, the participants are mainly young people/students.Authors need to mention this as a major limitation.This limits the study to generalize the findings to the general public.It would have been nice to focus only on the students rather than the general public in this case.
The Introduction section has to mention more about the probable mechanism of stroke in COVID-19 patients.Authors need to focus more on the topic with more literature added.
It is not clear why authors have chosen 'hypertension' to assume the prevalence of stroke.This needs more explanation.
The questionnaire design is not clearly mentioned in the methodology section.The construct, content, and face validity need to be mentioned in detail.The final questionnaire must be added as an appendix.The authors also need to mention why they developed a new questionnaire rather than adopting an existing one.What is the uniqueness of the newly developed tool?The actual Cronbach alpha value has to be mentioned.The data collection process has to be elaborated.What was the mode of circulation of the questionnaire?How were the subjects chosen?
The discussion rarely mentions about the relationship between COVID-19 and stroke knowledge.Hence some rewriting is needed.
The Conclusion is misleading.How can the authors say the knowledge on stroke is 'inadequate' and 'suboptimal' attitudes?Authors need to first establish the criteria for how they arrived at such conclusions.This has to be clearly mentioned in the methodology.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Pharmacovigilance
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Author Q 6.The questionnaire design is not clearly mentioned in the methodology section.The construct, content, and face validity need to be mentioned in detail.The final questionnaire must be added as an appendix.The authors also need to mention why they developed a new questionnaire rather than adopting an existing one.What is the uniqueness of the newly developed tool?The actual Cronbach alpha value has to be mentioned.The data collection process has to be elaborated.What was the mode of circulation of the questionnaire?How were the subjects chosen?
A) The construct, content, and face validity need to be mentioned in detail Answer: Thank you for this comment.The bolded text is the additional info added to the manuscript to clarify this point as requested.
The survey started with a brief introduction that described the study objectives, emphasized the confidentiality of the participants, and informed them that completing the survey represents consent to participate in the study.The survey included socio-demographic questions, twenty-five questions evaluating the knowledge of stroke comprising the organ affected, stroke attributes (preventable or recurrent), effect on daily activities, treatment, prevention, risk factors, and signs and symptoms.Six questions evaluating attitude (the approach) towards preventative measures and actions to take if someone showed signs and symptoms of a stroke.All knowledge and attitude questions had a yes/no answer.Lastly, there was a question about the sources of information.For the 25-item knowledge questions, the score range was 0-25.For attitudes, the score range was 0-6.Each correct statement for knowledge and optimal attitude got a 1; otherwise, 0.
A questionnaire draft was written and sent to a panel of experts in the pharmacy profession at Al-Ain University for face and content validity.They examined many factors of the questionnaire, including the length, conciseness, language, clarity, time, appropriateness, and bias of questions.Content validation of a questionnaire was aligned with recommendations.
The content validity was as follows: B) The final questionnaire must be added as an appendix.
Answer: Thank you for this comment.Please find the questionnaire at the extended data section: Open Science Framework: Stroke Study, https://doi.org/10.17605/OSF.IO/5WNAF. 58Stroke questionaire.docx C) The authors also need to mention why they developed a new questionnaire rather than adopting an existing one.What is the uniqueness of the newly developed tool?Answer: Thank you for this valuable comment.The yellow highlights is the additional info.that was added to the methods section (Design of questionnaire): The questionnaire was developed after a careful literature review of previous studies utilizing standardized and validated instruments (25-28).Some questions were included to suit the public within the UAE e.g.city of residence, place of birth.The uniqueness of this questionnaire is that it is designed to suit the UAE public.To the best of our knowledge and up to the time this study was conducted, there was not any single study that was conducted across the UAE.

D)
The actual Cronbach alpha value has to be mentioned.
Answer: Thank you.The following was added The Cronbach alpha value determined was 0.72.According to Nunnally's criteria, an α ≥ 0.70 should be regarded as an acceptable reliability E) The data collection process has to be elaborated.Answer: Thank you for this comment.The following was included: Data was collected from study participants using Google Forms between September 2021 to January 2022.Participants were briefed about the study's purpose and informed about the study's confidentiality and anonymity policy.Each participant was invited to answer the survey after consent.The questionnaire was self-administered.Answer: Thank you for the feedback.The following will be inserted after 7 th paragraph of the discussion (highlighted yellow in the manuscript).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 (Belani  et al. 2020).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 (Elfasi et al. 2021).Hence, stroke knowledge-based educational campaigns provided and led by health care personnel are of utmost importance during the pandemic.
how they arrived at such conclusions.This has to be clearly mentioned in the methodology.
Answer: The following was placed in the methodology section-Design of the of questionnaire: Based on the modified Bloom's cut-off point, a participant who scored ≥80% of the correct knowledge questions (≥20 points out of 25) was considered as having "good/adequate knowledge"; moderate if the score was between 60 and 79%, (≥15-19 out of 25), and poor/inadequate if the score was less than 60% (<15 points out of 25

