The Effectiveness of Stroke Awareness Campaign in Promoting Knowledge on Stroke Among the Public in Malaysia

doi:10.21203/rs.3.rs-1676500/v1

Background and objectives: Despite the advancement in managing acute ischemic stroke, the global burden would not be reduced without extensive public health efforts to raise awareness among the public. Moreover, the lack of knowledge and healthcare-seeking practice among the public in developing nations proved to be a hindrance in combating stroke. Therefore, this study aimed to assess the effectiveness of stroke awareness campaigns in raising stroke awareness based on knowledge of stroke recognition, actions to be taken during stroke, and a healthcare-seeking attitude among the public in Malaysia.

Methods: This is a cross-sectional study of adults aged 18 and above attending media-driven health promotion initiatives i.e., ResQ Stroke Campaign (RSC) in conjunction with World Stroke Month 2021 in Malaysia. One hundred and seventy-one consented respondents have agreed to complete the pre and post questionnaire on knowledge, action and attitude with regards to stroke.

Results: In terms of knowledge, post-RSC respondents were more likely to recognize FAST up to 80 % increase compared to pre-RSC respondents. While, in terms of action, calling for an ambulance or going to the nearest hospital within 4.5 hours on the same day were the main action in response to stroke. However, although three-quarters of respondents indicated they would call emergency medical services, still a substantial number of respondents indicated they would seek medical help using non-emergency means.

Conclusions: There is an improvement in knowledge, action and attitude towards stroke after our median driven RSC. However, continuous campaigns are needed to maintain public awareness of stroke symptoms and appropriate action.

Stroke campaign

Acute stroke

Knowledge

Attitude

Action

FAST

Stroke is a preventable disease. The World Stroke Organization (WSO) estimates the lifetime risk of stroke is 1 in 4[1]. In Malaysia, stroke is the third leading cause of death among males and the second leading cause of death among females. Despite the advancement in managing acute ischemic stroke, the global burden would not be reduced without extensive public health efforts to raise awareness among the public, especially in the high-risk groups. Therefore, primary prevention is vital in curbing the high morbidity associated with stroke. The WSO proposed a three-pronged approach centred around creating awareness of stroke symptoms and risk factors among the public through self-risk assessment and engaging health professionals in tackling modifiable risk factors [1].

Stroke prevention is achievable and practical, and it is demonstrated to be effective in approximately 80% if appropriate precautions and measures are taken based on understanding disease risk factors [2–3]. However, studies have shown a vast gap of knowledge between developing and developed countries where poor knowledge of stroke recognition is seen in developing countries. Furthermore, patients in developing countries tend to seek complementary alternative treatment instead of prompt attention to medical facilities [4–7]. This is vital as current hyperacute stroke treatment depends on presentation to a stroke-ready hospital within the golden window period.

Lack of knowledge and healthcare-seeking practice among developing nations proved to hinder in combating stroke. Therefore, this study aims to determine the baseline knowledge on stroke recognition, actions to be taken during stroke, and a healthcare-seeking attitude among the public in Malaysia. We would also aim to assess the effectiveness of our stroke awareness campaign (ResQ Stroke Campaign, RSC) in conjunction with World Stroke Month (WSM) in October 2021.

Sample

A cross-sectional study was done among adults aged 18 years and above who registered to join our RSC, mainly our Virtual ResQ Stroke Runs, from May until November 2021. As this was an open virtual public campaign and fun run, the sample size was not calculated. A universal sampling method was used to recruit participants who consented to fill in the questionnaire and were recruited to the study via a google form link.

Study recruitments and measurements

This study is divided into two parts, i.e. pre and post-WSM celebration in 2021. A validated questionnaire was taken from a study done to assess the stroke awareness of the public in Malaysia [8].

Measurement

The questionnaire content was developed by three by two senior consultant neurologists and three primary care physicians. The study explores three main topics, i.e., knowledge of stroke and recognition of stroke symptoms, attitude towards medical treatment of stroke and knowledge on actions to be taken during a stroke. The questionnaires contained questions assessing awareness of the cause of stroke, stroke risk factors, stroke warning signs, appropriate behavioural response to stroke symptoms and understanding of acute interventions for stroke. The respondents were assessed with questions about stroke warning signs and the appropriate behavioural response and action toward acute stroke management. These questions also acted as 'control' questions and facilitated the evaluation of the sensitivity and specificity of the FAST message.

