Stroke Awareness among Hypertensive Patients: Institutional Based Survey in Western Rajasthan, India.

Dear Sir,

Stroke incidence has more than doubled in low–middle income countries and decreased by 42% in high-income countries over the last four decades. The average number of deaths due to stroke is more in the low–middle-income countries compared to in high-income countries since 15 years. Stroke affects individuals and their productive life, leading to an enormous negative impact on the socio-economic development of the countries.[1]

Stroke is the second and third major cause of death and disability-adjusted life years, respectively worldwide. Some Indian studies prove that the stroke incidence is approximately 116 to 163 per 100,000 population. The Indian Council of Medical Research has also reported that stroke is the fouth main cause of death and fifth major cause of disability-adjusted life years in India (2016).[2]

Stroke is the most common complication of hypertension. The prevalence of complications that occur due to hypertension is highest in rural communities, whereas the prevalence of hypertension is high in urban communities.[3]

Worldwide hypertensive patients are not having adequate awareness regarding causes, risk factors, prevention, and treatment of stroke. So, this survey was conducted to assess stroke awareness among hypertensive patients.

This descriptive survey was conducted among 400 hypertensive patients to assess stroke awareness, during the period of January 2020 to January 2021 in an institute of western Rajasthan, India, after obtaining prior permission from the institutional ethical committee with the reference number AIIMS/IEC/2020-21/2099. The sample size was calculated using Slovin's formula n = N/[1+ (N e2)], and sampling was done using nonprobability purposive sampling technique.

The hypertensive patients were included based on the following inclusive criteria such as more than 18 years of age, diagnosed with hypertension at least 6 months before, willing to participate, and understanding the study language. Hypertensive patients who had been diagnosed with any type of stroke, brain tumor, head injury, intellectual disability, and mental illness, and hypertensive patients in their perinatal period were excluded from the study.

Socio-demographic Performa was used to collect the socio-demographic details (personal as well as clinical) of the participants. A self-structured awareness questionnaire which was validated by seven experts was used to collect the data through face-to-face interviews. The range between maximum and minimum total score of the questionnaire was divided into three categories. A pilot study was conducted on 10% of the main study as sample.

The data were analyzed by using IBM SPSS version-20. Descriptive and inferential statistics were used to describe the socio-demographic variables of the hypertensive patients using frequency, percentage, mean, and standard deviation. Chi-square was used to make an inference and to determine the association of awareness with socio-demographic variables.

Over the 1-year period, total of 400 hypertensive patients consented to participate in institutional-based stroke awareness survey. The mean standardized age of hypertensive patients was 53.85 ± 14.81 years. About 58.8% of the hypertensive patients were male, and 41.3% were female [Table 1].

Table 1

Frequency and percentage distribution of hypertensive patients according to personal and clinical variables

Variables	n=400
	f	%
Personal variables:
Age in years
18-30	27	6.8
31-60	241	60.3
>60	132	33
Gender
Male	235	58.8
Female	165	41.3
Marital status
Unmarried	16	4
Married	347	86.8
Widow/widower	37	9.3
Education
Non-formal education	167	41.8
Primary	58	14.5
Secondary	33	8.3
Higher Secondary	51	12.8
Graduation and above	91	22.8
Occupation
Government Employment	69	17.3
Private Employment	57	14.2
Unemployment	18	4.5
Self- employment	136	34
Home maker	120	30
Income per month
<10,000	49	12.3
10,000-20,000	114	28.5
20,000-50,000	179	44.8
>50,00>50,000	58	14.5
Social background
Rural	235	58.8
Urban	165	41.3
Clinical variables:
Duration of hypertension
6 month-1 year	61	15.3
2-5 years	199	49.8
6-10 years	102	25.5
>10 years	38	9.5
Duration of treatment
<1 year	141	35.3
2-5 years	166	41.5
6-10 years	66	16.5
>10 years	27	6.8
Co-morbidity of kidney diseases and diabetes mellitus
Yes	162	40.5
Diabetes	90	55.55
Kidney disease	42	25.92
Both co-morbidity	30	18.51
No	238	59.5
Variables	F	n=400 %
Family history of hypertension, kidney diseases and diabetes mellitus
Yes	255	63.7
Hypertension	113	44.31
Diabetes	50	19.60
Kidney disease	12	4.70
Multiple disease	80	31.37
No	145	36.3
Body mass index
< 18.5 Underweight	19	4.8
18.1-24.9 Normal weight	249	62.3
25-29.9 Overweight	117	29.3
30-34.9 Class-I Obesity	15	3.8
Previous information regarding stroke
Yes	303	75.8
No	97	24.3

The level of stroke awareness among hypertensive patients was good, fair, and poor [Table 2]. Mean percentage distribution of domains of stroke awareness among hypertensive patients was meaning of stroke, causes and risk factors, warning signs and symptoms, diagnostic test, treatment, and prevention [Figure 1].

