Original Article

Knowledge of stroke among stroke patients and their

relatives in Northwest India
Jeyaraj Durai Pandian, Guneet Kalra, Ashish Jaison, Sukhbinder Singh Deepak,
Shivali Shamsher, Yashpal Singh, George Abraham*
Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, Punjab - 141 008, India, *Saint Vincent Hospital at
Worcester Medical Centre, Worcester, MA 01608-1320, USA

Background: The knowledge of warning symptoms and

risk factors for stroke has not been studied among patients
with stroke in developing countries. Aims: We aimed to
assess the knowledge of stroke among patients with stroke
and their relatives. Settings and Design: Prospective
tertiary referral hospital-based study in Northwest India.
Materials and Methods: Trained nurses and medical
interns interviewed patients with stroke and transient
ischemic attack and their relatives about their knowledge
of stroke symptoms and risk factors. Statistical Analysis:
Univariable and mulivariable logistic regression were used.
Results: Of the 147 subjects interviewed, 102 (69%) were
patients and 45 (31%) were relatives. There were 99 (67%)
men and 48 (33%) women and the mean age was
59.714.1 years. Sixty-two percent of repondents
recognized paralysis of one side as a warning symptom
and 54% recognized hypertension as a risk factor for stroke.
In the multivariable logistic regression analysis, higher
education was associated with the knowledge of correct
organ involvement in stroke (OR 2.6, CI 1.1 6.1, P=0.02),
whereas younger age (OR 2.7, CI 1.17.0, P=0.04) and
higher education (OR 4.1, CI 1.510.9, P=0.005) correlated
with a better knowledge regarding warning symptoms of
stroke. Conclusions: In this study cohort, in general, there
is lack of awareness of major warning symptoms, risk
factors, organ involvement and self-recognition of stroke.
However younger age and education status were
associated with better knowledge. There is an urgent need
for awareness programs about stroke in this study cohort.
Key words: Stroke, awareness, patients, knowledge, risk
factor, India.

Introduction
Despite recent advances in stroke therapy, the majority of stroke

patients do not seek immediate medical attention.[1] Even in

developed countries like USA,[1,2] UK[3] and France[4] there is a
lack of knowledge among stroke patients about warning symptoms
and risk factors. In a multi-centre survey in USA, over one-half
of patients at increased risk for stroke were unaware of their risk
factors.[5]
Intravenous (IV) recombinant tissue plasminogen activator (rtPA) is being used for acute ischemic stroke in India.[6-8] Knowledge
about stroke warning symptoms and risk factors are essential for
the patients to effectively utilize the thrombolytic therapy for acute
stroke. There are no studies from India and other developing
countries regarding stroke patients knowledge about warning
symptoms and risk factors. We aimed to assess the knowledge of
stroke warning symptoms and risk factors among stroke patients
and their relatives.

Materials and Methods

The Stroke section, Department of Neurology in a tertiary
referral centre in Northwest India, conducted this study and the
study period was 15 months, from June 2002 to September 2003.
Stroke and transient ischemic attack (TIA) patients admitted
through emergency department and their relatives formed the
subjects. Trained nurses and medical interns conducted a
standardized structured interview with open-ended questions. The
questionnaire was adapted and modified from a previous survey
among general public conducted in Northwest India.[9] The first
section of the questionnaire gathered demographic information.
Education was categorized into illiterates, primary (below 5th
standard), secondary (6th standard to 12th standard) and college
education. Income was classified into upper (Indian National
Rupees > 5000 per month) and lower (Indian National Rupees
< 5000 per month) income groups. In section two, the time of
onset of stroke, patients or relatives initial reaction to stroke
symptoms, onset to arrival time to the hospital, were noted. The

Jeyaraj Durai Pandian

Stroke Unit, Department of Neurology, Level 7, Ned Hanlon building, Royal Brisbane and Womens Hospital, Herston Road, Brisbane, Queensland,
Australia 4029. E-mail: jeyarajpandian@yahoo.co.in

