Reacting to stroke

Saxion University of Applied Science iU'f f Reacting to stroke An explorative study regarding to knowledge and decisions of relatives of older stroke patients at the first stroke TPUONO OH DIED CX/dNG _ TiAJJt DTH I TiiU'VIEN S6 ANP Student: Pham Thi Thu Huong Tutor: Professor Joy Notter Supervisor: Mr Pham Thanh Nam Master of Advanced Nursing Practice Course E n sch ch ed e, Reacting to stroke EXPLANATION OF ORIGINALITY I declare that I, Pham Thi Thu Huong was bom on January, 19th, 1981, in Namdinh city, Vietnam as the author of this research report This study: “An exprorative study regarding to knowledge and decisions o f relatives o f older stroke patients at the first stroke” was not carried out previuosly If I used research carried out before by others, this is stated in the text The study was done by myself, with the support of my tutors Professor Joy Notter, Ir Ria Lohuis- Heesink and supervisor Mr Pham Thanh Nam The permission for this study was granted by the Medical Ethical Testing Committee and Management Broad of Saxion University, The Netherland Pham Thi Thu Huong SUMMARY Background: Stroke is a major killer with 10% of the deaths worldwide linked to strokes Strokes are more common in adults particularly the elderly but can also affect children There are certain risk factors associated with stroke, and these include hypertension, diabetes and alcohol abuse Vietnam is a developing country, where stroke is a major health problem According to the WHO (2005) report regarding Vietnam, strokes are one in ten the leading causes of deaths Objectives: The aims of thừ study is development of information for nurses working with the families of patients who have been assessed as being at risk of a stroke based on regarding the experiences and actions of relatives of stroke patients during the time they suspected the person was having a stroke, and whether they had any prior knowledge of stroke Methods: A quasi-qualitative approach within the positivist paradigm was used The interviewees were the relatives of patients with stroke, who witnessed the stroke happened and/or made the decision to take the patient to hospital The data were collected by using the standardized open-ended interview guide Results: 20 participants aged from 22 to 71 were recruited to the research At least one of symptoms of stroke was recognized and hypertension as a risk factor was also awared by many respondents But most of them did not understood what a stroke is In the situation when their relatives were suspected of having a stroke, a wide range of reactions of participants was actual Actions at the point of event include looking for a help from medical staff; transfer directly patients to hospital or self-treatment such as keeping the patient in bed then puting on him or her one of antihypertensive Respondents also met obstacle in seeking help such as there was not consensus from other family members or long distance to hospital Conclusions: The important findings that emerge from this study is the alarming lack of knowledge about stroke A minority of subjects correctly identified the brain as the affected organ in stroke, and ignorance of the warning symptoms and risk factors for stroke was common The deficiency in knowledge about stroke led to inappropriate actions to first stroke of family members Under pressure of the others, expenditure also influence of objective conditions as far distance, lack of emergency medical service, contact to medical staff before hospitalization, people delay and loose the important time to cure the patients ÌĨ Reacting to stroke TOM TAT Boi canh: dot quy dugc xem la mot “ke gilt nguai ghe gam”, chilm 10% ting si cac ca tu vong tren toan the gioi Dot quy chu yeu xay a nguai gia nhirng cung co thl co a tre nho Cac yeu to nguy ca cua dot quy bao gom huyet ap cao, tieu duong va viec lam dung rugu Viet Nam la mot nuac dang phat trien, noi ma dot quy la mot vdn de sire khoe noi com Theo bao cao cua to chiic Y te the gioi, dot quy la mot miroi nguyen nhan gay tu vong hang dau tai Viet Nam nam 2005 Muc tieu: muc tieu nghien curu la bo sung thong tin ve dot quy cho dieu duong, tu cung clp cho nguai nha nguai benh co nguy ca bi dot quy nhung thong tin ca ban vl dot quy tren ca sa tim hieu nhurng trai nghiem va phan ung cua nguai nha nguai benh tai thai diem nghi nga nguai bi dot quy va tim hieu lieu rang ho co kien thuc vl dot quy Phirong phap nghien cun: nghien curu su dung phuomg phap gan dinh tinh, thirc chung Doi tugng nghien cuu la nguai nha