Nicol and Thrift aspirin within 48 hours (Chen et al 2000), and treatment in a stroke care unit (Stroke Unit Trialists’ Collaboration 2004). For the first of these therapies, patients need to attend hospital within approximately 2 hours of stroke onset. Currently, only about 1%–2% of patients receive this treatment (Birbeck et al 2004). The most common reasons that patients are not treated with tPA are that they do not attend hospital within the treatment time window (Kleindorfer et al 2004), that there are insufficient trained staff, and that patients are ineligible for treatment. Although the proportion receiving therapy could be improved by increasing the number of centers in which this therapy could be administered, reducing the delay to hospitalization would also considerably improve access to this therapy. The second way in which we can reduce the burden of stroke is to reduce the number of people experiencing a stroke. This could be undertaken by implementing good primary and secondary prevention measures at an individual and population level. The individual (or high-risk) approach involves identifying high-risk people and altering their risk factor profile by either reducing risky behaviors or introducing treatments. The population (or mass) approach involves either mass screening or education campaigns to reduce risky behaviors at the population level. To reduce delays to hospitalization following stroke and to improve risk factor profiles of the population requires knowledge about stroke and its risk factors. In view of the importance of understanding the level of community awareness of stroke, we undertook a review of the literature in this area. The aim of this review is to compile the findings of a number of groups that have investigated levels of knowledge of stroke signs, symptoms, and risk factors. Drawing these results together will provide readers with some insight into different communities’ understanding of stroke, and thereby highlight areas where improvements can be made with targeted campaigns. Table 1 provides a summary of the publications discussed in this review. As can be seen from this table, there is a mix of both open-ended and closed-ended types of approaches to studying stroke knowledge. Although open-ended survey questions provide the researcher with the most “open and honest” assessment of the respondent’s knowledge, the results are often difficult to compile and analyze. For the results of an open-ended survey to be reported, it is often necessary for the researcher to make a decision as to what the intention of a subject’s response was and to group responses into similar categories. Because this coding 138 process involves judgment decisions, it is always possible that the results may be biased by this decision process. Rowe et al (2001) attempted to address this issue by coding responses using two individuals, and where a discrepancy was found, a third party was used to resolve the issue. When knowledge of stroke symptoms is assessed using closed-ended questions, a different type of response is evoked, as the act of asking the question provides the respondent with some indication of what the answer could be. In the two studies in this review where respondents are asked to identify stroke symptoms from a provided list (Yoon et al 2001a; Greenlund et al 2003), there is a tendency for all suggested symptoms of stroke (including those that are definitely not stroke symptoms) to be identified as actual symptoms – this may be a reflection of some of the inherent difficulties in using closed-ended questions. Positive responses identifying a particular stroke symptom appear to be more prevalent when using closed-ended rather than open-ended questions. For example, Rowe et al (2001) utilized both approaches: for closed-ended questions, between 77% and 95% of respondents correctly identified different symptoms of stroke, while for open-ended questions, these values were between 7% and 24%. In seven of the studies, telephone contact was used as the method of survey administration. Although this method is definitely more efficient and cost-effective than face-to- face interviews, there is a small degree of selection bias whereby people without a telephone are excluded from the study, although this effect is likely to be small as these studies were all performed in areas where telephone access would be very high. For example, Pancioli et al (1998) noted that 96% of all households in their survey area had reported having a telephone service. In one study, nonrespondents included a group that were not interviewed due to a communication barrier (Rowe et al 2001). It is possible that this process may have reduced the generalizability of results, as people from non-English-speaking backgrounds and those with speech difficulties may have been excluded from the study group. Sample size is an important issue in any study, particularly in population-based research, where large numbers of respondents are needed to provide adequate power. The largest study among the group reviewed here is that of Greenlund et al (2003), in which more than 61 000 individuals were surveyed across the USA. Although this study is extremely large, the response rate was relatively low – a median value of 53% was stated. Three of the studies in this review were conducted using very small (< 200) Vascular Health and Risk Management 2005:1(2)