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Pandian et al.: Patients awareness about stroke

time of onset of stroke was defined as the time neurological deficit

was first noticed by the patient or a relative or caregiver. When the
symptoms were first noted on awakening, the time of awakening
was recorded as the time of onset because it represents the time
when medical help could be sought.[1,10-12] The third section
consisted of questions to explore the knowledge of organ affected
in stroke, warning symptoms and risk factors for stroke. There
were options for multiple responses, in questions concerning
warning symptoms and risk factors for stroke. The type of stroke
(ischemic or hemorrhagic), neurological findings and patients
risk factors were documented in the fourth section of the
questionnaire. When the stroke patients were unable to participate
because of speech and language involvement or altered sensorium,
one of the relative was interviewed. The questions were asked
during a one-to-one interview in the local vernacular language
(either Punjabi or Hindi). No attempt was made to prompt the
respondents by suggesting answers directly. The questionnaire
was pretested using a sample of 25 patients. Changes were made
in the questionnaire to various terms that are used for stroke in
the local languages Punjabi and Hindi. This was done entirely to
differentiate heart attack and stroke in the local language. To
minimize the in-hospital stroke education, all subjects were
interviewed within 48 hours of admission.
We compared the knowledge of stroke between different groups;
early arrivers (who arrived in hospital less than 6 hours after
the onset of stroke) versus late arrivers (who arrived in hospital
more than >6 hours of the onset of stroke) and between patients
and relatives.

Statistical analysis
All statistical analysis was performed using SPSS software
version 10.05 (SPSS Inc. Chicago, Illinois). 2 tests were used to
assess the univariable relationship between components of stroke
knowledge, warning symptoms, risk factors and demographic
variables. Multivariable logistic regression was used to assess the
predictors of knowing a single correct response to various questions.
Variables included in the model were age (less or more than 60
years), gender, religion (Hindus vs. others), education (lower
[illiterates and primary] vs. higher [secondary and college
education]), income (upper vs. lower) and place of residence (urban
vs. rural). Variables were eliminated in a stepwise backward fashion
if they failed to reach significance (P<0.05) until a final model
resulted. Finally, odds ratios (OR) and 95% CI were generated
for all the terms in the final models. 2 test and Fishers exact tests
were used to compare the knowledge of stroke between different
groups. The hospital research committee had approved this study
and informed consent was obtained from the patient or the relative.

There were 99 (67%) men and 48 (33%) women. The mean age
was 59.7 14.1 years (range 23-95 years). The demographic
characteristics of the study cohort was similar to that of the
population of Punjab,[14] except for the elderly age group (>60
yrs) and the place of domicile [Table 1]. The proportion of elderly
subjects was higher (52%) than the population of Punjab (9%).[14]
Sixty-two percent of the study cohort were from urban area as
compared to the population of Punjab (34%).[14]

Subjects initial reaction to stroke symptoms

One-hundred and seven subjects (73%) were not aware that
the initial symptoms were due to stroke. Fifty-six (38%) subjects
reached the hospital immediately. The rest consulted a private
doctor 86 (59%) or called a relative 5 (3%).
Organ affected in stroke
Only one third of the subjects interviewed recognized that the
organ injured in stroke is brain [Figure 1]. In the univariable
analysis higher education (OR 2.3, CI 0.163.1, P=0.02) was
associated with a better knowledge about the organ injured in
stroke [Table 2]. In the multivariable logistic regression analysis,
Table 1: Demographic data of the interviewees (n=147)
compared with Punjab data
Gender
Men
Women
Age
20-40
41-60
61-80
>81
Religion
Hindus
Sikhs
Others
Place
Rural
Urban

Punjab [14] (%)

N (%)

53
47

99 (67)
48 (33)

48
20
8
1.2

16
54
68
9

37
60
3

82 (56)
57 (39)
8 (5)

66
34

56 (38)
91 (62)

(11)
(37)
(46)
(6)

Results
Of the 173 subjects contacted, 147 subjects consented to
participate in the study. One hundred and two (69%) patients and
45 (31%) relatives were interviewed. The stroke type was ischemic
in 96 (65%), hemorrhagic in 39 (27%) and TIA in 12 (8%).
Neurology India | June 2006 | Vol 54 | Issue 2

Figure 1: Responses to the question organ affected in stroke

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Pandian et al.: Patients awareness about stroke

higher education remained a significant factor of knowing the

correct organ involved in stroke [Table 3].