nguai benh bi dot quy, nhung nguai da churng kiln dot quy xay va/ hoac dua quyet dinh dua nguod benh den vien So lieu dugc thu thap blng viec sir dung bo cau hoi ma tieu chuan Ket qua: 20 nguai tuoi tir 22 den 71 dugc mai tham gia vao nghien cuu It nhlt mot trieu chirng cua dot quy da dugc nhan va huyet ap cao dugc nhieu nguai tham gia chu y la mot nguy ca cua dot quy Tuy nhien, phan Ion so hg khong hieu dot quy la gi Diln biln tarn ly phirc tap va nhieu hanh dong da dien de phan urng lai veri dot quy tai thai diem ho nghi nga nguai than bi dot quy Cac phan ung bao gom goi nhan vien y tl, chuyen nguai benh den benh vien hay tir dieu tri nhu da nguai benh len giuang va cho uong thuoc huylt ap Nguai tham gia cung gap can tra viec tim kiem giup da y tl tir cac vien khac gia dinh hay gap kho khan van chuyen Ket luan: mot kit qua quan nli bat nghien curu la sir thieu hieu bilt vl dot quy Mot ty le rlt nho cac vien co thl xac dinh chinh xac nao la ca quan bi anh huong dot quy xay ra, va sir han chi viec nhan bilt cac dau hieu cung nhu cac ylu tl nguy ca cua dot quy dugc liru y Do thilu hilu bilt ve dot quy, cac vien gia dinh da co cac phan urng khong phu hgp voi dot quy Ap lire cua cac vien khac, van de tai chinh cung nhu anh huong cua cac dilu kien khach quan nhu khoang each, thieu phuomg tien clp curu, lien lac voi nhan vien y te tai cho truac den vien, ho da lam cham tre va lam la thai gian cho viec dieu tri hieu qua cho cac ca dot quy in Pham Thi Thu Huong LIST OF ABBREVIATION CPR Cardiopulmonary Resuscitation CT scan Computer Tomography scanner EMS Emergency Medical System MRI Magnetic Resonance Imaging PhD Doctor of Philosophy TIA Transient Ischemic Attack WHO World Health Organization Reacting to stroke ACKNOWLEDGEMENTS I would like to express my great thanks to all institutions: Nuffic of The Netherland; Ministry of Health, Vietnam; Namdinh University of Nursing, Vietnam; Saxion Universities of Applied Sciences, The School of Health, The Netherland and every one who has contributed to and helped me with my training and research My sincerely thanks should also go to relatives of stroke patients, the medical staff of Cardiovascular department in Namdinh General hospital participated in my study and willingly shared their experiences, views and opinions with me on the research topics Their contributions are invaluable and unforgettable Especially, I would like to say forever thanks and carve deeply in my heart the most sincere gratitude to my tutors and supervisor Professor Joy Notter, Dr Pham Thanh Nam, Ir Ria Lohuis- Heesink You always give me your hands in my research work by the most effective way and at the same time you encourage me to go further and to make me more confident I would like to express many special thanks to: Mr Do Dinh Xuan, PhD, the Rector of Namdinh University of Nursing, Director of the “Improving the Qualitive o f University and Collage Level Nursing Training in Vietnam” Project in Vietnam side for his support to my study I would like to gratefully and sincerely thank all professors and lecturers of the School of Health, Saxion University Apply Science, The Netherland who gave me lectures, ideas and comments to complete this research I also wish to extend my thanks to my colleagues in Fundamental of Nursing department as well as other teachers in Namdinh University of Nursing, Vietnam, where I am working, for their help, encouragement, and especially their willingness to share my work when I am away for training In particular, I would like to thank Ms Cao Thi Thanh Mai, Dr Tran Quang Huy, PhD, Dr Ngo Huy Hoang and my ANP friends for valuable and useful discussions, Pham Thi Thu Huong comments related to research work, as well sharing their experiences with me in many other aspects I dedicate this thesis and deepest gratitude to my parents who always encourages me to study, and to my parents in law as well as to my family all, especially to my husband, Nguyen Ba Tam, my son Nguyen Hoang for your love, sympathies, understanding, encouragement, patience, and, as well your tolerance I understand deeply in my heart that behind this thesis is my own family, without you, I cannot have enough courage and energy to go ahead For that I am very grateful Thanks to all ! vi Reacting to stroke Content EXPLANATION OF ORIGINALITY i SUMMARY ii LIST OF ABBREVIATION iv ACKNOWLEDGEMENTS v CHAPTER 1: INTRODUCTION CHAPTER 2: BACKGROUND 2.1 Stroke 2.2 Stroke - a big problem .4 2.3 Delay help-seeking decision of stroke patients 2.4 Knowledge of stroke CHAPTER 3: METHODOLOGY 3.1 Study activities 11 3.2 Research area 12 3.3 Population and sample 12 3.4 Data collection 13 3.5 Data analysis 15 3.6 Methodological quality 16 3.7 Ethical consideration 17 CHAPTER 4: FINDINGS 18 Biographic data 18 4.1 Knowledge about stroke 19 4.2 Experiences and actions to strokes 22 CHAPTER 5: DISCUSSION 31 5.1 Knowledge about strokes 31 5.2 Reacts to stroke 32 CHAPTER 6: CONCLUSION AND RECOMMENDATION 35 6.1 Conclusions 35 6.2 Recommendations 35 CHAPTER 7: DEVELOPING INFORMATION FOR NURSES 37 REFERENCE 44 APPENDIX .48 Appendix A: Interview guide .48 Appendix B: About stroke 50 Appendix C: The informed consent 51 Reacting to stroke CHAPTER 1: INTRODUCTION Namdinh is a small town in the North of Vietnam, where over a half the people live from agriculture, and coping with a stroke is extremely difficult for them Traditionally, the different generations in a family live together, sometimes this can be two or three, even four generations with young people working and taking care of their parents However, community health care is not good enough for all elderly people particularly those without health insurance, with the result that a stroke will impact on all aspects of family life It is therefore very important for people to be able to recognize the signs and symptoms of stroke and seek help as quickly as possible to try to minimize the long term consequences that can follow a stroke In Namdinh General hospital, a consideration number of elderly stroke patients come to the hospital too late for treatment to be effective Their health problems become worse because of complications such as developing pulmonary or urinary infection Many of these patients have little education, and this makes the provision of care more difficult as the patients not understand what has happened to them In addition, although in the cardiovascular department, most of the patients have heart diseases, hypertension, or other risk factors for strokes, patients and their families report that they receive little information from the nurses and other health workers as well In a study led by (Shah, Makinde, & Thomas) (2007) only one quarter of the patients and bystanders considered their doctor or nurse to be a source of stroke information Follow that, a question is emerged invented how far the stroke patients’ family understand about stroke warning symptoms and it’s risk factors However, most research has focused on controlling symptoms and there is a need to identify risk factors for family members, who can then help patients having a first stroke to reach hospital in time for treatment Internationally, there are many studies concerned with knowledge of stroke symptoms and risk factors for stroke patients (Dearborn & McCullough, 2009; Derex L, Adeleine P, Niqhoqhossian N, Honnorat J, & Trouillas P, 2004; Greenlund, et al., 2003), but in Vietnam, such studies are not available so far Therefore, the aim of this study is to ascertain what family members know about stroke warning symptoms Pham Thi Thu Huong and describe the decision making process they use prior to seeking help for their relative Based on this, an information pack will be developed for nurses to use when working with the family members of those who are at risk of having a stroke Furthermore, a second and equally important objective of the research is secondary prevention (WHO, 2009) to reduce the risk of stroke occurrence, and finally a third objective is to improve the quality of care Research statement The development of information for nurses working with the families of patients with high blood pressure, heart disease and/or diabetes who have been assessed as being at risk of a stroke To meet the aims of this study information needed to be gathered in Vietnam, regarding the experiences and actions of relatives o f stroke patients during the time they suspected the person was having a stroke, and whether they had any prior knowledge of strokes? Pham Thi Thu Huong the provision of a leaflet to not only relatives but also for the nurses to be used as the basis of education for this group Participants were asked for thinking about the long term outcome of stroke as expenditures, communicative relationship, work or fear, the most common senses were worry and nervousness as the following comments illustrated: “This is not a simple disease, one-two days, to prolong to cold feet.” “ We must take care of him untill to the day he dead.” One women reported “ afraid of the loneliness after he goes away” Others gave examples of the