Stroke awareness campaign (ResQ Stroke Campaign, RSC)

Among the stroke awareness activities carried out include:

Virtual stroke forum (RSC Talk) via online webinars by the Consultant Neurologists. The topic and objectives of this forum are listed in the next paragraph.
A Virtual RSC Fun Run 8 KM or 10,000 steps (Theme: Run FAST for Stroke) was conducted, particularly emphasizing FAST. The fun run was carried out throughout October 2021.
FAST campaign, i.e. stroke recognition via mnemonic FAST (Facial weakness, arm weakness, speech difficulties and time to call an ambulance) through social media.
Regular information on stroke was updated on our Facebook page, which participants were invited to follow to get updated on our RSC and details regarding stroke.

Five RSC Talks were organized via online platforms from April until November 2021. Each RSC Talk will cover a different aspect of stroke management and involve specialists from multidisciplinary such as; 1. RSC Talk 1.0: What is a stroke? (Promote the public's basic understanding of stroke recognition and prevention of stroke, 2. RSC Talk 2.0: Stroke – Prevention and Treatment (reiterate the importance of early stroke recognition and presentation to the hospital) 3. RSC Talk 3.0: Stroke – Diet and Exercise (importance of exercise and a healthy diet to prevent stroke) 4. RSC Talk 4.0: Stroke during COVID-19 Pandemic (emphasize to the public the importance of early hospital visits even during the COVID-19 pandemic), 5. RSC Talk 5.0: Stroke Patients Need Help (focusing on helping stroke patients, especially during the pandemic because stroke patients were significantly affected socially and economically).

Statistical analysis

The latest version of SPSS 26 was used to analyze p < 0.05 and was determined as a significant difference and association for variables calculated. Data were not normally distributed; hence the non-parametric analysis was used. Data is represented as n (%) and IQR. McNemar's, Chi-square, and Fisher exact tests were used in this study.

A total of 178 respondents have agreed to participate in this pre-and post-study (Table 1). The respondents were 109 females (61.2%) and 69 males (38.8%); more than half of the respondents, 103 (57.9%), were married with a median age of 35 years old (IQR:30–42). The majority were Malay Muslims (62.9%) with tertiary education (93.8%). Almost one-third of respondents had a medical background. In terms of medical comorbidities, 23 (12.9%) have hypertension, 13 (7.3%) diabetes mellitus, and 25 (14%) hyperlipidemia. More than half had their blood pressure (BP) regularly checked, with the majority having home BP self-check.

Summaries from the Table 4, which there were significant improvements in;

Domain 1: Knowledge

4.1% in general knowledge, 14.1% in knowledge on causes and risk factors for stroke, 79.8% in FAST as recognition of signs of stroke ;(F) Facial weakness 53.4%, (A) Weakness of arms and legs 58.9, (S) Speech difficulties 57.5%, and (T) Call ambulance 104.5% (2.9% prevention of stroke).

Domain 2: Action

75% Call general practitioner or family doctor, 36.1% Go to the hospital within 4.5 hours, 63.5% Go to hospital on the same day and 17.2% Call an ambulance.

Domain 3: Attitude

Going to the hospital is only 4.1% and will get a combination of hospital and faith treatment 2.9%.

Overall Knowledge Of Stroke

Respondents' unprompted descriptions of what constitutes a stroke are summarized in Tables 2, 3 and 4. Domains 1 were compared between surveys using McNemar's analysis test. The comparison was determined based on pre and post campaigns. During the pre-campaign, the respondents could not identify the target organ involved in stroke and the recognition sign of stroke (FAST). It was significantly less likely to provide a wrong description than saying they didn't know during the pre-campaign. However, there were overall significant changes and increments in pre and post that involved understanding what constitutes stroke, the cause and risk factors of stroke; the warning signs of stroke; the recognition of stroke symptoms (FAST); and how to prevent stroke.

1. Knowledge of stroke warning signs

Knowledge of the warning signs for stroke was assessed using an open-ended question with no prompts. Good knowledge was defined as correctly identifying two or more signs classified by NINDS (National Institute of Neurological Disorders and Stroke) [9]. Based on the questionnaire provided, 87.6% of respondents reported being able to identify the symptom of stroke during the pre-questionnaire and 100% on the post questionnaire. The study reported significant p < 0.001 changes in the pre-and post-campaign on warning signs of stroke but not on positive symptoms (weakness or paralysis in one side of the body and numbness of one side) and all negative symptoms except for confusion or disorientation p < 0.001. Tabulated the positive and negative symptoms are reported in Table 4.