Warning symptoms
The most common warning symptom described by the subjects
was paralysis of one side of the body 91(62%) [Figure 2]. Fifty
(34%) subjects correctly identified one symptom, 42 (29%)
identified two symptoms, only 12 (8%) knew three or more
symptoms, while 43 (29%) did not know even a single warning
symptom. In univariable analysis, younger age (OR 2.4, CI 1.1
5.1, P=0.04) and higher education (OR 3.3, CI 1.56.9,
P=0.006) correlated with knowing at least one warning symptom
[Table 2]. In multivariable logistic regression, both younger age
and higher education remained significant [Table 3].
Risk factors
Hypertension 79 (54%) and diabetes 45 (31%) were the two
most common risk factors identified by the study cohort [Figure
3]. Only 55 (37%) of the subjects could identify one risk factor
correctly, 31 (21%) subjects two risk factors and only 19 (13%)
3 or more risk factors. In the univariable analysis, higher education
(OR 2.0, CI 0.98 - 4.1, P = 0.03) correlated with better knowledge
of at least one risk factor [Table 2]. However, in the multivariable
logistic regression analysis, none of the variables reached any
statistical significance.
Risk factor recognition among high risk individuals
There were 120 (82%) subjects who had various risk factors
for stroke. A high proportion of subjects with hypertension 64/
93 (69%) and diabetes 36/50 (72%) were able to correctly identify
their risk factors for stroke. However, a very low proportion of
cohort who had other risk factors such as heart disease 4/18
(22%), dyslipidemia 11/38 (29%) and smoking 13/36 (36%)

could recognize their own risk factors for stroke.

Comparison of knowledge of stroke between different

subgroups
We compared the knowledge of stroke between early (n=61,
41%) and late arrivers (n=86, 59%) to the hospital and also
between the patients (n=102, 69%) and the relatives (n=45,
31%). We did not find any differences between the two groups
with regards to knowledge about organ involved in stroke, warning
Table 3: Final model in multivariable logistic regression
analysis
Odds
ratio

Confidence
interval

P
value

2.6

1.1 6.1

0.02

2.7
4.1

1.1 7.0
1.5 10.9

0.04
0.005

Organ involved in stroke

Higher education
Warning symptoms
Younger age
Higher education

Figure 2: Responses to the question warning symptoms of stroke

Table 2: Responses to major stroke awareness questions

Organ affected

Risk factors

Not aware
%%

Aware

Not aware
%

Aware
%

Not aware
%

28
37

72
63

59
75

41
25

72
69

28
31

35
27

65
73

69
63

31
37

73
67

27
33

46
27

54
73

83
60

17#
40

83
66

17
34

26
37

74
63

61
71

39
29

64
76

36
24

31
34

69
66

70
63

30
37

72
69

28
31

34
32

66
68

62
70

38
30

66
74

34
26

%
Age
<60 (n=70)
>60 (n=77)
Sex
Men (n=99)
Women (n=48)
Education*
Higher (n=72)
Lower (n=75)
Income
Upper (n=60)
Lower (n=87)
Religion
Hindus (n=82)
Others (n=65)
Place
Urban (n=91)
Rural (n=56)

Symptoms

Aware

*Education- lower (Illiterate and primary), higher (secondary and college), Income-lower (<Rupees 5000), upper (>Rupees 5000), Religion- Others
(Sikhs, Muslims and Christians), P<0.05, #P=0.006

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Pandian et al.: Patients awareness about stroke

Figure 3: Responses to the question risk factors for stroke

symptoms and risk factors for stroke.

