No. 2, April 2005
Rural Community Knowledge of Stroke Warning Signs
and Risk Factors
Lynda L. Blades, MPH, Carrie S. Oser, MPH, Dennis W. Dietrich,
MD, Nicholas J. Okon, DO, Daniel V. Rodriguez, MD, Anne M.
Burnett, RN, MN, Joseph A. Russell, NREMT-P, Martha J. Allen, RN,
Crystelle C. Fogle, MBA, MS, RD, Steven D. Helgerson, MD, MPH,
Dorothy Gohdes, MD, Todd S. Harwell, MPH
Suggested citation for this article:
Blades LL, Oser CS, Dietrich DW, Okon NJ, Rodriguez DV, Burnett
AM, et al. Rural community knowledge of stroke warning signs and
risk factors. Prev Chronic Dis [serial online] 2005 Apr
[date cited]. Available from: URL:
Rapid identification and treatment of ischemic stroke can lead
to improved patient outcomes. Public education campaigns in
selected communities have helped to increase knowledge about
stroke, but most data represent large metropolitan centers
working with academic institutions. Much less is known about
knowledge of stroke among residents in rural communities.
In 2004, 800 adults aged 45 years and older from two Montana counties
participated in a telephone survey using unaided questions to
assess awareness of stroke warning signs and risk factors. The
survey also asked respondents if they had a history of atrial
fibrillation, diabetes, high blood pressure, high cholesterol,
smoking, heart disease, or stroke.
More than 70% of survey participants were able to correctly
report two or more warning signs for stroke: numbness on any side
of the face/body (45%) and speech difficulties (38%) were
reported most frequently. More than 45% were able to correctly
report two or more stroke risk factors: smoking (50%) and high blood pressure (44%) were reported most frequently. Respondents
aged 45 to 64 years (odds ratio [OR] 2.44; 95% confidence interval [CI], 1.78–3.46), women (OR
2.02; 95% CI, 1.46–2.80), those with 12 or more years of
education (OR 1.96; 95% CI, 1.08–3.56), and those with high
cholesterol (OR 1.68; 95% CI, 1.17–2.42) were more likely
to correctly identify two or more warning signs compared with respondents
without these characteristics. Women (OR 1.48; 95% CI, 1.07–2.05) and
respondents aged 45 to 64 years (OR 1.35; 95% CI, 1.01–1.81) were also more
likely to correctly identify two or more stroke risk factors compared with men and
Residents of two rural counties were generally aware of stroke
warning signs, but their knowledge of stroke risk factors was
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Public health efforts to promote stroke awareness and the need
to seek urgent treatment have assumed a new importance in the
years since the publication of a major clinical trial showing
decreased short-term disability and improved outcomes for
patients experiencing an ischemic stroke after thrombolytic
therapy (1). Prehospital barriers to prompt treatment for
ischemic stroke include the lack of awareness of stroke warning
signs in patients and family members, underuse of 911 emergency
medical services (EMS), and long distances to tertiary-care facilities
that provide diagnostic and treatment services (2-5). These
barriers can lead to delayed presentation to the emergency
department and to ineligibility for time-dependent treatment.
Achieving increased use of thrombolytic therapy within the
three-hour window in one community required a multilevel
intervention to influence the knowledge and behavior of the
public, the response of EMS, and the
coordination of diagnostic and treatment facilities at the
From a public health perspective, an important component for
the success of stroke interventions is to improve public
knowledge about stroke, particularly focusing on individuals at
high risk and their family members and caregivers. Public
education campaigns in selected communities have been effective
in increasing the level of knowledge about stroke, but most data
have come from large metropolitan centers working with academic
institutions (7,8). Much less is known about basic knowledge of
stroke symptoms, risk factors, and the need for urgent
intervention among residents in rural communities that are
relatively isolated from major metropolitan centers.
We conducted a telephone survey in two rural counties in
Montana in 2004. This report describes the level of awareness of
stroke warning signs and risk factors and the public perception
of the need to call 911 EMS for stroke in
residents aged 45 years and older.