2. Knowledge of stroke campaigns (FAST)

Respondents were asked if they were aware of the FAST campaign. Only (55%) of respondents were aware of the FAST campaign. The sources of information during the pre-campaign were healthcare facilities (84%), social media (61.8%), and friends and relatives (44.9%). After being educated regarding FAST during RSC, the majority of all patients could describe several details of the FAST (Table 4).

3. Action and response to stroke

When asked how they would respond if they thought they were having a stroke or witnessing someone having a stroke, respondents in post-campaign were significantly more likely to state that they would call an ambulance (99.4% compared to 84.8% in pre-campaign; Table 6). The majority of the respondents will call a general practitioner or call a family doctor post-campaign (86.5% compared to 49.4%), go to the hospital within 4.5 hours (91% compared to 66.9%), go to the hospital on the same day (98.3% compared to pre-campaign 60.1%). Very few participants (0.6%) said they would do nothing or try to ignore it. However, (1.7%) did not know what to do. But, after the post-campaign, none of the respondents reported they did not know what to do (Table 5).

</div>

4. Attitude toward stroke treatment

The attitude toward the stroke treatment was assessed as a Domain 3 (Table 6), which determined the behaviour of the respondents regarding what medical treatment. Our study noticed that most of the respondents chose multiple selections. The majority of them will go to the hospital, and half of them will seek a combination of complementary tradition and faith and medical treatment.

Our study is Malaysia's first small-scale nationwide survey of general community knowledge of stroke, and it follows the introduction of the FAST campaign among the Malaysian population. The findings demonstrate a significant improvement in the public capability to detect stroke warning symptoms, particularly those highlighted by the FAST campaign, and a corresponding reduction in those who had incomplete or inaccurate beliefs about stroke, such as chest pain or palpitations. The campaign was also successful in cueing recognition to action, with a substantial correlation between the ability to name stroke warning signs and recollection of media advertising (Table 7) and the intention to contact an ambulance.

Stroke risk factor knowledge was strong, and rates differed between pre and post-campaign. Risk factor knowledge was greater in this study than in previous studies [10–12], with nearly three-quarters of the sample correctly identifying two or more risk factors. The most commonly mentioned risk factors were hypertension, cardiovascular disease, smoking, and a sedentary lifestyle (obesity, unhealthy diet and lack of exercise). Several studies have shown comorbidities including hypertension, diabetes mellitus, hyperlipidemia, cardiovascular disease, environmental and social factors including lifestyle, smoking, and alcohol as risk factors of developing stroke [13–17]. Many participants are likely to have recognized general risk factors for health disorders, reflecting the media's attention on obesity and smoking in Malaysian health policy. However, public awareness was significantly lower when particular risk factors associated with an elevated risk of stroke were investigated. For example, although the population prevalence of blood pressure is relatively high, [17] respondents had low levels of awareness of blood pressure as a risk factor for stroke.

Knowledge of stroke warning signs and proper action increased significantly pre and post RSC campaigns. The ability of respondents to identify two or more stroke warning signs nearly doubled. It is a considerable increase over pre and a somewhat greater improvement than previous research. [10–12] The campaign's most frequently reported warning signs were facial weakness, slurred speech, FAST symptoms, and weakness or paralysis on one side of the body. Post-campaign respondents were more likely to recognize FAST (50–80% increase), positive symptoms (10–20% increase), and negative symptoms (10% increase) than pre-campaign respondents. However, a few respondents identified the inaccurate warning symptoms such as shortness of breath and chest pain, showing persistent misunderstanding between stroke and heart attack warning signs.

In terms of immediate response to stroke, following exposure to the RSC, respondents were significantly more likely to call for an ambulance or go to the nearest hospital within 4.5 hours or the same day if symptoms occurred. Over three-quarters of respondents indicated that they would call emergency medical services and others would seek medical help using non-emergency means, including contacting a GP, visiting the community health centers and asking for advice from alternate healthcare members, for example physiotherapist or pharmacist. Compared with other studies [22–24], with the increase of 30 to 60% in pre and post findings, there is a relative improvement in the impact of the FAST campaign on appropriate behavioural intentions among the Malaysian population.