Discussion
This is the first study to examine the knowledge of stroke warning
symptoms and risk factors among stroke patients in a developing
country. The majority (73%) of subjects did not realize that the
symptoms were due to stroke. Only a third of the study cohort
correctly identified the brain as the affected organ in stroke. Even
though our subjects had a better knowledge to some of the stroke
warning symptoms and risk factors, only a smaller proportion of
the subjects were able to recognize other warning symptoms and
risk factors.
In this study self recognition of stroke symptoms by patients
was lower (27%) when compared to what has been reported in
other similar studies in developed countries, 36% in the Cincinnati
study2 and 40% in the UK study,[3] but was similar to other studies,
21% in the France study[4] and 25% in the Indianapolis study.[1]
The knowledge regarding the organ injured in stroke in our
cohort was less (33%) when compared to the study in Cincinnati
(49%).[2] A small proportion of our subjects (2%) were unable to
differentiate heart attack from stroke. In a recent survey conducted
among the general public in Northwestern India,[9] 10% of the
respondents had difficulty in differentiating heart attack and
stroke. Recognizing symptoms of stroke in the community is more
difficult than recognizing heart attack, because stroke symptoms
are more heterogeneous.[15]
The majority of our respondents correctly answered paralysis
of one side (62%) as a warning symptom and hypertension (54%)
as a risk factor for stroke as compared with the study from
Cincinnati (26% and 27%, respectively).[2] However, only a
minority of our subjects were able to identify other warning
symptoms and risk factors.
We found a positive relationship between stroke knowledge and
higher education. The plausible explanation is that, majority
(62%) of our patients were from urban area and in India
educational opportunities are more in the urban than in the rural
areas. However, Kothari et al[2] did not find any correlation between
Neurology India | June 2006 | Vol 54 | Issue 2

better awareness and education. Most studies on public awareness

of stroke from developed countries have found that knowledge
about stroke varies positively with education.[16-18]
We acknowledge the limitations of our study. Firstly, we
interviewed the family members when the patients were unable to
participate, because of dysphasia or altered sensorium. The sample
may not fully reflect the knowledge of stroke among stroke
population. In India, the structure of the family is different from
the developed world. Approximately 26% of the population in
Punjab lives in a joint family system i.e. two or three families live
together in a single house, with their parents.[19] It is highly
essential in an Indian family setup, for the relatives of stroke
patients to be aware of the warning symptoms and risk factors.
This is one principal reason why we included the relatives of stroke
patients in our study. Moreover, knowledge of stroke did not differ
between patients and relatives. Secondly, this is a hospital-based
study with a small sample size and may not exactly represent the
entire population of Punjab, hence the findings limits
generalisability. Moreover, India is a vast country with diverse
socio-cultural and linguistic practices. Our findings can not be
extrapolated to other states in the country. Thirdly, the observations
in the present study is not different from a previous study of
awareness of stroke among the general public in Northwestern
India.[9] The added value of this study is that it provides new
information for the first time, regarding the knowledge of stroke
among stroke patients in a developing country. Moreover, this
study would enable us to develop appropriate educational
campaigns for the stroke patients and their relatives to improve
the prevention and early treatment of stroke.
In conclusion, we observed a better knowledge in our study cohort,
to some of the warning symptoms and risk factors. However, the
awareness of other major warning symptoms, risk factors, organ
involved in stroke and self-recognition of stroke symptoms were
poor. Community based studies are required in the future including
both urban and rural populations to confirm our findings. There is
an urgent need to educate our patients and their relatives and such
educational programs should also target high risk groups.

Acknowledgements
We sincerely thank Mrs. Soosamma Verghese and Ms. Dewinder Kaur for their assistance
in data collection. We are grateful to Mr Douglas J Lincoln MBiostat, Royal Brisbane and
Womens Hospital Research Foundation, Brisbane, for his help in the statistical analysis.

