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Stroke
Knowledge and action in stroke—are either good enough?
  1. K M McPherson1,
  2. P Kersten2
  1. 1School of Health Professions and Rehabilitation Sciences, University of Southampton, Southampton SO17 1BJ, UK
  2. 2School of Medicine, University of Southampton, Southampton SO17 1BJ, UK
  1. Correspondence to:
 Dr K M McPherson
 School of Health Professions and Rehabilitation Sciences, University of Southampton, Southampton SO17 1BJ, UK; k.mcphersonsoton.ac.uk

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It is important that education on stroke is provided in ways that people can really understand

Getting people to hospital quickly for specialist care after a stroke saves lives and reduces disability.1 However, for many people, the most appropriate care is delayed and, in some cases, may not happen at all. Other than the ongoing lack of specialist stroke services, what is it that impedes access to best services for patients who have a stroke?

Huge efforts have been made to highlight the seriousness of stroke and the importance of getting swift medical attention. However, the long lasting effects of education and screening campaigns are debatable,2–4 providing a reminder (if one were needed) of the complexity of health promotion for behaviour change. Key questions to face are whether the level of knowledge about stroke is good enough, and whether that knowledge leads to appropriate action when people experience a stroke.

A number of recent studies have explored the quality of the public’s knowledge about stroke and many make depressing reading.2,3 The recent study by Carroll et al5 (summarised in the “Echo” which appears on page 168 of this issue of QSHC) presents contrasting findings about the level of knowledge, and prompts some interesting questions about what we do in relation to that knowledge that is important for practitioners, researchers, and policy makers alike. On the positive side, Carroll et al5 found a “good” level of knowledge among four groups of people (comprising patients in hospital after a stroke, those at risk of stroke from specialist clinics, members of the public who were visitors to other wards of the hospital, and nurses on general medical wards) in comparison with other studies. The majority knew at least one symptom of stroke and considered the event a medical emergency. Interestingly, hospital nurses were the only group who did not consider it to be an emergency, although this may result from their frame of reference (an acute medical ward) leading to a tighter definition of medical emergency such as cardiac/respiratory arrest. It would be interesting to know how primary care health professionals in the area—including district nurses, health visitors and general practitioners—would answer the same questions, given their role in the community to advise people who are at risk of or experience a stroke. Certainly, a recent study of general practitioners found that the majority considered stroke an emergency and would call an ambulance.6 Most participants in the study by Carroll et al stated that they too would call an ambulance for assistance. However, the reality of what actually happened was different, with those in the stroke group calling their general practitioner or seeking help from a family member to do so.

The apparent conflict between what people say they would do and what they actually do is intriguing. On the one hand, it is not unusual for people—including probably most of us—to make plans for actions that are then not carried out, particularly in new and stressful circumstances. Along with this general caveat, it may also be that factors such as severity and type of stroke are important mediators of action taken. One could imagine that severe signs of stroke such as unconsciousness, hemiparesis, or aphasia might be more likely to prompt a call for an emergency ambulance than less obvious or transient symptoms including visual disturbance, weakness in a limb, or slurring of speech. Certainly, people who have had a stroke have reported not recognising the symptoms they experience because they were so different from those they had read about.7 Furthermore, if a diagnosis of stroke is not always straightforward for qualified medical practitioners,8 it is perhaps not surprising that patients themselves have difficulty in self-diagnosis or are reluctant to call out emergency services. It would seem that, in order to design and target education more effectively, further exploration concerning the messages people actually hear about stroke from the information given is needed.

The title of Carroll et al’s paper states that “knowledge was good but action was poor”, yet the figures for recognition of risk factors, particularly among the health professional group, seem low (median of 2 for nurses compared with a median of 1 for the other groups). This level of knowledge is surely not good enough, given that these were staff in medical wards (albeit not specialist neurology wards) and that a number of important and modifiable risk factors such as atrial fibrillation were rarely mentioned. As for the people who actually had risk factors, only one third could recall having been advised of that risk. Interestingly, the investigation by Sug Yoon et al7 found that those who recalled being advised about their risk of having a stroke were actually no better at recognising their own symptoms.

So where does this leave us when thinking about and targeting education on risk factors and their relation to stroke? Given that stroke remains a common and poorly understood condition,9,10 education for the general population and health professionals, as well as those with risk factors, is vital. There is no doubt that advances have been made in understanding the importance of the content, context and timing of “information giving” to enhance knowledge. However, while knowledge is power in some domains of life, catalysts to action are clearly less well understood in the case of stroke. It is important that we provide education—whether for at risk groups or the general population—in ways that people can really understand and, indeed, act upon the knowledge gained. Simply providing “more” education is not an adequate response.

With the continued efforts of organisations such as the Stroke Association and others, increased prioritisation of research into stroke appears to be happening, at least in the UK. Along with other research priorities, how people make potentially life and death decisions when they have a stroke is clearly worth more detailed investigation if we are to provide timely appropriate services and improve our record in stroke care.

It is important that education on stroke is provided in ways that people can really understand

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