However, in terms of the treatment of stroke, many participants will still consider alternative, complementary and faith as their treatment choice. Various studies reported using traditional and alternative therapies for disease treatment and management, especially among the Asian population [18–21]. However, the issues are sensitive to be discussed. And, we do believe most of the Asian population, especially the Malaysian population has a strong belief and attitude toward traditional treatments as a part of stroke treatments.

Aside from that, poor retention mentioned by Hickey et al., 2018 stated that the inadequate translation of knowledge, action and attitude towards acute stroke and warning sign indicates the inappropriate behavioral response towards emergency stroke management. Respondents in this study were asked about their knowledge of acute stroke interventions within one month. Unfortunately, the majority of the respondents were aware that there are emergency stroke interventions available, however they were unable to identify the acute intervention and management due to the gap time that was conducted during pre and post RSC.

The FAST advertisement campaign is widely utilized worldwide to raise public awareness of stroke warning signs and appropriate responses [26]. This study shows that the RSC has a considerable influence on stroke warning sign awareness and, to a lesser extent, on proper emergency response. But, the message is highly specific, as evidenced by the campaign's lack of impact on population awareness of aspects of stroke not addressed by the FAST message. There are solutions to improve the FAST message that can and should be implemented. The 'T' component, in particular, does not appear to be assimilated by the general population.

Findings from this campaign indicate there is an improvement in knowledge, action and attitude toward stroke. But, belief, culture, and time gap between campaign hinder the awareness of acute stroke management and intervention. Further and continuous campaigns are needed to maintain the public understanding of stroke signs and appropriate responses. Particularly, there is a need to highlight the importance of the emergency response and attitude to stroke.

Several limitations should be taken into consideration in this study. Campaign of acute stroke is only being done during the WSM and not continuously being advocated. Thus, respondents' knowledge may decrease and action and attitude may vary. Moreover, a small sample size and a single-centred campaign due to the pandemic may lead to deflecting results which a bigger sample size with multicenter data should consider for better results. Other than that, this study did not show the significant association toward the demographic and risk factors related due to limited sample size. Also, the selected population is mostly from the Asian population. Some of the respondents still stick on the belief, and culture as one of the supplementary or additional treatment for the acute stroke.

In conclusion, RSC was a successful event in improving stroke knowledge. RSC demonstrates the significant influence of media-driven health promotion initiatives in improving population knowledge and awareness (Table 7). However, this campaign should not be a one-off effort, and continuous campaigns are needed to maintain public awareness of stroke symptoms and appropriate action.

RSC

ResQ Stroke Campaign

WSO

World Stroke Organisation

WSM

World Stroke Month

FAST

Facial asymmetry, Arm Weakness, Speech Difficulties, Time to call 999

NINDS

National Institute of Neurological Disorders and Stroke

GP

General Practitioner

IQR

Interquatile Range

COVID-19

Corona Virus Disease 2019 caused by SARS-CoV-2

Acknowledgements

We would like to thank members of the general public who gave their time to participate in this national survey. We also thank Hospital Pengajar Universiti Putra Malaysia and Boehringer Ingelheim under the ANGELS Initiative for support during the fieldwork and campaign.

Authors’ contributions

AHKYK, LWC, JB, FKH, SMC, LNIM, HB contributed to the study design and conception. MZB, AHKYK, LWC, JB, AMAR, AI, WAWS involved in the data collection and data fieldwork. MZB, NKD, SMC, AHKYK involved in the data analysis and data intepretation. MZB, AHKYK, JB, LWC, AI, AMAR involved in the drafting of the initial manuscript. NKD, SMC, LNIM, FKH, WAWS and HB involved the review of the manuscript and assist in drafting the final manuscript. MZB, AHKYK, JB, LWC, AI, AMAR involved in the drafting of the final draft. All authors reviewed the manuscript and approved the final version.

Funding

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Ethical approval and consent to participant

This study was approved by the Ethics Committee Involving Human Subjects Universiti Putra Malaysia (JKEUPM-2020-121). All methods were carried out in accordance with the JKEUPM guideline and regulation. All respondents consented and informed consent was obtained via the google link form.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Authors details

¹ Nephrology Unit, Department of Medicine, Faculty of Medicine and Health Sciences Universiti Putra Malaysia

²Nephrology Unit, Department of Medicine, Hospital Pengajar Universiti Putra Malaysia

³ Department of Neurology, Faculty of Medicine and Health Sciences Universiti Putra Malaysia

⁴ Departmen of Neurology, Hospital Pengajar Universiti Putra Malaysia.