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The population for this study included residents living in
Cascade and Yellowstone counties, which include the cities of
Great Falls (Cascade County) and Billings (Yellowstone County).
The 2000 census population for Cascade County was 80,357 (9).
Fourteen percent of the population was aged 65 years and older
and 23% was aged 45 to 64 years. The majority of residents were
white (91%) or American Indian (4%). The 2000 census
population for Yellowstone County was 129,352. Thirteen percent
of the Yellowstone County population was aged 65 years and older,
and 23% was aged 45 to 64 years. Similar to Cascade County, the
majority of residents were white (93%) or American Indian
(3%). Both Cascade and Yellowstone counties are classified as
rural counties — Cascade County has a population density of 29.8 persons
mile, and Yellowstone County has a population density of 49.1 persons per square mile. These communities are served by three tertiary-care
hospitals that provide comprehensive stroke diagnostic and
treatment services. These facilities provide services for large multicounty areas that extend across state boundaries.
From February 2004 through April 2004, the Montana Department of Public
Health and Human Services conducted a random-digit–dial telephone survey of
adults aged 45 years and older living in Cascade (n = 400) and Yellowstone (n =
400) counties. Eligible persons living in households with more than one eligible
respondent were randomly selected. A trained interview team using
computer-assisted telephone interviewing software conducted the survey. The
survey was field tested to detect potential problems with questions or answer
categories and then revised as needed. A total of 3520 calls were made as part of
the survey. Of these calls, 1002 (28%) were nonworking numbers, 754 (21%) were
households with no eligible respondent, 426 (12%) were not private residences,
and 252 (7%) were no answer/answering machine or busy. Of the remaining calls to
persons in eligible households (n = 1086), 800 (74%) were completions, 224 (21%)
were refusals, 39 (4%) were unable to complete due to communication/language
barriers, and 23 (2%) were not completed because the eligible respondent was not
available during the interviewing period. Up to 15 attempts were made to complete unanswered calls.
The survey included questions on the warning signs and risk
factors for stroke, use of 911 EMS,
previous diagnoses of risk factors for stroke, and demographic
information. Open-ended questions adapted from Pancioli et al were used to assess respondents’ knowledge of
the warning signs and risk factors for stroke (2). Respondents
were prompted to name up to three warning signs and three risk
factors for stroke. Respondents were asked four questions adapted
from Yoon and colleagues to identify what they would do if they
witnessed someone having a stroke or if they experienced sudden
stroke warning signs including numbness, paralysis, and speech
problems that would not go away (10). Respondents were also asked
a series of questions from the Behavioral Risk Factor
Surveillance System Survey to identify if they had a history of
heart attack, angina, coronary heart disease, stroke, transient
ischemic attack (TIA), atrial fibrillation, diabetes, high blood
pressure, or high cholesterol and if they currently smoked
cigarettes (11). Respondents who reported a history of a heart
attack, angina, or coronary heart disease were classified as
having a history of heart disease. Female respondents who had
been told only that they had gestational diabetes were not categorized
as persons with a current diagnosis of diabetes. Respondents who
reported that they smoked cigarettes every day or some days were
categorized as current smokers.
Based on current recommendations from national organizations
(12-15), we considered the following as established warning signs
for stroke: dizziness, difficulty understanding speech or slurred
speech, severe headache, problems with vision, weakness on one or
both sides of body or face, numbness on one or both sides of body
or face, trouble walking, loss of balance, or lack of
coordination. We considered high blood pressure, high
cholesterol, smoking, diabetes, heavy alcohol use, history of
heart disease, and history of stroke or TIA
to be established stroke risk factors.
Data analyses were completed using SPSS V11.5 software (SPSS
Inc, Chicago, Ill). Chi-square tests were used to compare
differences in respondent knowledge of two or more warning signs,
two or more risk factors for stroke, and use of 911 EMS by age, sex, and history of stroke risk factors.