Adrià Arboix
Cerebrovascular Division, Department of Neurology, University of Barcelona, Barcelona, Spain The authors present the results of a cross-sectional study aimed to assess the general public knowledge and attitudes on stroke and stroke risk factors in the United Arab Emirates during the COVID-19 pandemic.500 participants ≥ 18 years and from the general public in The United Arab Emirates completed a self-administered questionnaire constructed in Arabic and English on sociodemographic characteristics and stroke knowledge and attitudes.The authors identified poor knowledge and suboptimal attitudes toward stroke.For a better presentation of the data, it is necessary to clarify the following issues: It would be interesting to know if there were differences between the young (18-25 years old) and non-young healthy recruits with respect to knowledge and attitudes toward stroke. 1.
In the Discussion, it should be noted that in a study on the knowledge of stroke in Catalonia (Spain) it was observed a scant knowledge of cerebrovascular disease in a sample of teenagers.Therefore, this knowledge should be integrated into the school curriculum (see and add this reference Rev Neurol 2003; 37: 500).

2.
A brief concluding comment on other possible lines of future research on the presented topic would be appreciated 3.

toward stroke.
Author Response: Thank you for your comment.Indeed, our findings suggest that knowledge among young participants (18-25 years old) was not statistically different in comparison to the ³ 65 years old group (estimate coefficient= 0.87; P=0.84, Table 4).Similarly, there was not a statistical difference in attitude scores when comparing the two groups (estimate coefficient= -0.42; P=0.84, Table 5).Response: Thank you for this comment.Below is the additional information added to the manuscript to clarify the domains.

○
The survey started with a brief introduction that described the study objectives, emphasized the confidentiality of the participants, and informed them that completing the survey represents consent to participate in the study.The survey included the following domains: socio-demographic questions, twenty-five questions evaluating the knowledge of stroke comprising the organ affected, stroke attributes (preventable or recurrent), effect on daily activities, treatment, prevention, risk factors, and signs and symptoms.Six questions evaluating attitude (the approach) towards preventative measures and actions to take if someone showed signs and symptoms of a stroke.All knowledge and attitude questions had a yes/no answer.
media.Note that the study was conducted during 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 limited healthcare provider-led educational campaigns during quarantine.Also, the lack of use of electronic media by the participants could have contributed to the public's gap in knowledge.Hence, the lack of accessibility to healthcare providers and perhaps also to electronic media could have resulted in poor stroke awareness and knowledge.
~ 30% of the UAE are bachelor's graduates.However, post-analysis, nearly half of the subjects were young and undergraduate students.Provide the implication regarding this discrepancy?
○ Response: The authors agree with the comment.The following is mentioned in the limitation section of the manuscript: " 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" ○ What about rural-based participants?Were they included in the study?This needs to be included in the limitation section ○ Response: The following has been added to the limitation section: "While the study was conducted in several UAE major urban cities, rural cities participants were not represented."

Competing Interests: None declared
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com

Figure 1 .
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 .
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.

F)Q 7 .
What was the mode of circulation of the questionnaire?Answer: The following was added to the method sections The online, self-administered survey was randomly distributed via a convenience sampling technique G) How were the subjects chosen?Answer: Thank you for your comment.Please refer to the Inclusion and exclusion criteria: They were the following: UAE residents (> 2 years living in the UAE) regardless of their nationality, over the age of 18 years and consented (on the questionnaire by ticking the agreement option) to participate were included in this study.Participants who lived < 2-years in the UAE or did not consent to participate were excluded.The discussion rarely mentions about the relationship between COVID-19 and stroke knowledge.Hence some rewriting is needed.

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

Table 3
. Participant responses to questions on attitudes toward stroke (n = 500).Response = yes N (%) Do you think stroke requires prompt treatment?436 (87.20)If someone shows signs and symptoms of stroke, what do you think you should do first?
N = 491 instead of 500 as we excluded people with a history of stroke for the regression analysis.*P-value ≤ 0.05.**P-value ≤ 0.01.

2. Keywords: Need to be alphabetically arranged Answer
Response 10 Oct 2023Thank you for taking the time to review our work titled "Are we aware of stroke risk factors and warning signs amid COVID-19?Knowledge and attitude towards risk-factors, signs and symptoms of stroke among the UAE population during COVID-19 pandemic: A crosssectional study" and providing us with your insightful feedback to improve the manuscript.We have included answers in the manuscript to the questions put forth.Please see below the point-by-point responses to the questions.
Q1. Title: The title should be made simple and clearer.Currently, it is too long and confusing.Are we aware of stroke risk factors and warning signs amid COVID-19?Knowledge and attitude towards risk-factors, signs and symptoms of stroke among the UAE population during COVID-19 pandemic: A cross-sectional study Answer: Thank you for your comment.The above title was shortened to "Assessment of Knowledge and attitude towards Stroke among the UAE population during COVID-19 pandemic: A cross-sectional study" Q : Please see the re-arranged keywords that were inserted in the manuscript Attitude, Awareness, Cross-sectional, Knowledge, Stroke, Survey Q 3.