⁵ Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

⁶ Department of Family Medicine, Hospital Pengajar Universiti Putra Malaysia.

Lindsay MP, Norrving B, Sacco RL, Brainin M, Hacke W, Martins S, Pandian J, Feigin V. World Stroke Organization (WSO): global stroke fact sheet 2019.
Oliveira GB, Avezum A, Roever L. Cardiovascular disease burden: evolving knowledge of risk factors in myocardial infarction and stroke through population-based research and perspectives in global prevention. Frontiers in cardiovascular medicine. 2015 Aug 13;2:32.
Dar NZ, Khan SA, Ahmad A, Maqsood S. Awareness of stroke and health-seeking practices among hypertensive patients in a tertiary care hospital: a cross-sectional survey. Cureus. 2019 May 28;11(5).
Kalkonde YV, Alladi S, Kaul S, Hachinski V. Stroke prevention strategies in the developing world. Stroke. 2018 Dec;49(12):3092-7.
Khalil HM, Lahoud N. Knowledge of stroke warning signs, risk factors, and response to stroke among Lebanese older adults in Beirut. Journal of Stroke and Cerebrovascular Diseases. 2020 May 1;29(5):104716.
Komolafe MA, Olorunmoteni OE, Fehintola FO. Effect of health education on level of awareness and knowledge of Nigerian in-school adolescents on stroke and its risk factors. Journal of Stroke and Cerebrovascular Diseases. 2020 May 1;29(5):104757.
Kandola DK. Exploring the Use of Emergency Health Services for Stroke: What is Known about when to Seek Emergency Help and how Transport Decisions Impact In-hospital Emergency Care (Doctoral dissertation, University of Northern British Columbia).
Bin Basri, Hamidon & Kee, Hoo & Chung, Law & Looi, Irene & Yong, Tan & Sulaiman, Wan & abdul aziz, Zariah & Wan Zaidi, Wan Asyraf & Yusof Khan, Abdul Hanif Khan & Ch'ng, Alan & Cheah, Wee-Kooi & Ganasegeran, Kurubaran & Albart, Stephenie. (2021). Clinical Practice Guidelines Management of Ischaemic Stroke 3rd Edition 2020.
Kehne JH, Klein BD, Raeissi S, Sharma S. The national institute of neurological disorders and stroke (NINDS) epilepsy therapy screening program (ETSP). Neurochemical research. 2017 Jul;42(7):1894-903.
Nordanstig A, Asplund K, Norrving B, Wahlgren N, Wester P, Rosengren L. Impact of the Swedish National Stroke Campaign on stroke awareness. Acta Neurologica Scandinavica. 2017 Oct;136(4):345-51.
Lecouturier J, Rodgers H, Murtagh MJ, White M, Ford GA, Thomson RG. Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment. BMC public health. 2010 Dec;10(1):1-0.
Hartigan I, O'Connell E, O'Brien S, Weathers E, Cornally N, Kilonzo B, McCarthy G. The Irish national stroke awareness campaign: a stroke of success?. Applied Nursing Research. 2014 Nov 1;27(4):e13-9.
Ruan Y, Guo Y, Zheng Y, Huang Z, Sun S, Kowal P, Shi Y, Wu F. Cardiovascular disease (CVD) and associated risk factors among older adults in six low-and middle-income countries: results from SAGE Wave 1. BMC public health. 2018 Dec;18(1):1-3.
Ciumărnean L, Milaciu MV, Negrean V, Orășan OH, Vesa SC, Sălăgean O, Iluţ S, Vlaicu SI. Cardiovascular risk factors and physical activity for the prevention of cardiovascular diseases in the elderly. International Journal of Environmental Research and Public Health. 2021 Dec 25;19(1):207.
