Knowledge of Stroke Risk Factors and Warning Signs among Undergraduate Nursing Students in Thailand, Indonesia and Myanmar

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2015 ANPOR ANNUAL Conference
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Knowledge of Stroke Risk Factors and Warning Signs
Among Undergraduate Nursing Students in Thailand, Indonesia and Myanmar1
Panitnat Chamnansua
1
Kultida Panidchakul
Wiyakarn Sanghuachang
Boromarajonani College of Nursing Saraburi, Thailand
Siritorn Yingrengreung
Boromarajonani College of Nursing Bangkok, Thailand
Nattiya Peansungnern
Boromarajonani College of Nursing Nakhon Ratchasima, Thailand
Sirikul Karuncharernpanit
Boromarajonani College of Nursing Chakriraj, Thailand
Yelmi Reni Putri5,
Fort De Kock Health Science College, Bukittingi Indonesia
Gede Putu Darma Suyasa6,
Research and Community Services Unit, STIKES, Bali, Indonesia
Mar Lar Win
University of Medicine Mandalay, Myanmar
1
Correspondence concerning this article should be addressed to Dr., Panitnat Chamnansua at Email:
panitnat@bcns.ac.th

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ABSTRACT
Background: Stroke is the most significant cause of disability and death worldwide. It is categorized as the
critical condition and required alerting nursing care. Nursing students who will graduate and provide care
should be prepared about knowledge of stroke.
Purpose: This study aims to evaluate the level of knowledge of risk factors and knowledge of Stroke warning
signs among undergraduate nursing students in Thailand, Indonesia and Myanmar.
Methods: This study was conducted in January - June 2015 using an online survey. Participants were 2,063 the
1st to 4thyear nursing students who enrolled in the nursing institutes from three countries in Southeast Asia
including Thailand, Indonesia and Myanmar. Descriptive statistics were calculated.
Results: Nursing students from all three countries performed at a high level of knowledge on stroke’s risk
factors (M= 36.65, S.D. = 9.94) and warning signs (M= 4.11, S.D.= 2.08) . Considering the knowledge level on
stroke’ risk factor in each person, most students (7.1%) can get scores at high level 20.7% of those at moderate
level 20.7% of those were at moderate level and only 9.2 % of those were at mild level. Furthermore, details
of knowledge on warning signs. the results showed that most nursing students can answer that
weakness/numbness of any parts of body was reported at the highest score(75.4%), Furthermore, sudden
onset of severe headache(69.7%), and face asymmetry(68.8%) were reported as the second and third rank.
However, nursing students recognized the suddenly blurred and double vision or loss of vision as a warning
sign at the lowest level (62.2%). Comparing among three countries, average scores of all three countries were
in the moderate level. Average scores of Thai and Indonesian students were not much different; however, the
average score of Myanmar nursing students was tend to lower than other countries. It may due to cultural and
contextual differences.
Conclusions and Recommendations: This study provides information about knowledge levels of nursing
students among three countries on risk factors and warning signs of stroke. These issues will be taken into
consideration to arrange for knowledge improvement program which can be integrated into the curriculum or
extra curriculum of nursing students at undergraduate level. This improvement may improve nursing students’
knowledge and may affect the quality of care for stroke prevention or early detection in the future.
Keywords: Stroke, Risk Factors, Warning Signs, Nursing Students
BACKGROUND OF THE STUDY
Stroke is the most significant cause of disability and death worldwide (World Health
Organization, 2014), South East Asia regions and Thailand. Stroke is a medical emergency condition that
occurs when interrupting blood flow to an area of the brain from thrombosis, embolism or hemorrhage.
Stroke health promotion, prevention and early detection can reduce disability. If stroke occur, it may
result in a loss of his abilities to control speech, movement, and memory (Acker JE III, Pancioli AM,
Crocco TJ, et al. 2007). To prevent disability, medical emergency responses or Stroke Fast track was
recommended. Stroke fast track aims to help patients to receive the effective stroke treatment as fast as