Multiple logistic regression analyses were conducted to identify
demographic and self-reported risk factors independently
associated with knowledge of warning signs and risk factors for
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The mean age of respondents (N = 800) was 61 years (range 45
to 95); 60% were female; 96% were white; 2% were American
Indian; and 93% reported 12 or more years of education. Ten
percent reported a history of atrial fibrillation; 6% reported a
history of diabetes; 37% reported a history of high blood
pressure; 31% reported a history of high cholesterol; 17%
currently smoked cigarettes; and 40% were
former smokers. Eight percent reported a history of heart
disease, and 6% reported a history of stroke or TIA. Overall, 80%
reported one or more risk factors for stroke, and 56% reported
two or more risk factors for stroke.
Numbness on any side of the face or body (45%) and speech
problems (38%) were the most frequently reported established
warning signs for stroke (Table 1). Fewer respondents reported
vision problems (18%) or difficulty walking (11%). Overweight
(56%), smoking (50%), and high blood pressure (44%) were the most
frequently reported risk factors for stroke (Table 1).
The majority of respondents (70%) could identify two or more
warning signs for stroke (Table 2).
Women (75%) were more likely than men (62%) to identify two or more established
warning signs for stroke, and respondents aged 45 to 64 years (76%) were more
likely than those aged 65 years and older (59%) to identify two or more
established warning signs for stroke. Just under half of the respondents (45%)
could identify two or more established risk factors for stroke. Respondents aged
45 to 64 years (48%) were more likely to identify two or more established risk
factors for stroke compared with those aged 65 years and older (40%).
Adjusting for multiple factors using logistic regression analyses, women,
individuals aged 45 to 64 years, those with 12 or more years of education, and
individuals with a history of high cholesterol were more likely to identify two
or more established warning signs for stroke compared with respondents
without these characteristics (Table 3). Women and respondents
aged 45 to 64 years were more likely to identify two or more
established risk factors for stroke compared with men and with respondents aged 65 years and older.
Overall, the majority of respondents (76%) indicated they
would call 911 EMS if they witnessed
someone having a stroke (Table 4). There were no differences by
age, sex, or years of education in the proportion of respondents
who indicated they would call 911 if they witnessed someone
having a stroke (data not shown). When asked what they would do
if they were experiencing sudden difficulty speaking, numbness,
or weakness or paralysis, 43% to 49% of individuals indicated
they would call 911. Depending on the symptom, 17% to 23%
indicated they would go to the hospital, 14% to 19% would call
their doctor, 11% to 18% would call their spouse or a family
member, and 3% to 5% would do something else (Table 4).
Respondents aged 65 years and older were more likely than
respondents aged less than 65 to indicate they would call 911 if
they experienced sudden difficulty speaking (49% vs 42%, P
= .04), numbness (50% vs 40%, P = .006), or weakness or
paralysis (55% vs 45%, P = .004). There were no
differences by sex or years of education in the proportion of
respondents who indicated they would call 911 if they experienced
any of these warning signs (data not shown).
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The majority of respondents from these rural counties were aware of the
established warning signs for stroke, and awareness was higher in women, younger
respondents, those with a higher level of education, and those with a history of
high cholesterol compared with respondents without these characteristics.
Interestingly, respondents with a history of other major stroke risk factors
(e.g., high blood pressure) were no more aware of the warning signs compared
with respondents without these
conditions. Overall, fewer respondents were aware of the
established risk factors for stroke. We also found that the
majority of respondents would call 911 if they thought someone
was having a stroke, but less than half would call 911 if they
were experiencing stroke warning signs.
Individuals responding to the survey lived in communities that
are typical of many communities across the United States, where
health care for a large region is centered in a nearby town.
Awareness of established stroke warning signs and risk factors
was higher than awareness levels reported in other community surveys
(10,16,17). In 1999, only 30% of adults surveyed in Michigan
identified two or more warning signs correctly, and 34%
identified two or more risk factors correctly (17). In 2000, more than 40% of respondents
in Cincinnati, Ohio, identified two or more
warning signs for stroke, and 32% identified two or more
established risk factors for stroke (16). A study of adults
living in an urban area of Australia in 1999 found that 26% of
respondents to a telephone survey identified two or more warning
signs for stroke, and 50% identified two or more risk factors for
Our findings on what respondents would do if they witnessed
someone having a stroke or if they were experiencing warning
signs of stroke are comparable to previous studies from Australia
and Michigan (10,17). In Australia, 67% of respondents would call
an ambulance if they witnessed someone having a stroke, while
less than half of respondents would call an ambulance if they
were experiencing sudden stroke warning signs (45% difficulties
with speech, 38% numbness/weakness, 35% weakness or paralysis).