Ahmed AA, Al-Shami AM, Jamshed S, Zawiah M, Elnaem MH, Ibrahim MI. Awareness of the Risk Factors for Heart Attack Among the General Public in Pahang, Malaysia: A Cross-Sectional Study. Risk Management and Healthcare Policy. 2020;13:3089.
Yusoff YS, Rahim NA, Hasmi MH. Review on Cardiovascular Disease Risk Factors Among Selected Countries in Asia. InProceedings of the 6th International Conference on Fundamental and Applied Sciences 2021 (pp. 655-670). Springer, Singapore.
Chan YY, Sahril N, Rezali MS, Kuang Kuay L, Baharudin A, Abd Razak MA, Azlan Kassim MS, Mohd Yusoff MF, Omar MA, Ahmad NA. Self-Reported Modifiable Risk Factors of Cardiovascular Disease among Older Adults in Malaysia: A Cross-Sectional Study of Prevalence and Clustering. International journal of environmental research and public health. 2021 Jan;18(15):7941.
Salah AO, Salameh AD, Bitar MA, Zyoud SE, Alkaiyat AS, Al-Jabi SW. Complementary and alternative medicine use in coronary heart disease patients: a cross-sectional study from Palestine. BMC complementary medicine and therapies. 2020 Dec;20(1):1-4.
Risso-Gill I, Balabanova D, Majid F, Ng KK, Yusoff K, Mustapha F, Kuhlbrandt C, Nieuwlaat R, Schwalm JD, McCready T, Teo KK. Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach. BMC health services research. 2015 Dec;15(1):1-5.
Jiraporncharoen W, Pinyopornpanish K, Junjom K, Dejkriengkraikul N, Wisetborisut A, Papachristou I, Hashmi A, Angkurawaranon C. Exploring perceptions, attitudes and beliefs of Thai patients with type 2 diabetes mellitus as they relate to medication adherence at an out-patient primary care clinic in Chiang Mai, Thailand. BMC family practice. 2020 Dec;21(1):1-9.
Griva K, Ng HJ, Loei J, Mooppil N, McBain H, Newman SP. Managing treatment for end-stage renal disease–a qualitative study exploring cultural perspectives on facilitators and barriers to treatment adherence. Psychology & Health. 2013 Jan 1;28(1):13-29.
Hartigan I, O'Connell E, O'Brien S, Weathers E, Cornally N, Kilonzo B, McCarthy G. The Irish national stroke awareness campaign: a stroke of success?. Applied Nursing Research. 2014 Nov 1;27(4):e13-9.
Hickey A, Mellon L, Williams D, Shelley E, Conroy RM. Does stroke health promotion increase awareness of appropriate behavioural response? Impact of the face, arm, speech and time (FAST) campaign on population knowledge of stroke risk factors, warning signs and emergency response. European stroke journal. 2018 Jun;3(2):117-25.
Mellon L, Hickey A, Doyle F, Dolan E, Williams D. Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign. Emergency Medicine Journal. 2014 Jul 1;31(7):536-40.
Frass M, Strassl RP, Friehs H, Müllner M, Kundi M, Kaye AD. Use and acceptance of complementary and alternative medicine among the general population and medical personnel: a systematic review. Ochsner Journal. 2012 Mar 20;12(1):45-56.
Sudirman H, Yuliyanti C, Sari AI. Effectiveness of 'FAST'stroke campaign for fast stroke recognition and response: a systematic review. InProceedings of the International Conference on Applied Science and Health 2018 Aug 2 (No. 3, pp. 112-121).

