Knowledge and Attitude about risk factors and warning signs of stroke among general population in Chintamani Taluk, Karnataka

Introduction

With rapid urbanization, industrialization and increasing level of affluence, the price that the society is paying is a tremendous load of “NonCommunicable” diseases.¹ Globally, stroke is second leading cause of death and seventh leading cause of disability.² Low and middle-income countries (LMIC) account for 85.5% of total stroke deaths worldwide and the number of disabilityadjusted life years in LMIC is approximately seven times that in high-income countries.³ In India, ICMR estimates in 2004 indicated that stroke contributed to 41% deaths and 72% of disability adjusted life years amongst the non-communicable diseases.³ Considering the limitation of health infrastructure and magnitude of the problemin our country, it is deemed wiser to focus attention on preventive measures⁴ and major contribution to reduction in stroke death will come from primary prevention.⁵

It is imperative to identify the knowledge gap and commonly held belief regarding any health related conditions in the community inorder to plan, implement and evaluate community education programme.⁶ Furthermore, knowledge about risk factors and clinical features of stroke will help individuals to adopt activities aimed at preventing the occurrence of stroke and also seek timely and appropriate care when needed.This is essential to prevent and reduce mortality and morbidity fromstroke in the community.⁴ Against this background the present study was undertaken to assess the knowledge and attitude regarding risk factors and warning signs & symptoms of stroke among the general population of Chintamani taluk, Chikkaballapur district, Karnataka.

Materials and methods

Study area: This study was conducted in Chintamani Taluk of Chikkaballapur District in the state of Karnataka. Birth rate and death rate in Chikkaballapur district is 18.5/1000 population and 5.68/1000 population respectively (2011). District has a literacy rate of 69.8% (census 2011). There are 9 primary health centers, one community health center and one taluk hospital in Chintamanitaluk.

Study Period: Study was conducted in the months of June and July 2012.

Study design: Cross sectional study

Study population: People living in ChintamaniTaluk, aged 18 years & above and who were permanent residents of the study area.

Exclusion criteria: those who are not willing to participate and eligible individuals who were not available even after two successive visits to the family were excluded. Individuals who were not able to comprehend the questions were also excluded.

Sample size: Sample size was calculated based on the pilot study, which revealed that 10% of the population possessed adequate knowledge on Non-Communicable diseases. Based on the above findings with an absolute precision of +/-2 and confidence level of 95%, the minimum sample size estimated was 900 adults.

Sampling method: List of villages and list of wards formed the sampling frame for rural and urban area respectively. In order to ensure that sample population represents Chintamani taluk, it was decided to select one village from each Primary health centre (PHC) and Community Health Centre (CHC) administrative area. On an average each primary health center in the taluk covers 30 villages. From nine PHC &one CHC administrative area, one village each was selected using simple random sampling technique. Thus 10 villages were selected from rural area of Chintamani Taluk. Similarly, two wards were selected from Chintamani town (urban area) using simple random sampling technique. In the selected villages and wards, every house was visited by trained medico social workers and from these houses those who are aged 18 years and above and who were permanent residents (residing for more than 6 months) of the taluk were enrolled for the study.

Statistical analysis: data was entered in excel sheet and analysis done by employing SPSS 18.0 version. Proportion of population possessing adequate knowledge and right attitude was estimated. To test for differences in proportion between Sociodemographic factors and awareness of stroke, chi square test of significance was used.

Study tool: Questionnaire consisted of 3 parts: First part had information on socio-demographic characteristics of the study participants, second on knowledge about risk factors and symptoms of stroke and the third part included questions on attitude towards stroke. Attitude was ascertained using 5-point Likert scale.

Data collection: A pretested semi structured questionnaire was developed to collect the data. Questionnaire was translated to local language and was administered by four medico social workers who were trained on interview techniques by the investigators. Response to questions about awareness on various aspects of stroke was elicited through one-to-one interview with the study participants. Medico social workers were periodically supervised to ensure that they collected good quality data. During the supervisory visits to the filed, investigator looked at the completeness and accuracy of the data collected by randomly visiting few households which were earlier visited by the MSWs.

Results and discussions

This is a population-based survey done in Chintamani taluk, Chikkaballapur district in the state of Karnataka. A total of 1245 individuals were enrolled for the study and of them, 482 (38.7%) were males and 763 (61.3%) were females. Proportions of females (61.3%) were more compared to males (38.7%) among the study participants and females are overrepresented in the age group of 18 to 45 years (Fig.1). This could probably be due to the fact that employed males were not available for interview, during the working hours of the day. However, males and females comprised of 50.7% and 49.3% of the Chintamani taluk population respectively.⁷ Among the study subjects, 241(19.4%) and 1004(80.6%) were from urban and rural area respectively (Fig 2).This distribution is closer to the urban (25.6%) and rural(74.4%) distribution of the entire population of Chintamani taluk.7 Not literate constituted 39.0% of the study population and 47.1% of the participants had educated upto high school. Only 6.0% of the participants had completed their degree course (Fig 3). According to 2011 census, 34.1% of the population in Chintamani taluk is not literate. Except for proportionate distribution of males & females, other demographic parameters observed among our study participants is more or less similar to demographic characteristics of chintamani taluk. Hence findings from this study wouldreflect the knowledge and attitude regarding stroke among the general population of Chintamani taluk.