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they can, for instance, starting medication at emergency room and there is a short time to manage or
provide care for possible after warning signs of stroke occur (Kernan et. Al.,2014). As a result, knowledge
and observation for stroke warning signs should be alerted by health profession and caregivers. The
stroke’s warning signs can be easily recognized using “FAST” acronym. Details of each letter are
described that the letter F stands for facial weakness on the one side of the body, A stands for
weakness/numbness of arm or leg any part of the body, S stands for speech difficulties, and T stands for
time or duration that stroke occurs. (Flaher ML, Klindorfer, Kissela BM, 2004).
Reducing the time from stroke onset to hospital and improving control of stroke risk factors
depend on knowledge of health care providers on stroke’s risk factors and stroke’s warning signs,
particularly, the knowledge of nursing students who will be the frontline health care providers . However,
there is a lack of evidence about knowledge of nursing students at undergraduate level on stroke’s risk
factors and stroke’s warning signs. Therefore, researchers paid attention to the knowledge of nursing
students at undergraduate level. Moreover, Thailand and other countries will join the Association of
South East Asia (ASEAN) community and nursing will be one occupation which can flow independently,
so basic knowledge regards stroke’s risk factors and warning signs among nursing students from three
countries; Thailand, Indonesian and Myanmar should be addressed. These results may help educational
sector to understand an overview regards knowledge on stroke’s risk factors and warning signs and use
this information to set up the policy to improve quality of care, especially, improving the quality of
nursing profession.
PURPOSE OF THE STUDY
This study aims to evaluate the level of knowledge of risk factors and knowledge of Stroke
warning signs among undergraduate nursing students in Thailand, Indonesia and Myanmar.
METHODS
Design:
Descriptive research: cross-sectional surveying was used in this study.
Sampling:
This study was conducted in January - June 2015 using an online survey. The Cluster sampling
was used, therefore, undergraduate nursing students from three countries in South East Asia including
Thailand (1,367 students), Indonesia (376 students) and Myanmar (320 students) were 2,063 nursing
students on the 1st to 4th year recruited to the study.
Instruments:
The three part- questionnaires for this study: personal information, risk factors of stroke and
stroke warning signs that was developed by The American Health Association and the National Institute
of Neurological Disorders and Stroke (American Health Association, 2012; National Institute of

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Neurological Disorders and Stroke, 2009) were used in this study:
1. Personal information. The 4 items were age, gender, year in educational program and school
location.
2. Risk factors of stroke knowledge. The 9 items included tobacco smoke, high blood pressure,
dyslipidemia, Parents or brothers/sisters had a stroke disease, diabetes, obesity, lack of exercise, alcohol
and stress.
3. Stroke warning signs knowledge. The 6 items included Sudden onset of face asymmetry,
weakness/numbness of arm or leg any part of the body, Sudden difficulty in speaking or understanding,
Suddenly blurred and double vision, or loss of vision, Sudden onset of severe headache, and sudden onset
of dizziness or vertigo.
The reliability of these questionnaires of the risk of factors stroke was 0.897 and the stroke
warning signs 0.867
Data collection:
Three main steps were undertaken:
1. After the approval on Ethical consideration of this study was obtained from Boromarajonani
College of Nursing, Saraburi which is one significant center of this study, the link of online invitation
letter which explained about the project in terms of activities, harm and benefit and right of the
participants were posted in the nursing or public health colleges’ website.
2. When the proposed participants agreed, they answered the online questionnaires from the
link assigned.
3. All participants were able to withdraw from the study when they are uncomfortable or any
reasons without any negative impact.
Data analysis:
Descriptive statistic was used for frequency, percentages, means and standard deviation.
RESULTS
There were 3 parts of the results:
Personal information
Most participants were female (91.5%). Considering the detail of genders of nursing students in
each country, differences were found that most Thai nursing students which are the biggest group were
(66.3%). However, in Myanmar and Indonesia were found that most of them were (18.3 % and 15.5%)
respectively.
Age of participants were varied and ranged from 16-52 years old. The mean age was 20.13 year
(S.D. = 2.898).
Most participants were the third year students (33.8%) the second year (28.1%) the first year
(20.9%) and the fourth year (17.2%).