TABLE 1: Sociodemographic

Demographic	n (%)	Median	IQR
Age		35	30	42
Gender
Male	69(38.8)
Female	109(61.2)
Marital status
Married	103(57.9)
Single	71(39.9)
Divorce	2(1.1)
Widowed	2(1.1)
Religion
Islam	112(62.9)
Christian	12(6.7)
Buddhist	51(28.7)
Others	3(1.7)
Smoking
Yes	14(7.9)
Highest level of education
Primary (S1-6)	2(1.1)
Secondary (F1-5)	9(5.1)
Tertiary (University/College)	167(93.8)
Medical background
Yes	66(37.1)
Comorbidity
Hypertension	23(12.9)
Diabetes Mellitus	13(7.3)
Hypercholesterolemia	25(14)
Renal related disease	3(1.7)
Cancer	2(1.1)
Blood pressure (BP) reading
Yes	139(78.1)
Last BP reading
Last year	18(10.1)
This year	123(69.1)
Unknown/No	37(20.8)
Where BP measured
Clinic	76(42.7)
Pharmacy	6(3.4)
Others/Home BP.	96(53.9)

Table 1: Data is not normally distributed. Thus, data represent as median and IQR (interquartile range)

DOMAIN 1: Knowledge

KNOWLEDGE	Pre		Post		Increment%	Reduction%	*p-value*
KNOWLEDGE	n	%	n	%	Increment%	Reduction%	*p-value*
Organ of the body is affected by stroke
Brain	171	96.1	178	100	4.1		0.016
Heart	52	29.2	40	22.5		-23.19	0.000
Kidney	19	10.7	10	5.6		-47.32	0.004
Liver	8	4.5	4	2.2		-50	0.125
Lungs	9	5.1	1	0.6		-88.89	0.008
Don’t know	1	0.6	0	0		-100	1.00
Stroke more than once
Yes	176	98.9	178	100	1.10		0.5
No	2	1.1	0	0		-100	0.5
Stroke effect on daily activities
Yes	176	98.9	178	100	1.14		0.5
No	2	1.1	0	0		-100	0.5

Table 2: General knowledge on stroke. There is a significant difference in perspective in Domain:1 (General knowledge) with p < 0.005 except for liver. The increment and reduction of choice post-campaign were listed above.

p-value <0.05

* McNemar's test

KNOWLEDGE: CAUSES AND RISK FACTORS FOR STROKE
	Pre		Post		*p-value*	Increment	Reduction
	n	%	n	%		%	%
Risk factors for stroke
Yes	156	87.6	178	100	0.000	14.12
No	22	12.4	0	0	0.000		-100
Risk factors for stroke
Older age	106	59.6	148	83.1	0.000	39.60
Diabetes	96	53.9	163	91.6	0.000	6979
Hypertension	154	86.5	175	98.3	0.000	13.63
Cardiovascular disease	154	86.5	172	96.6	0.002	11.68
Sedentary lifestyle (Obesity, Bad diet and Lack of exercise)	140	78.7	167	93.8	0.000	19.28
Smoking	112	62.9	159	89.3	0.000	41.9
Alcohol	91	51.1	129	72.5	0.000	41.7
Stress	134	75.3	136	76.4	0.000	1.49
Genetics	76	42.7	141	79.2	0.000	85.52
Migraine	27	15.2	87	48.9	0.000	222.2
Cancer	16	9.0	137	77.0	0.000	756.25
Oral contraceptive	20	11.2	16	9.0	0.541		-20
Poor hygiene	4	2.2	20	11.2	0.000
Tremor	5	2.8	10	5.6	0.063
Witch craft	2	1.1	1	0.6	1.00		-50

Table 3: Knowledge of the risks factors of stroke. There is a significant difference in perspective in domain:1 (knowledge: causes and risk factors of stroke) with p < 0.005 except for oral contraceptive, tremor and witchcraft. The increment and reduction of choice in post-campaign were listed above.

*McNemar's test

KNOWLEDGE OF STROKE WARNING SIGNS
	Pre		Post		*p-value*	Increment	Reduction
	n	%	n	%		%	%
Symptom of stroke
Yes	156	87.6	178	100	0.000	14.10
No	22	12.4			0.000		-100
Warning signs of stroke
*Positive symptoms of stroke*
Dizziness	83	52.8	137	77	0.000	65.06
Blurred or double vision or loss of vision	108	60.4	130	73.0	0.024	20.37
Headache	79	44.4	140	78.7	0.000	77.21
Sudden difficulty in speaking or understanding or reading or slurred speech	150	84.3	178	100	0.000	18.66
Weakness or paralysis in one side of the body	155	87.1	156	87.6	1.000	0.64
Numbness of one side	124	69.7	125	70.2	1.000	0.80
Imbalance	111	62.4	178	100	0.000	60.36
*Negative symptoms of stroke*
Fainting black out collapse	89	50.0	92	51.7	0.916	3.37
Weakness or paralysis in both left, right body	111	62.4	112	62.9	1.000	0.90
Numbness of any body part	98	55.1	99	55.6	1.000	1.02
Tiredness	34	19.1	34	19.1	1.000
Fever	4	2.2	-	-	0.125
Shortness of breath	24	13.5	24	13.5	1.000
Chest pain or chest tightness	36	20.2	36	20.2	1.000
Nausea/vomiting	36	20.2	36	20.2	1.000
Confuse or disorientation	81	45.5	178	100	0.000	119.7
F.A.S.T as recognition of signs of stroke	Pre		Post		*p-value*	Increment	Reduction
F.A.S.T as recognition of signs of stroke	n	%	n	%	*p-value*	%	%
Yes	99	55.6	178	100	0.000	79.79
F.A.S.T component
Facial weakness	116	65.2	178	100	0.000	53.44
Weakness of arms and legs	112	62.9	178	100	0.000	58.92
Speech difficulties	113	63.5	178	100	0.000	57.52
Numbness	33	18.5	26	14.6	0.016		-21.21
Headache	8	4.5	8	4.5	1.000
Dizziness	8	4.5	8	4.5	1.000
Call ambulance	87	48.9	178	100	0.000	104.55
Is stroke preventable?
Yes	173	97.2	178	100	0.063	2.89
How to prevent stroke?
Healthy lifestyle (Healthy diet, regular exercise and healthy weight)	172	96.6	178	100	0.063	3.48
Sugar, Blood pressure and cholesterol control	163	91.6	178	100	0.000	9.20
Traditional medication or supplement	17	9.6	69	38.8	0.000	305.88
Regular follow up with your doctors	147	82.6	178	100	0.000	21.04
Taking blood thinners if had previous heart attack or stroke	107	60.1	156	87.6	0.000	45.79
Identify and treat atrial fibrillation (irregular heart beat)	91	51.1	169	94.9	0.000	85.71
Stop or reduce alcohol intake	120	67.4	126	70.8	0.625	5
Stop smoking	135	75.8	152	85.4	0.038	12.59
Manage stress and depression	129	72.5	153	86.0	0.002	18.60