Stroke is generally considered to occur in elderly people. However, in this research, the participants are mainly young people/students. Authors need to mention this as a major limitation. This limits the study to generalize the findings to the general public. It would have been nice to focus only on the students rather than the general public in this case.
Answer: The authors agree with the comment.The following is mentioned in the limitation section of the manuscript: " 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 Introduction section has to mention more about the probable mechanism of stroke in COVID-19 patients. Authors need to focus more on the topic with more literature added.
Answer: Thank you for the suggestion.The following was added to the introduction section.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-angiotensinaldosterone system, hence impacting blood flow, oxidative stress and excessive platelet aggregation(Wijeratne etal.2021).Reference: Wijeratne T, Gillard Crewther S, Sales C, Karimi L. COVID-19 Pathophysiology Predicts That Ischemic Stroke Occurrence Is an Expectation, Not an Exception-A Systematic Review.Front Neurol.2021;11:607221.Published 2021 Jan 28.

It is not clear why authors have chosen 'hypertension' to assume the prevalence of stroke. This needs more explanation.
Answer: Thank you for this valuable comment.Hypertension is the single most important modifiable stroke risk factor therefore, its value from the literature was used in the calculation of the sample size.This approach has also been used in previous literature: https://www.tandfonline.com/doi/full/10.1080/2331205X.2017.1327129(Namaganda P, Nakibuuka J, Kaddumukasa M, Katabira E. Stroke in young adults, stroke types and risk factors: a case control study.BMC Neurol.2022;22(1):335.Published 2022 Sep 6. doi:10.1186/s12883-022-02853-5) ).For attitude, a respondent who scored ≥80% of the correct attitude questions (≥4.8 points out of 6) was considered as having a "good attitude" or moderate/suboptimal attitude if the score was between 60 and 79%, (≥3.6-4.7 out of 6), and poor attitude if the score was less than 60% (<3.6 points out of 6)(Feleke et al. 2021).This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

, it should be noted that in a study on the knowledge of stroke in Catalonia (Spain) it was observed a scant knowledge of cerebrovascular disease in a sample of teenagers. Therefore, this knowledge should be integrated into the school curriculum (see and add this reference Rev Neurol 2003; 37: 500).
Page 10, last paragraph: "This was in contrast to our study, as gender etc.." doesn't fit the context.Revise the statement ○Is

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Thank you for taking the time to review our work titled "

Are we aware of stroke risk factors and warning signs amid COVID-19? Knowledge and attitude towards risk- factors, signs and symptoms of stroke among the UAE population during COVID-19 pandemic: A cross-sectional study" and
providing us with your insightful feedback to improve the manuscript.We have included answers in the manuscript to the questions put forth.Please see below the point-by-point responses to the questions.Presently, this is of utmost necessity, given the increased occurrence of stroke and its severity among COVID-19 patients."Rewordthissentence as it is unclear Response: Thank you for your comment.The sentence has been reworded to "Presently, this is of utmost necessity, given the increased occurrence of stroke and its severity during the COVID-19 pandemic " Indicate what co-morbidities that can increase the risk of occurrence, given that the survey has questions regarding medical history of subjects.Response: Thank you for your comment.The following has been added to the end of the 1 st paragraph in the introduction section."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 (Zhang et al. 2021, Elamy et al. 2020)" "Analysis of reports pertaining to the COVID pandemic shed light etc…," insert had after the word pandemic Analysis of reports pertaining to the COVID pandemic had shed light, etc….Need to expand on why COVID increase stroke occurrence.Provide recent references Response.Thank you for the comment.The following was added to the intro section: 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.Also, ACE receptors, where the COVID-19 virus binds to gain intracellular entry, are expressed in many cells, including endothelial cells of the blood vessels.This could disrupt the renin-angiotensin system, which modulates blood flow, further contributing to the pathogenesis process(Wijeratne etal.2021).Response: Wijeratne, T., Gillard Crewther, S., Sales, C., & Karimi, L. (2021).COVID-19 Pathophysiology Predicts That Ischemic Stroke Occurrence Is an Expectation, Not an Exception-A Systematic Review.Frontiers in neurology, 11, 607221.https://doi.org/10.3389/fneur.2020.6072215) Elaborate on why the COVID vaccine can cause stroke.Response: 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 (Kolahchi et al. 2022).Reference: Kolahchi, Z., Khanmirzaei, M., & Mowla, A. (2022).Acute ischemic stroke and vaccine-induced immune thrombotic thrombocytopenia post COVID-19 vaccination; a systematic review.Journal of the neurological sciences, 439, 120327.https://doi.org/10.1016/j.jns.2022.120327 ○Response: "○ 4)