INFLUENCING FACTORS OF STROKE AWARENESS AMONG HYPERTENSIVE PATIENTS IN COMMUNITY HEALTH CENTERS IN INDONESIA Author Information

The global burden of stroke is still high, particularly in developing countries, with hypertension serves as the main risk factor. Knowledge related to stroke is essential to establish better prevention strategies. This study aimed to identify factors associated with stroke awareness among hypertensive patients in Indonesia. This was a cross-sectional study conducted in five Community Health Centers in Indonesia. We used a standardized questionnaire to asses stroke awareness and the influencing factors. The knowledge on hypertension was assessed using Hypertension Knowledge Level Scale (HK-LS). Multivariate logistic regression analysis was performed to measure factors associated with stroke awareness. A total of 457 hypertensive patients were included. Majority of patients (77.46%) had low stroke awareness. Having higher Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 16 June 2021 doi:10.20944/preprints202106.0430.v1 © 2021 by the author(s). Distributed under a Creative Commons CC BY license. knowledge on hypertension, higher income, and a history of previous stroke were associated with higher level of stroke awareness (odds ratio [OR] 1.878, 95%CI 1.176-2.999, p 0.008; OR 1.887, 95%CI 1.170-3.045, p 0.009; OR 5.276, 95%CI 2.210-12.594, p<0.001, respectively). This study suggests that knowledge on hypertension, income, and history of previous stroke are factors which may influence the level of stroke awareness. This emphasizes the need to provide better campaign and education program to raise stroke awareness in a community

knowledge on hypertension, higher income, and a history of previous stroke were associated with higher level of stroke awareness (odds ratio [OR]  This study suggests that knowledge on hypertension, income, and history of previous stroke are factors which may influence the level of stroke awareness. This emphasizes the need to provide better campaign and education program to raise stroke awareness in a community setting.
Keywords: stroke awareness, hypertensive patients, community health center, Indonesia Background Stroke is the leading cause of morbidity and disability worldwide [1]. The global burden of stroke is still high with the estimated incidence is 15 million new cases per year, in which two thirds of them occur in developing countries [2]. The disability-adjusted life years of stroke patients was more than 87% in developing countries and this was seven times higher than in developed countries [3,4].
Indonesia has the highest rates of age-sex standardized mortality and disability adjusted life-years among South East Asian (193.3/100,000 person-years and 3,382.2/100,000 people, respectively) [5]. The average age of stroke patients in Indonesia is lower than those in developed countries [6], thus leads to higher disability rate, reduce the quality of life and more economic lost [7]. The high burden of stroke is attributable to modifiable risk factors such as behavioral, metabolic, and environmental risk factors [8]. Hence, knowledge related to stroke warning signs and risk factors is crucial to reduce the incidence of stroke and prevent subsequent mortality [9].
A recent cross-sectional study in Spain revealed that the knowledge related to the warning signs and risk factors among hospitalized stroke patients was low. Previous history of stroke and high education level were predictors which could increase the knowledge [10]. In contrast, prior study in Nigeria demonstrated different findings that the knowledge of stroke risk factors was quite high among hypertensive and diabetic patients. However, the compliance with action to do stroke prevention was sub-optimal [11].
Hypertension is the most common risk factors for stroke and the main modifiable factor attributed to disability after stroke [12,13]. The Indonesia Family Life Survey-5  reported that the prevalence of hypertension in people with the mean age of 43.3 years old was quite high, reaching 33.4%. In addition, the awareness of hypertension was low, the treatment and control were very poor [14]. These may further contribute to increase risk of stroke.
Raising public stroke awareness would be beneficial for better stroke prevention strategies, particularly for population at risk. Approximately 80% of new stroke incidence could be avoided by improving knowledge related to risk factors of stroke [15]. The knowledge about stroke as a complication of hypertension is also essential for establishing the effective prevention programs. Nevertheless, no prior studies reporting the level of stroke awareness in Indonesia. The present study aimed to identify the influencing factors of stroke awareness among hypertensive patients in Community Health Centers in Indonesia.

Study Design and Participants
This study had cross-sectional design. We included patients from five Community Health Centers in Banyumas Regency, Central Java Province, Indonesia during April -August 2019.
These five Community Health Centers were located in rural (3) and urban (2) region, thus representing the characteristics of both populations.
Hypertensive patients aged >35 years old who came to the Community Health Centers for a routine checkup were consecutively recruited. Hypertensive patients with comorbidities such as aphasia, dementia or other neuropsychiatric diseases were excluded from the study.
A total of 457 patients were investigated in this study. All patients signed a written informed consent prior to the investigation. Ethical approval for this study has been obtained Demographic characteristics included sex, age, education level, marriage status (married/widow), living with (family/alone), and income. Income was categorized as <minimum regional payment (MRP) or <134 USD/month, and >MRP (>134 USD/month) based on the minimum standard income in Indonesia [16].
We measured patients' knowledge on hypertension as a risk factor for stroke by using The Hypertension Knowledge-Level Scale (HK-LS). HK-LS has high validity and reliability for measuring the level of knowledge on hypertension in adults [17]. It has been translated and validated to Indonesian version with good reliability [18]. The final scale has 22 items related to hypertension which divided into six subdimensions namely definition, medical treatment, drug compliance, lifestyle, diet, and complications. The maximum score is 22 for the entire scale. The minimum score is zero for the entire scale and for all subdimensions [17]. HK-LS was further classified as low knowledge on hypertension (HK-LS <17) and high knowledge (HK-LS 18-22) [19].
Comorbidities included history of headache, medication adherence, history of hypertension (controlled/uncontrolled), history of diabetes mellitus, history of dyslipidemia, history of stroke, history of atrial fibrillation, history of heart failure, history of anxiety, and history of sleep apnea. Medication adherence was measured by five-item scale about selfreported adherence related to blood pressure medicine [20]. Patients were categorized as not adhere to the medication if the scale was <5, and adhere if the scale was 5.
In the last part of the questionnaire, we asked participants regarding their perceived health status related to stroke risk. We measured their perception using Likert scale (1-5). Scale 1 means patient was very unsure to be at risk for a stroke, scale 2 means unsure, scale 3 means patient undecided, scale 4 means sure, and scale 5 means very sure. Patients with Likert scale <3 were categorized as having low-level of stroke awareness, and those with Likert scale >3 were having high-level of stroke awareness.