fear that the patient would no longer be able to work, particularly for those living in rural areas: “ stay in hospital one week, the result from cultivating one hectare is empty.” This example illustrates that the problems extend beyond the patient, with attendance for care needed at the hospital two people are unable to work, both the patient and the career There are long term potential problems with this, fields left uncultivated mean loss of income for the whole family, so increasing the financial burden for the whole family that arises following a stroke 30 Reacting to stroke CHAPTER 5: DISCUSSION 5.1 K now ledge about strokes Although some of respondents defined brain as the affected organ in stroke, the explanation about mechanism and cause of stroke was very limit None of them could give any information about common kinds of stroke The difference between ischemic stroke and hemorrhage stroke is a complex issue, not of all can understand particularly, even among medical staff The most common warning symptoms identified by family members in my study was weakness or numbness The rate of respondents who mentioned weakness of one side of the body as a symptom of stroke was comparable with other studies from Northwest India (J D Pandian, et al., 2005) and Michigan (Reeves, et al., 2002) However, it not always happen Sometimes, stroke appears with the imbalance in standing or the serious headache, even only dropping on the face These signs are ignored or confused easily to others diseases for people without stroke knowledge According to recommendation from Stroke Associations, stroke happens when patients have experience with one of five symptoms (Appendix B), that more simple for people to remember and define a stroke The proportion of subjects who named hypertension as a risk factor was similar to observations from Cincinnati, Ohio (49%), Australia (31.8%), and Michigan (32.3%) (Pancioli, et al., 1998; Reeves, et al., 2002; Sug Y Levi s, Heller RF, c, Wiggers J, & PE, 2001) Can be seen that the rate of respondents who had positive answers for other risk factors, such as diabetes, smoking, and high cholesterol, were much lower as compared with other studies (Pancioli, et al., 1998; Parahoo K, et al., 2003; Reeves, et al., 2002; Sug Y s, et al., 2001) Only one participant believed heart disease was reason for stroke though they were treated in Cardiovascular department Just explain for the result is there was lacking in transmitting information about stroke from medical staff One notice point from the result of the research, although all of patients and a half of respondents were elderly, they rarely know that old age is one of risk factor for stroke 31 ' Pham Thi Thu Huong 5.2 R eacts to stroke The research indicated the significant role of close relatives in helping patients cope with stroke Recognize stroke symptoms and take patients to hospital immediately is important actions to prevent and reduce disability of stroke The limitation in knowledge about stroke, also the lack of information of mass media or medical staff in guiding people to cope with stroke leaded to inappropriate decision of them Face to the situation that the patients who were suspected having a stroke, their relatives took them to a hospital or would take other actions, including leaving the patient resting in bed or giving him or her anti­ hypertensive medications like other research findings (Mikulik, et al., 2008; PontesNeto, et al., 2008) or someone choose using oil to massage as a solution to treat “cold” (J D Pandian, et al., 2005) Discuss more about the perception and awareness of stroke symptoms and risk factors, a remarkable of respondent (29%) in a research said “stroke is not serious” (Shah, et al., 2007) Similarly, the participants in this study intended keeping their relative at home to treat With others, to deal with the situation that they did not know what was happening to the patients, they contacted with medical staff, (J D Pandian, et al., 2005) By contrast, they did not understand the consequence of the deficient experience of them Some medical staff gave patients anti-hypertension, maybe they did not think the lack of blood to brain, more serious to patient if the low pressure took place too fast Physicians and family doctors need to be educated about referring patients to stroke centers within the window period of intervention This is true for developing countries like our nation, where the number of neurologists available to any population is proportionately much less