Table 4: Knowledge of warning sign and FAST recognition

DOMAIN 2: ACTION

	Pre		Post		*p-value*	Increment	Reduction
	n	%	n	%		%	%
ACTION TO BE TAKEN DURING STROKE
Planned response to an event of stroke
Call general practitioner or family doctor	88	49.4	154	86.5	0.000	75
Ask family members or relatives to help	72	40.4	137	77.0	0.000	90.27
Go to chemist or pharmacy for advice or medication	3	1.7	3	1.7	1.000	0
Self-medication	1	0.6	-	-	-		-100
Ask friend or neighbours for help	35	19.7	91	51.1	0.000	160
Go to hospital on the same day	107	60.1	175	98.3	0.000	63.5
Go to hospital within 4.5 hours	119	66.9	162	91	0.000	36.13
Visit community health centre	29	16.3	29	16.3	1.000
Visit alternative health care providers	7	3.9	7	3.9	1.000
Seek spiritual healing (prayer)	1	0.6	-	-	-		-100
Invite a Physiotherapist	14	7.9	-	-	-		-100
Call ambulance	151	84.8	177	99.4	0.000	17.21
Others and don't know	3	1.7	-	-	-		-100

Table 5: Data showed on the action that needs to be taken during stroke.

DOMAIN 3: ATTITUDE

ATTITUDE TOWARDS MEDICAL TREATMENT	Pre		Post		*p-value*	Increment	Reduction
ATTITUDE TOWARDS MEDICAL TREATMENT	n	%	n	%		%	%
Will you go to see medical treatment if you have stroke?
I will go to hospital/medical facilities only	171	96.1	178	100	0.016	4.09
I will go for complementary and traditional medication only	2	1.1	-	-	-		-100
I will go for faith treatment only	-	-	-	-	-
I will get combination of hospital and complementary traditional medication	48	27.0	48	27	1.000
I will get combination of hospital and faith treatment	34	19.7	35	19.7	1.000	2.94

Table 6: Data showed the attitude of respondents toward medical treatment.

SOURCE OF INFORMATION

SOURCES OF INFORMATION ABOUT STROKE	Pre		Post		*p-value*
SOURCES OF INFORMATION ABOUT STROKE	n	%	n	%
Health care providers	150	84.3	178	100	0.000
Friends and relatives	80	44.9	82	46.1	0.500
Social media	110	61.8	178	100	0.000
Radio	39	21.9	39	21.9	1.000
TV/Television	61	34.3	61	34.3	1.000
Newspapers	53	29.8	53	29.8	1.000
Electronic media	108	60.7	108	60.7	1.000
Others	20	11.2	-	-	1.000

Table 7: Percentage of the pre and post of the source of information during the campaign

No competing interests reported.

The Effectiveness of Stroke Awareness Campaign in Promoting Knowledge on Stroke Among the Public in Malaysia

Status:

Version 1

Abstract

Introduction

Methods

Results

Domain 1: Knowledge

Domain 2: Action

Domain 3: Attitude

Overall Knowledge Of Stroke

1. Knowledge of stroke warning signs

2. Knowledge of stroke campaigns (FAST)

3. Action and response to stroke

4. Attitude toward stroke treatment

Discussion

Limitations Of The Study

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1