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

Authors:
2015 ANPOR ANNUAL Conference
1
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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2015 ANPOR ANNUAL Conference
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
2015 ANPOR ANNUAL Conference
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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 strokes 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
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
2015 ANPOR ANNUAL Conference
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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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Thijs, V., Grittner, U., Dichgans, M., Enzinger, C., Fazekas, F., Giese, A.-K., Rolfs, A. (2015). Family
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Article
Full-text available
Background: Stroke is a neurological emergency that requires prompt and precise diagnosis and treatment. However, errors in diagnosis and treatment are still frequently seen. One of the main causes of this problem is the lack of doctors’ knowledge. This study aims to determine the level of knowledge among undergraduate medical students about stroke. The results of this study can be used as basic information to provide educational interventions to medical students to prevent and minimize the occurrence of medical errors. Methods: This study used a quantitative-descriptive method with a cross-sectional approach. The study subjects were third-semester medical undergraduate students at the Medical Faculty of Padjadjaran University during the 2018/2019 academic year. Samples were 43 secondary data collected from ischemic and hemorrhagic stroke Students Objective Oral Case Analysis (SOOCA) exam scores and 168 primary data collected using a 30-item questionnaire regarding stroke knowledge. The data obtained was then analyzed descriptively and the result was categorized into 3 levels of knowledge: Good, moderate, and poor. Results: Each variable demonstrates a varying degree of knowledge. However, based on the total scores and averages collected from both the questionnaire and the SOOCA exam, most of the students had a moderate level of knowledge regarding ischemic and hemorrhagic stroke. Conclusion: Most of the students had a moderate level of knowledge about stroke, so educational interventions and student’s capabilities improvement are required to increase knowledge of stroke.
Article
Family history of stroke is an established risk factor for stroke. We evaluated whether family history of stroke predisposed to certain stroke subtypes and whether it differed by sex in young patients with stroke. We used data from the Stroke in Fabry Patients study, a large prospective, hospital-based, screening study for Fabry disease in young patients (aged <55 years) with stroke in whom cardiovascular risk factors and family history of stroke were obtained and detailed stroke subtyping was performed. A family history of stroke was present in 1578 of 4232 transient ischemic attack and ischemic stroke patients (37.3%). Female patients more often had a history of stroke in the maternal lineage (P=0.027) than in the paternal lineage. There was no association with stroke subtype according to Trial of Org 10172 in Acute Stroke Treatment nor with the presence of white matter disease on brain imaging. Patients with dissection less frequently reported a family history of stroke (30.4% versus 36.3%; P=0.018). Patients with a parental history of stroke more commonly had siblings with stroke (3.6% versus 2.6%; P=0.047). Although present in about a third of patients, a family history of stroke is not specifically related to stroke pathogenic subtypes in patients with young stroke. Young women with stroke more often report stroke in the maternal lineage. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583. © 2015 American Heart Association, Inc.
Article
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
Public awareness of stroke is improving. However, public knowledge of acute stroke symptoms and the need to seek immediate medical attention for those symptoms continues to lag despite various educational endeavors. Knowledge of stroke risk factors is better, reflecting an overlap with risk factors for coronary heart disease, but there is still a gap in awareness. Clearly, there is need for additional improvements in educational strategies to the lay public.
Article
To assess the knowledge of stroke risk factors and warning signs in a representative statewide sample of Michigan adults. Respondents to the 1999 Michigan Behavioral Risk Factor Survey, a random-digit-dialed statewide survey of >2,500 adults, were asked to report up to three risk factors and warning signs for stroke. Predictors of inadequate knowledge (defined as not reporting any correct responses) of stroke risk factors and warning signs were identified using multiple logistic regression. Eighty percent reported at least one correct risk factor for stroke, and 28% reported three. The most frequently mentioned risk factors were hypertension (32%), smoking (29%), and physical inactivity (26%). Sixty-nine percent reported at least one correct warning sign of stroke, but only 14% reported three. The most frequently mentioned warning signs were sudden weakness or numbness (46%) and sudden slurred speech, disorientation, or difficulty understanding (30%). Predictors for inadequate knowledge of both stroke risk factors and warning signs were similar and included age, race, sex, education, hypertension, and smoking. Knowledge of stroke risk factors and warning signs was moderate at best. One in five respondents was not aware of any stroke risk factors, and almost one in three was not aware of any stroke warning signs. Stroke knowledge was poorest among groups that have the highest risk of stroke.
The top 10 causes of death. From http
World Health Organization. (2014, July 2015). The top 10 causes of death. From http://www.who.int/mediacentre/faactsheets/fs310/en/
  • V Thijs
  • U Grittner
  • M Dichgans
  • C Enzinger
  • F Fazekas
  • A.-K Giese
  • A Rolfs
Thijs, V., Grittner, U., Dichgans, M., Enzinger, C., Fazekas, F., Giese, A.-K., Rolfs, A. (2015). Family History in Young Patients With Stroke. Stroke (00392499), 46(7), 1975-1978. doi: 10.1161/strokeaha.115.009341