than that in developed countries A majority of the respondents suggested to take a person to the hospital when someone close to them had experienced symptoms of stroke Comparable responses 32 Reacting to stroke were seen in other studies (Parahoo K, et al., 2003; Reeves, et al., 2002)http://stroke.ahaiournals.org/cgi/content/full/36/3/644 - R16-409821 except in Korean subjects (Kim & Yoon, 1997) where only 46% of them mentioned that they would visit a hospital The participants’ interviews were analyzed to identify variables that seemed to be contributing to patient delay in this sample and to examine the relationship between variables suggested in the literature as contributing to longer patient delay These included no history of stroke, lack of recognition that what they were experiencing was a stroke or serious, type of primary symptom, patient awoke with symptoms present, did not use 115, lived in an urban setting, and contacted a provider before hospital admitted for stroke Other barriers delayed respondents from accessing medical attention for stroke were hampering from other family member or “experience in first aid” from other families before taking the patients to hospital Sometimes, it is not easy to affirm to the respondents that what should they at the first stroke, while the blood pressure of the patient is high, long distance and lacking of transport to the hospital Others reported postponing medical attention due to concerns about cost of treatment (Schroeder, et al., 2000) Some of respondents received stroke information from their friends or neighbor A few of them considered their doctor or nurse as a source of stroke information, more little then the number of participants in other research (Shah, et al., 2007) Even though more than resources information about stroke like school, during first aid class at the time of driver licensing, the proportion of individual reported having received information about stroke was still limit (Pontes-Neto, et al., 2008) The lack of public education about recognition, and treatment may contribute in a large scale to this worrisome reality Indeed, my study discloses alarming results on lay knowledge about stroke recognition and activation of emergency medical service (EMS) in Vietnam There is a difference in using (EMS) in this study compares to others (Brice, Griswell, Delbridge, & Key; Evensona, et al., 2001) As opinion of some participants, maybe, the quality of this service is still not high and need long time to reach to rural area j / 33 Pham Thi Thu Huong One more thing is in all most of them, there is not any information about EMS through media campaign, especially, with poor farmers, who have not time also condition to see TV or other like this In our country, health insurance also is challenge for improving community health service Especially, in rural area, not all of farmer has health insurance By this, influence to deciding help seeking in without insurance group was not deficient LIMITATIONS It is important to consider some limitations of my study, mainly related to the choice of personal interviews instead of the typical random sample Because of the pressure of study time, also the demanding in collecting participants, the researcher used convenience sample Another limitation belongs to researcher This is the first time for doing qualitative research, understand method and apply approach to study is really challenge to the researcher Writing in English also conducted a difficulty in showing all meaning of words to readers 34 Reacting to stroke CHAPTER 6: CONCLUSION AND RECOMMENDATION 6.1 C onclusions In conclusion, the important findings that emerge from this study is the alarming lack of knowledge about stroke A minority of subjects correctly identified the brain as the affected organ in stroke, and the ignorance of the warning symptoms and risk factors for stroke was common The deficiency in knowledge about stroke led to inappropriate action to first stroke of family members Under pressure of others, financial issue and also influence of objective conditions as far distance, lack of emergency medical sendee, people delay and loose the important time to treat the patients Try to contact to medical staff was one of decisions of a consideration rate Doctors or nurses, who were believed in by relatives of stroke patients, advised them react to stroke without explanation or based on their own experience 6.2 Recommendations Recom m endation for training Nowadays, the proportion of PhD and Master of Nursing is