Table 2

Level of stroke awareness among hypertensive patients

Level of awareness	f	%	n=400 Mean & SD
Poor (0-8)	111	27.8
Fair (9-16)	148	37	12.93±6.62
Good (17-24)	141	35.3

(Minimum score was 0, and maximum score was 24)

Figure 1

Mean percentage distribution of domains of stroke awareness among hypertensive patients

Awareness among hypertensive patients was found to have a significant association with age, education, occupation, income per month, social background, and it also had a significant association with duration of treatment, comorbidity, family history of hypertension, body mass index, and previous information regarding stroke [Table 3].

Table 3

The association of level of awareness regarding prevention of stroke among hypertensive patients with personal and clinical variables

Variables	Level of awareness among hypertensive patients			n=400
	Poor	Fair	Good	X2	df	P
Personal variables:
Age in years
18-30	12	6	9	10.57	4	0.032*
31-60	60	85	96
>60	39	57	36
Gender
Male	66	84	85	0.40	2	0.818
Female	45	64	56
Marital status
Unmarried	6	4	6	1.95	4	0.745
Married	95	128	124
Widow/widower	10	16	11
Education
Non-formal education	64.22	8	0.00*	64	77	26
Primary	12	26	20
Secondary	11	9	13
Higher Secondary	10	13	28
Graduation and above	14	23	54
Occupation
Government Employment	9	15	45	47.55	8	0.00*
Private Employment	15	15	27
Unemployment	4	6	8
Self- employment	47	59	30
Home maker	36	53	31
Income per month
<10,000	25	14	10	39.94	6	0.00*
10,000-20,000	41	46	27
20,000-50,000	37	72	70
>50,000	8	16	34
Social background
Rural	81	96	58	29.60	2	0.00*
Urban	30	52	83
Clinical variables:
Duration of hypertension
6 month-1 year	22	23	16	4.73	6	0.57
2-5 years	54	74	71
6-10 years	26	39	37
>10 years	9	12	17
Duration of treatment
<1 year	55	54	32	22.96	6	0.001*
2-5 years	40	62	64
6-10 years	11	24	31
>10 years	5	8	14
Co-morbidity of kidney diseases and diabetes mellitus
Yes	36	57	69	7.40	2	0.025*
No	75	91	72
Family history of hypertension, kidney diseases and diabetes mellitus
Yes	51	97	107	24.41	2	0.000*
No	60	51	34
Body mass index
< 18.5 Underweight	9	7	3	13.65	6	0.034*
18.1-24.9 Normal weight	70	97	82
25-29.9 Overweight	26	43	48
30-34.9 Class-I Obesity	6	1	8
Previous Information regarding stroke
Yes	32	17	134	184.37	2	0.000*
No	79	11	7

*Significant (P<0.05)

The finding of the present study shows the level of awareness among hypertensive patients regarding stroke. Around one-third of hypertensive patients were having awareness of one to two risk factors of stroke, three-fourth of them were having awareness regarding signs and symptoms such as loss of balance, one side body weakness, slurred speech, and visual disturbance. These results are in line with another study conducted by Khalil et al.[4] (2020) that showed that 68% of the participants were aware of at least one symptom, such as headache, hemiparesis, or dizziness. A total of 85.4% of the participants were aware of at least one risk factor of stroke i.e. hypertension, smoking, or stress.

The current study result revealed that 68.38% of the hypertensive patients had inadequate awareness about risk factors and causes of stroke, and 26.3% of the hypertensive patients were not aware of the sign and symptoms of a stroke. These findings are in concurrence with the study done by Chhabra et al.[5] (2019) who found that 28.85% of the participants were not aware of the risk factors and 46% of the participants were not knowing about warning signs of stroke.

The present study showed that 55% of the hypertensive patients were knowing about the meaning of stroke and that stroke is a disease of the brain. This conclusion was consistent with the findings of a study done by Dar et al.[6] that revealed that 80.5% of the participants were having knowledge about stroke, 71.6% were knowing someone with a stroke, and 76% knew that the brain is the affected organ in stroke.

The study was limited to a single institution, so the results could not be generalized. The present study concludes that hypertensive patients had poor awareness regarding causes and risk factors of stroke. The results also revealed that providing information about stroke through media, magazines, newspapers, role plays, pamphlets, information booklets, and health education to hypertensive patients will help to understand stroke and its prevention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.