References
1.
2.
3.
4.

5.
6.

Williams LS, Bruno A, Rouch D, Marriott DJ. Stroke patients knowledge of stroke:
Influence on time of presentation. Stroke 1997;28:912-5.
Kothari R, Sauerbeck L, Jauch E, Broderick J, Brott T, Khoury J, et al. Patients
awareness of stroke signs, symptoms and risk factors. Stroke 1997;28:1871-5.
Carroll C, Hobart J, Fox C, Teare L, Gibson J. Stroke in Devon: Knowledge was
good, but action was poor. J Neurol Neursurg Psychiatr 2004;75:567-71.
Derex L, Adeleine P, Nighoghossian N, Honnorat J, Trouillas P. Knowledge of
strokes in patients admitted to a French Stroke Unit. Rev Neurol
2004;160:331-7.
Samsa GP, Cohen SJ, Goldstein LB, Bonito AJ, Duncan PW, Enarson C, et al. Knowledge
of risk among patients at increased risk for stroke. Stroke 1997;28:916-21.
Pandian JD, Sethi V, Dhillon R, Kaur R, Padala S, Chakravorty R, et al. Is

155
CMYK155

Pandian et al.: Patients awareness about stroke

7.
8.

9.

10.
11.
12.

13.

intravenous thrombolysis feasible in a developing country? Cerebrovasc Dis

2005;20:134-6.
Khurana D, Saini M, Khandelwal N, Prabhakar S. Thrombolysis in a case of lateral
medullary syndrome: CT angiographic findings. Neurology 2005;64:1232.
Pandian JD, Kalra G, Jaison A, Deepak SS, Shamsher S, Padala S, et al. Factors
delaying admission to a hospital-based Stroke Unit in India. J Stroke Cerebrovasc
Dis 2006;15:81-7.
Pandian JD, Jaison A, Deepak SS, Kalra G, Shamsher S, Lincoln DJ, et al. Public
awareness of warning symptoms, risk factors and treatment of stroke in Northwest
India. Stroke 2005;36:644-8.
Derex L, Adeleine P, Nighoghossian N, Honnorat J, Trouillas P. Factors influencing
early admission in a French stroke unit. Stroke 2002;33:153-9.
Alberts MJ, Bertels C, Dawson DW. An analysis of time of presentation after stroke.
JAMA 1990;263:65-8.
Herderschee D, Limburg M, Hijdra A, Bollen A, Pluvier J, te Water W. Timing of
hospital admission in a prospective series of stroke patients. Cerebrovasc Dis
1991;1:165-7.
Ferro JM, Melo TP, Oliveira V, Crespo M, Canhoo P, Pinto AN. An analysis of the

14.
15.
16.

17.

18.

19.

admission delay of acute strokes. Cerebrovasc Dis 1994;4:72-5.

Census of India. Census data online. Available at: http://www.censusindia.net.
Accessed October 7 2004.
Yoon SS, Byles J. Perceptions of stroke in the general public and patients with
stroke: a qualitative study. BMJ 2002;324:1065-8.
Pancioli AM, Broderick J, Kothari R, Brott J, Tuchfarber A, Miller R, et al. Public
perception of stroke warning signs and knowledge of potential risk factors. JAMA
1998;279:1288-92.
Sug Yoon S, Sung BS, Heller RF, Levi C, Wiggers J, Fitzgerald PE. Knowledge of
stroke risk factors, warning symptoms and treatment among an Australian urban
population. Stroke 2001;32:1926-30.
Parahoo K, Thompson K, Cooper M, Stringer M, Ennis E, McCollam P. Stroke:
Awareness of the signs, symptoms and risk factors- a population based survey.
Cerebrovasc Dis 2003;16:134-40.
Niranjan S, Sureender S, Rama Rao G. Family structure in India-Evidence from
NFHS. Demogr India 1998;27:287-300.