little Moreover, the expert nursing training system, in this Cardiovascular expert nursing is not available yet A unanimous training programmer should deploy in Universities or Colleges of Nursing to improve quality of the profession Recom m endation for relatives o f risk of stroke patients The project has shown the need for the development of the information for relatives, it was a concern to find most of patients have delays in reaching treatment that will adversely affect their recovery This impacts not only on their quality of life, but also on that of their relatives There needs to be a concerted effort to introduce education to relatives of those at risk of a stroke and to the public as a whole The leaflet developed in this project is a first step in this process and is now ready to be submitted to the hospital board for consideration for use throughout the hospital It 35 Pham Thi Thu Huong was important that although international research was used as the basis for this information, it was modified and tailored to the situation in Vietnam R ecom m endation for nurse The approach used was appropriate as action research provided a structure and format that enabled new knowledge to be developed in context It has also provided the basis for further cycles which can be used to help evaluation and then refine the information for relatives, and ultimately a training programmer for Cardiovascular nurses and other healthcare professionals This approach was critical for this project due to the lack of previous research on the attitudes and behaviours about stroke Based on trained knowlege, the nurses should make careful recommendation to having a risk of stroke patients and their family before discharging about stroke R ecom m endation for comunity health service Most situations were defined high blood pressure at the time hospital admission, but only nearly a half of respondents considered hypertension as medical history of elderly stroke patients Increasing health insurance cover, rountin health check for people, especially, old people should be encouraged for community health services Family doctors, who are constructive assistants in first aid stroke patients, need to be educated about referring patients to stroke centers within the window period of intervention It means that coming to hospital in three hours from the firsts signs of ischemic stroke appear, the treatment would prevent disabilities of stroke Specialists at the hospitals should have a rountin health check programmer for comunity, special elderly people and also have health education for preventable diseases like stroke r 36 V Reacting to stroke CHAPTER 7: DEVELOPING INFORMATION FOR NURSES In finding process, I realized stroke document of National Institute of Neurological Disorders and Stroke (NINDS) with short and easy understand information can be a reference for my subject R efining the inform ation The first exert asked was the clinical supervisor who pointed out that there is a difference between Vietnam and other countries, the cost of t-PA is too high, nearly 20 millions Vietnam dong (income one year of a medium income person and this is 1000EU), so it is difficult to treat by this medical In addition, there is a need to monitor the coagulation continuously to prevent bleeding because risk of bleeding for this medical condition is very high However, some anti-coagulative medicines are now in use in Vietnam, and these include Aspirin, and Lovenox, both of which are seen as having value in stroke treatment Moreover, when patients admission, CT scan or MRI as soon as better to identify the kind of stroke, whether it is an ischemic stroke or a hemorrhagic stroke From that, the doctor give a prescription for appropriate medicines He also pointed out that finding medical staff who have the knowledge and ability to apply CPR (cardiopulmonary resuscitation) and appropriate first aid to patients before taking them to hospital is significant in the long term outlook and recovery of the patient However, it is not easy to find staff with these qualifications in rural areas Another Cardiovascular expert; believed it is a mistake to find a doctor who would try to control blood pressure before admission, believing that reducing blood pressure too fast limits the circulation of blood leading to deficiency of oxygen and nutrition to the brain, also dangerous for patients These differences demonstrate the problems in developing advice as there is at present no consensus regarding the treatments to be given