Statistical Analysis
We performed the Chi square test to analyze the differences between categorical variables in the baseline characteristics. Factors associated with stroke awareness were measured using univariate logistic regression analysis. Subsequently, these associated factors were further analyzed using multivariate logistic regression to measure their contribution to stroke awareness after controlling the covariates. Statistical significance was indicated by a p value of <0.05. SPSS version 16 was used for all the analyses.

Results
Baseline characteristics  In this study we found that the majority of the participants had low-level of stroke awareness. This finding is in accordance with prior studies which showed that most participants were not fully aware of stroke and its risk factors [15,21,22]. Moreover, the level of stroke awareness in the present study was positively associated with the level of knowledge on hypertension. Therefore, the reason why most of our patients had low stroke awareness was due to poor knowledge on hypertension. This may endanger their health status as patients could not prevent the future risk of stroke.
Corroborates with our findings, previous study reported that 78.3% patients had inadequate knowledge, 21.7% had moderate knowledge, and none of them had adequate knowledge on hypertension and stroke prevention [23]. Another cross-sectional study on hypertensive patients also demonstrated that 75.1% of participants had poor knowledge on stroke prevention [24]. Knowledge on hypertension is crucial to prevent increasing incidence of hypertension and to maintain normal blood pressure control [25]. Hence, knowledge deficits contributes to inadequate control of hypertension and poor medication adherence [19] which further increase the risk of stroke. Furthermore, two studies investigating the knowledge about stroke warning signs and risk factors in patients with acute cerebrovascular disease [26] and history of previous stroke [27] revealed similar findings.
In the present study, we also found that higher income was positively associated with stroke awareness. This finding is supported by prior study using data from the 2017 National Health Interview Survey in United States which showed that individuals with low income were more likely of not being aware of all stroke symptoms [28]. The level of monthly income is a factor that could predict stroke knowledge. Higher income is associated with good stroke knowledge [29]. Moreover, another cross-sectional study in Spain demonstrated that socioeconomic status including educational level, income, and employment status are independent factors for sufficient knowledge of stroke [30]. Patients with higher income are more likely to have better and prompt health-seeking behavior when they are being at risk of stroke [31].
Stroke awareness in this study is also influenced by having history of stroke. In accordance with our finding, a cross-sectional study among stroke patients in Spain reported that history of prior stroke was associated with higher knowledge on stroke warning signs and risk factors [10]. Another study showed that stroke survivors or patients with history of previous stroke were more likely to have more awareness on stroke warning signs including sudden numbness or weakness, sudden difficulty speaking or understanding speech, sudden dizziness, and sudden severe headache [32]. The contributing factor for higher stroke awareness among patients with history of prior stroke is the adequate information received during they stayed on hospital, from admission until discharge. This permits them to recognize the signs, symptoms, and risk factors of stroke which could prevent further delay in seeking care [10,27,33].
Results in the present study contribute to providing more evidence that stroke awareness is still insufficient in community setting. This indicates an urgent need to disseminate stroke education and awareness campaigns in Indonesia, particularly targeting people who have the higher risk of stroke. Nevertheless, this study has some limitations. First, stroke awareness in the present study was only related the participants' perceived health status of being at risk of stroke, using a "yes-no" questions. The investigation related to their knowledge on stroke warning signs was not explored. The cultural belief and perception regarding stroke and the risk factors for each participant were not either investigated. Second, duration of hypertension was not included in the analysis. In addition, we did not analyze whether the patients had endstage complications or not. Taken together, these may lead to bias and different findings. Third, the participants in this study were recruited only from five Community Health Centers in a region in Indonesia. Therefore, the findings need careful interpretation for generalization.
Finally, we only used cross-sectional design. Thus, we could not provide the causal relationship between stroke awareness and the influencing factors although the direction of the association was consistent with prior studies.

Conclusions
Stroke awareness among hypertensive patients were still low. Knowledge on hypertension, income, and history of previous stroke are factors which may influence the level of stroke awareness among hypertensive patients. This emphasizes the need to provide better campaign and education program to raise stroke awareness in a community setting.

Funding
This study received no external funding.