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Knowledge of stroke risk factors
For knowledge of stroke risk factors, the mean score was 36.65 (S.D. = 9.94) from total score
45 points. Most of participants were high score (31-45 score) 70.1%, median level (16-30 score) 20.7%
and low level (0-15 score) 9.2%.
Stroke risk factors knowledge (Table 1), stress (
x
=3.86 S.D.=1.389) high blood pressure
(
x
=3.80 S.D.=1.681) tobacco smoke (
x
=3.76 S.D.=1.247) were three highest level. The lowest level
stroke risk of factors knowledge was Parents or brothers/sisters had a stroke disease (
x
=3.32
S.D.=1.447). Further mor e , the t otal s c ore o f know ledge level of stroke risk factors were mostly
high level except parents or brothers/sisters had a stroke disease was moderate level.
Table 1 knowledge of stroke risk factors from nursing students of Thailand, Indonesia and Myanmar
(N=2063)
Risk factors of
Stoke
Thailand
Indonesia
Myanmar
Total
Level
x
S.D
x
S.D
x
S.D
x
S.D
Tobacco smoke
3.96
1.123
3.87
1.213
2.76
1.316
3.76
1.247
High
High blood
pressure
4.38
.938
4.49
.952
.54
.888
3.80
1.681
High
Dyslipidemia
4.29
1.037
3.26
1.653
1.73
1.389
3.71
1.543
High
Parents or
brothers/sisters
had a stroke
disease
3.27
1.465
3.41
1.624
3.40
1.104
3.32
1.447
Moderate
Diabetes
3.74
1.194
3.70
1.354
2.44
1.426
3.53
1.346
High
Obesity
3.96
1.121
3.96
1.208
1.68
1.279
3.60
1.425
High
Lack of exercise
3.86
1.086
3.97
1.179
1.73
1.297
3.55
1.379
High
Alcohol
3.94
1.126
3.98
1.300
1.17
1.185
3.52
1.543
High
Stress
4.26
.967
4.19
1.135
1.79
1.363
3.86
1.389
High
Knowledge on stroke warning signs
For knowledge stroke warning signs (Table 2), the three highest knowledge of stroke warning
signs were weakness / numbness of any part of the body (75.4), sudden onset of severe headache
(69.7%)and face asymmetry(68.8%).The lowest warning sign was the suddenly blurred and double vision
or loss of vision (62.2%).Considering each country found the lowest stroke warning sign knowledge were
Thailand had suddenly blurred and double vision or loss of vision(67.5%), Indonesia had suddenly
blurred and double vision or loss of vision knowledge (75.3%), and Myanmar had sudden difficulty in
speaking or understanding (8.1%)