However, both agreed that any information needed to be simple and easy to understand for everybody When asked, some of the nurses in the Cardiovascular department were asked about the stroke document, they reported that the stroke information in this paper 37 I Pham Thi Thu Huong was not new for them, although this was appositive result, it did not mean that the information had been given to relatives Using all the collected literature and advice from experts, the international information was modified and adapted to fit the Vietnamese context, taking account of the fact that knowledge about stroke of amongst the population is not high and medical services are not good enough or available for all individuals From all collected ideas, and references from experts of Cardiovascular, I changed information to fit to Vietnam, where knowledge about stroke of citizen is not high and medical services not good enough for all Final inform ation From ideas of experts and nurses in Cardiovascular department, I changed some part in the document to fit in Vietnam 38 Reacting to stroke - Know Stroke Stroke is the third leading cause ofdeath in the United States and a leading cause of serious, long-term disability in adults About 600,000 new strokes are reported in the U.S each year Ivstimalely, 2500 patients are admitlcn to CR hospital, HCM city for stroke every year Hie good news is that treatments are available that can greatly reduce the damage caused by a stroke However, you need to recognize the symptoms of a stroke and get to a hospital quickly Getting treatment within 60 minutes can prevent disability ' Pham Thi Thu Huong Know the Signs Because stroke injures the brain, you may not realize that you are having a stroke To a bystander, someone having a stroke mayjust look unaware or confused Stroke victims have the best chance if someone around them recognizes the symptoms and acts quickly Reacting to stroke WMIWms OF A STROKE? The symptoms of stroke are distinct because they happen quickly: ■ Sudden numbness or weakness o f Ihc face, arm, or leg (especially on one side o f Ihc body) a Sudden confusion, trouble speaking or understanding speech ■ Sudden trouble seeing in one or both eyes d Sudden trouble walking, dizziness, loss of balance or coordination ■ Sudden severe headache with no known cause What should a bystander do? If you believe someone is having a stroke - if he or she suddenly loses the ability to speak, or move an arm or leg on one side, or experiences facial paralysis on one side Please ask them one o f actions to recognize they arc having a stroke: - Ask them to smile - Ask them to raise both amis - Ask them to speak a simple word 41 Pham Thi Thu Huong REFERENCE World Health Organization Vietnam - Environmental Health Country Profile (March 10, 2005) The stroke association What is the stroke (2008) http://www.stroke.org.uk/information/index.html American Heart Association Heart Disease and Stroke Statistics—2005 Update Dallas, Tex: American Heart Association; 2005 Stroke, Cerebrovascular Accident WHO http://www.who.int/topics/cerebrovascular_accident/en/ Becker K, Fruin M, Gooding T, Tirschwell D, Love P , & T., M (2001) Community-based education improves stroke knowledge Cerebrovasc Dis, 7/(1), 34-43 Brice, J H., Griswell, J K., Delbridge, T R., & Key, C B Stroke: From recognition by the public to management by emergency medical services, [doi:] Prehospital Emergency Care, 6(1), 99-106 Dearborn, J L., & McCullough, L D (2009) Perception of Risk and Knowledge of Risk Factors in Women at High Risk for Stroke Stroke, 40(4), 1181-1186 Derex L, Adeleine P, Niqhoqhossian N, Honnorat J, & Trouillas P (2004) Knowledge about stroke in patients admitted in a French Stroke Unit Rev Neurol Paris, 160(3), 331-337 Evensona’K R., Rosamond3’W D., & Morrisb , D L (2001) Prehospital and In-Hospital Delays in Acute Stroke Care Neuroepidemiology 20, 65-76 10 Greenlund, K J., Neff, L J., Zheng, Z.-J., Keenan, N L., Giles, W H., Ayala, C A., et al (2003) Low public recognition of major stroke symptoms, [doi: DOI: 10.1016/S0749-3797(03)00206-X] American Journal o f Preventive Medicine, 25(4), 315-319 11 Herold, K S., & Cichon, M E (2004) Prehospital Stroke, [doi: DOI: 10.1053/j.scds.2005.04.005], Seminars in Cerebrovascular Diseases and Stroke, 4(3), 144-148 12 Jauch, E C„ Kissela, B„ & Stettler, B (2009) Acute Stroke Management Medscape 44 Reacting to stroke 13 Johnston, s c„ Mendis, s., & Mathers, c D (2009) Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling The Lancet Neurology,