Accepted on 20-03-2006

Invited Comments
This is the first study to assess knowledge of stroke warning
symptoms and risk factors in Northwest Indian stroke and
transient ischemic attack (TIA) patients and their relatives. This
is obviously a crucial issue as increased awareness may lead to
improved acute management and better prevention of
cerebrovascular diseases.
The present paper demonstrates an urgent need for public
education, similar to what has been observed in the Western
countries; lower educational status was associated with poor stroke
awareness, only 33% of individuals could correctly identify brain
as the involved organ in stroke and the majority of patients did
not realize that they were experiencing symptoms of stroke.
Reducing delays in patient response to stroke symptoms may
have the greatest impact on emergency treatment rates
(thrombolysis for ischemic stroke and ultra-early hemostatic
therapy for intracerebral hemorrhage in the future). The
California Acute Stroke Pilot Registry Investigators have recently
shown that if all ischemic stroke patients whose strokes did not
occur overnight had attributed their symptoms to stroke and had
made an immediate call to Emergency Medical Services (EMS),
the rate of thrombolytic treatment would have been as high as
29%.[1] Potential strategies for increasing the rate of thrombolysis
for stroke include educating people at risk of stroke and the general
public about the stroke warning signs and the immediate proper
response, improving emergency responses to calls and improving
in-hospital management of stroke.
However, optimizing patient response and reducing delays in
seeking help may be difficult. The discontinuity between
knowledge, attitude and behaviour change has long been discussed
by health educators. More important than stroke awareness is
probably behaviour in the event of a stroke. Indeed, knowledge of
stroke symptoms has not been consistently associated with early
admission[2] and it has recently been shown that perceptual, social
and behavioral factors are associated with delays in seeking medical
care in patients with symptoms of acute stroke.[3] The patients
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perception of the severity of his symptoms and the extent of

perceived control over them influence reaction times. In the setting
of TIA, despite the high risk of stroke in the hours and days after
TIA, an English study has demonstrated that patients delay seeking
medical attention irrespective of correct recognition of symptoms.[4]
Educational programs should not only increase awareness about
the recognition of stroke symptoms but also about the appropriate
response. We are facing a communication challenge to develop
simple and repetitive messages in order to change behaviours related
to stroke. In particular, the benefits associated with behaviour change
must be clearly presented. Mass media is most frequently named as
a source of information about stroke. However, health education
programs should be adapted to population social and cultural
characteristics. They should focus on population groups at risk for
lack of knowledge about stroke, such as older people or those from
an impaired socioeconomic background, who are also at an increased
risk of stroke.[5] Patience is required as public education tends to
work slowly and behaviour changes are often the result of consistent
campaigns over many years.

Laurent Derex
Unit Neurovasculaire, Hpital Neurologique, 59 boulevard
Pinel, 69003 Lyon, France. E-mail: laurent.derex@chu-lyon.fr

References
1.

2.
3.

4.

5.

California Acute Stroke Pilot Registry (CASPR) Investigators. Prioritizing

interventions to improve rates of thrombolysis for ischemic stroke. Neurology
2005;64:654-9.
Kothari R, Sauerbeck L, Jauch E, Broderick J, Brott T, Khoury J, et al. Patients
awareness of stroke signs, symptoms and risk factors. Stroke 1997;28:1871-5.
Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social and behavioral
factors associated with delays in seeking medical care in patients with symptoms
of acute stroke. Stroke 2006;37:1248-53.
Giles MF, Flossman E, Rothwell PM. Patient behavior immediately after transient
ischemic attack according to clinical characteristics, perception of the event and
predicted risk of stroke. Stroke 2006;37:1254-60.
Mller-Nordhorn J, Nolte CH, Rossnagel K, Jungehlsing GJ, Reich A, Roll S, et
al. Knowledge about risk factors for stroke. A population-based survey with 28 090
participants. Stroke 2006;37:946-50.

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