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Table 2 knowledge on stroke warning signs (N=2063)
Stroke warning signs
Thailand
Indonesia
Myanmar
Total
Yes
N(%)
Don’t
Know
N(%)
Yes
N(%)
Don’t
Know
N(%)
Yes
N(%)
Don’t
Know
N(%)
Yes
N(%)
Don’t
Know
N(%)
face asymmetry
1096
(80.2)
271
(19.8)
289
(76.9)
87
(23.1)
34
(10.6)
286
(89.4)
1419
(68.8)
644
(31.2)
weakness/numbness
of arm or leg any part
of the body
1174
(85.9)
193
(14.1)
349
(92.8)
27
(7.2)
32
(10.0)
288
(90.0)
1555
(75.4)
508
(24.6)
Sudden difficulty in
speaking or
understanding
1044
(76.4)
323
(23.6)
344
(91.5)
32
(8.5)
26
(8.1)
294
(91.9)
1414
(68.5)
649
(31.5)
Suddenly blurred and
double vision or loss
of vision
923
(67.5)
444
(32.5)
283
(75.3)
93
(24.7)
78
(24.4)
242
75.6
1284
(62.2)
770
(37.8)
Sudden onset of
severe headache
1062
(77.7)
305
(22.3)
314
(83.5)
62
(16.5)
61
(19.1)
259
(80.9)
1437
(69.7)
626
(30.3)
sudden onset of
dizziness or vertigo
1017
(74.4)
350
(25.6)
295
(78.5)
81
(21.5)
55
(17.2)
265
(82.8)
1367
(66.3)
696
(33.7)
DISCUSSION
This study is the database survey for evaluated the Level of Knowledge of stroke risk factors and
knowledge of stroke warning signs among Undergraduate Nursing Students in Thailand, Indonesia and
Myanmar.
Nursing students from all three countries performed at a high level of knowledge on stroke’s risk
factors (M= 36.65, S.D. = 9.94). Considering the knowledge level on stroke’ risk factor in each person,
most students (7.1%) can get scores at high level, 20.7% of those at moderate level and only 9.2 % of
those were at poor level.
This may result from the significant health problems of all three countries are stroke, therefore,
all nursing students is required to understand the risk factors of stroke. This knowledge may be provided
by extracurricular activities or extracurricular activities of the nursing course.
Furthermore, stress, high blood pressure and tobacco smoking were recognized as the first three
risk factors for stroke. This phenomenon was similar to the study report of Michigan adults hypertention
which listed as higher common risks of stroke patients which may lead to burden (Reeves, Hogan
&Rafferty, 2002).
However, the lowest score of risk factors was Parents or brothers/sisters had a stroke disease
which was at moderate level. The reason that most students did not recognized that the family history

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was a risk factor of stroke because it can be a risk factor of young or early onset stroke (age < 55 years
old) (Thijs, & et al., 2015), whereas, most common stroke patients in all three countries usually was the
normal onset or older aged group. Therefore, it may be a reason to support this phenomenon.
Knowledge of stroke warning signs among nursing students is important due to they would be
health professionals who could care for prevent stroke and medical emergency response for patients to
receive the effective stroke treatment. The results of knowledge stroke warning signs, found the three
highest knowledge of stroke warning signs were weakness / numbness of any part of the body (75.4),
sudden onset of severe headache (69.7%) and face asymmetry (68.8%). However, the lowest warning sign
was the suddenly blurred and double vision or loss of vision )62.2%). Considering detail from each
country, the result showed that the lowest stroke warning sign of Thailand and Indonesia was the same
warning sign which was suddenly blurred and double vision or loss of vision (67.5% and 75.3%).
Nevertheless, the lowest score from Myanmar nursing students was having sudden difficulty in speaking
or understanding (8.1%). However, the studies of Stroke awareness in the United States, Europe, and
Asia found that majority of people did not recognize stroke warning signs. The most people recognized
were acute or severe headache, weakness on one side of the body or arm, and dizziness (Flaher,
M.L.,Klindorfer, D., Kissela, B.M.: 2004; Mano, H:2009). So, it may lead to the lowest scores that they
ranked for warning signs.
CONCLUSION AND RECOMMENDATIONS:
Results of this study illustrated that the nursing students in three countries had a high level of
knowledge of stroke risk factors. However, lack of knowledge as the family history such as parents or
brothers/sisters had a stroke disease were found for nursing students in these three countries. it may be
the need for educational program to address this knowledge gap and improve their knowledge in the
future.
As well as, the results of knowledge stroke warning signs found a lack of knowledge of stroke
warning signs such as suddenly blurred and double vision or loss of vision and Sudden difficulty in
speaking or understanding.
This study provide basis information for improvement and integrating of issues in risk factors of
stroke and stroke warning signs in undergraduate learning of nursing program for early detection and
effective prevention.

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