In Michigan, however, 79% indicated they would call 911 if
someone was having a stroke.
There are a number of limitations to this study. First, the
survey does not reflect the experience of residents without
telephones. Second, self-reported information regarding risk
factors for stroke is subject to recall bias. Previous studies,
however, have found that self-reported risk factors for
cardiovascular disease are reported reliably (18,19). Third,
respondents were asked unaided questions to assess respondent
knowledge of the warning signs and risk factors for stroke. Some
previous studies assessing awareness of stroke warning signs used
aided questions and found higher levels of knowledge than the
levels found in this study (20). It is possible that unaided
questions may underestimate the awareness of the warning signs of
stroke, and aided questions may overestimate awareness. Fourth,
this study was conducted in a rural non-Hispanic white
population, and there may be significant variation in awareness
of stroke warning signs and risk factors in other geographic and
racial and ethnic communities in the United States.
Our findings about stroke awareness in rural communities are important
because they are similar to studies published from academic centers working in
urban areas (10,16,17). This effort, however, represents a collaboration between
a state public health agency and several regional health care systems not only
to understand the levels of stroke awareness in two communities at baseline but
also to promote community awareness and increased use of EMS and to define regional approaches for prompt stroke
treatment in cooperation with the stroke referral centers in these
counties. Based on the findings reported here, the Montana
Cardiovascular Health Program and these partners have developed
and implemented a multifaceted intervention to increase community
awareness of the warning signs of stroke and the need to use
911 adapting strategies that have been shown to be successful
It is reassuring that levels of community awareness and knowledge about
stroke in rural settings are not markedly different from levels found in urban
environments. Others have shown that multifaceted interventions to increase
community awareness, use of EMS, and availability of prompt diagnosis and
treatment can succeed (7,8). Strategies to reduce barriers to prompt stroke
treatment may be somewhat different across large frontier areas compared with urban environments. Cooperative
efforts between public health agencies, communities, and prehospital and acute care systems, however, can build on the
published experience of others to understand and improve
knowledge about stroke warning signs and risk factors as part of
broader public health interventions targeted to stroke prevention
and treatment. In the United States, public health programs are
only beginning to develop partnerships and work toward developing
and documenting successful interventions in a wide variety of
settings. This report represents the beginning of efforts to meet
the challenges in rural communities in Montana and across many
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The authors thank Linda Priest and staff members from Northwest Resource
Consultants for their work and expertise conducting the telephone survey and the
Great Falls Stroke Coalition for their support of this project. This project was
supported through cooperative agreement with the Centers for Disease Control and
Prevention, Division of Adult and Community Health (U50/CCU821287-02) in Atlanta, Ga.
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Corresponding Author: Todd S. Harwell, MPH, Montana Department
of Public Health and Human Services, Cogswell Building, C-314, PO Box 202951,
Helena, MT 59620-2951. Telephone: 406-444-1437.
Author Affiliations: Lynda L. Blades, MPH, CHES, Carrie S. Oser, MPH, Crystelle C. Fogle, MBA, MS, RD, Steven D. Helgerson,
MD, MPH, Dorothy Gohdes, MD, Montana
Department of Public Health and Human Services, Helena, Mont;
Dennis W. Dietrich, MD, Anne M. Burnett, RN, MN, Benefis
Healthcare, Great Falls, Mont; Nicholas J. Okon, DO, Martha J.
Allen, RN, BSN, St Vincent Healthcare, Billings, Mont; Daniel V.
Rodriguez, MD, Deaconess Billings Clinic, Billings, Mont; Joseph
A. Russell, NREMT-P, City of Great Falls Fire and Rescue, Great
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