Knowledge of risk factors and warning signs of stroke Northrhine-Westfalian area, Germany, 2000 (a) Cincinnati, USA, 1997 (b) Cincinnati, USA, 2003 (c) Michigan, USA, 2002 (d) Cincinnati, USA, 1998 (e) Newcastle, Australia, 2001 (f) Georgia, USA, 2001 (g) 70.0% s ign 60.0% s g n fy i 50.0% i t n ied 40.0% y l t c re 30.0% r o c ge 20.0% a t n rce 10.0% e P 0.0% 0 correct 1 correct 2 correct 3 or more correct Figure 3 Number of stroke warning signs correctly identified using open-ended questions. (a) Weltermann et al 2000, (b) Kothari et al 1997, (c) Schneider et al 2003, (d) Reeves et al 2002, (e) Pancioli et al 1998, (f) Yoon et al 2001b, (g) Rowe et al 2001. questionnaires. It appears that survey respondents are more likely to identify a particular stroke symptom when they are provided with a list of potential symptoms, as positive identification of various stroke symptoms was almost twice as high in the studies utilizing closed-ended questions (Figures 1 and 2). As mentioned previously, closed-ended type studies may provide the respondent with some prompt as to what the correct answer should be, and may therefore be more likely to elicit positive responses when compared with open-ended methods. Addition of an incorrect symptom or sign to a list of possible symptoms can give the reader some indication of the respondent’s tendency to provide positive responses to all proffered symptoms when utilizing closed-ended questions. Greenlund et al (2003) added “chest pain” to the list of possible symptoms of stroke, and 37.8% of respondents incorrectly identified this as a warning sign for stroke. However, this particular symptom may not be the best test of this behavior, as the authors of many open-ended studies in this review have found that symptoms and signs for heart attack are often confused with those for stroke (Pancioli et al 1998; Hux et al 2000; Yoon et al 2001b; Reeves et al 2002; Schneider et al 2003). The number of established warning signs identified by individual respondents using open-ended questions has been summarized in Figure 3. Weltermann et al (2000), who used stroke support group members as subjects, had the highest levels of knowledge of stroke warning signs. This result is not surprising, as this group of individuals have a confirmed history of being exposed to the condition in question and would be expected to be more aware of stroke signs and symptoms than the general public. The results shown in Figure 3 highlight the lack of knowledge of stroke warning signs among the general public: the proportion of individuals unable to name a single warning sign of stroke varied from slightly less than 30% up to 60%. Regression analyses Nine of the studies of stroke warning signs included the results of regression analysis of factors associated with increased knowledge of stroke warning signs and symptoms (Table 2). The common factors used in the regression analyses were basic demographic data: age, sex, education, and income level. In addition to this, other established stroke risk factors such as history of stroke, hypertension, and smoking were often included. Younger age was found to be a significant predictor of improved knowledge of stroke warning signs in seven of the nine studies that included a regression analysis, although the very young (18–34) age groups also had a tendency toward lower stroke knowledge in some studies. In three of the studies (Reeves et al 2002; Greenlund et al 2003; Schneider et al 2003), knowledge was lower in both older and younger age brackets, with middle-aged people having the greatest knowledge of stroke warning signs. These results provide some evidence that those most at risk of stroke (older people) are the group with the least knowledge of stroke symptoms. Therefore, this age group could be the focus of targeted awareness campaigns. Vascular Health and Risk Management 2005:1(2) 141