The major modifiable behavioral and biological risk factors identified for stroke in the World Health Report 2002 includes: tobacco use, harmful alcohol consumption, unhealthy diet (low fruit and vegetable consumption), physical inactivity, overweight and obesity, raised blood pressure, raised blood glucose, abnormal blood lipids and its subset raised total cholesterol.⁸ We have attempted to collect information on awareness about all these important risk factors.

In the present study, it was observed that nearly 2/3rd of the study participants were not aware about the common risk factors of stroke. 67.2 % of the study population responded that they didn’t know that lack of exercise is a risk factor for stroke, whereas for diabetes and hypertension it was 67.0% and 62.9% respectively. Close to 50% of the study population responded that they were not aware of smoking and harmful intake of alcohol being the risk factor for stroke. Similarly, family history of stroke was not recognized as risk factor by 55.3% of the study participants (Table 1). On the positive side, unhealthy diet was identified as a risk factor for stroke by 48.0% of the study population and 39.9% said that old age is a risk factor for stroke. This information presumably indicates that people in Chintamani taluk lay more emphasis on diet and old age as factors associated with stroke and half of them are of the opinion that stroke is not familial.

Overall, the participants had a low level of awareness about all the risk factors of stroke and unhealthy diet (48.0%)was the most commonly identified risk factor for stroke. This would be a challenge/barrier for effective prevention of stroke in the community. In studies conducted elsewhere, hypertension was the most commonly identified risk factor for stroke and it ranged between 29.0% to 54.0%.^{9 -14} However, in a study done in Australia¹⁵ and Brazil¹⁶ smoking was the most commonly identified risk factor. In the present study awareness about risk factors of stroke was significantly better among males when compared to females (table 2) and this could be due to the difference in literacy status between males and females, the former being more literate. Studies have shown that those who are more literate have better awareness about risk factors when compared to those who are less or not literate.^10,11 Rural population had better awareness about risk factor when compared to urban population (p<0.05) (table 3) with respect to many of the risk factors. However urban participants had better knowledge when it comes to hypertension and elevated blood cholesterol as risk factors for stroke. Reasons for this difference in awareness of risk factors for stroke between urban and rural area could be multitude in nature and needs to be further explored.

Sudden weakness/ numbness of face, sudden weakness of arm or leg and difficulty in speech were correctly identified as warning signs of stroke by 89.7%, 88.9% and 89.8% of the study participants respectively. Dizziness and severe headache were identified as symptoms by 45.9% and 39.5% of the study population respectively (table 4).

Most commonly recognized warning signof stroke in our study was Paralysis of any part of the body and difficulty in speech. This finding is in compliance with many other studies.^9-11 However in our study close to 90.0% of the participants identified the above symptom, whereas in other studies proportion of participants identifying paralysis as symptom of stroke was in the range of 53.6%-65%.^9-11 In a Study conducted in Australia¹⁵ blurred and double vision or loss of vision in one eye was the most common stroke warning sign identified by respondents. Difference in study setting and differing study population may explain the observed variation in knowledge about warning signs of stroke between our study and other studies. Awareness about symptoms other than paralysis was relatively low in our study and this could probably become a barrier to seek early hospital care in the event of occurrence of stroke.

Stroke as a serious condition adversely affecting individuals and their families was agreed upon by 86.2% of the study population and 68.5% agreed that stroke is a preventable condition. More than 50% of the study population agreed that eating healthy diet, maintaining healthy weight and being physically active reduces once chance of getting stroke. From this we may opine that, though awareness about risk factor is low in the study population, they feel general wellbeing may prevent stroke. Nearly 50% of the study population agreed that taking treatment for hypertension, diabetes mellitus and elevated lipid level reduces once chances of getting stroke. This is a contrary finding in the context of awareness about these risk factors among study population. We assume that some of the participants who would have respondent by saying that they don’t know that diabetes, hypertension and elevated lipids are risk factor for stroke, could have opted for favorable response for attitude related question. Only 45.1% and 50.3% of the individuals agreed that avoiding smoking and alcohol respectively would reduce one’s chance of getting stroke. Interestingly, 13.7% and 12.0% of the study population disagreed that avoiding smoking and alcohol respectively will reduce someone’s chance of getting stroke (table 5). Majority(75.0%) agreed that family support is necessary for person affected with stroke, and this attitude of the study population may help planners to focus more on rehabilitation at family level for stroke affected individuals.

Realizing the burden and the need for intervention for Non communicable diseases, Government of India launched on pilot basis National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS) on 4th Jan 2008.¹⁷ Presently this programme is being implemented in select districts of our country.¹⁸ One of the important strategies of the programme is health promotion for behavioral and lifestyle changes through massive health education at various level.¹⁹ Success of any health education campaign depends on the extent of adherence to the principles of health education, and the one of the important principles is proceeding from “known to unknown”.¹⁸ Therefore, we feel that findings from our study will provide valuable input for designing effective IEC campaign with respect to stroke in Chintamani taluk.

In conclusion, awareness about risk factors of stroke is poor among the general population of Chintamani taluk. Paralysis of any part of the body is widely recognized as warning sign of stroke, however awareness about other warning sign are not satisfactory. This suggests the need for an intensified, multimodal IEC campaign for effective prevention and control of stroke in the Chintamani community. Attitude of the general population towards stroke, especially about the general perception and management, is found to be favorable which can be viewed as an opportunity to plan and implement effective stroke control programme.However there prevails unfavourable attitude on some of the common and important risk factors which needs to be addressed through community education programme.