The European Journal of Public Health Advance Access originally published online on June 7, 2005
The European Journal of Public Health 2005 15(3):313-316; doi:10.1093/eurpub/cki086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Miscellaneous |
Public understanding of the causes of high stroke risk in northeast Bulgaria
Klara G. Dokova1, Krassimira J. Stoeva1, Philip I. Kirov2, Nevjana G. Feschieva1, Stefka P. Petrova3 and John W. Powles4
1 Varna Diet and Stroke Study, Department of Social Medicine, Medical University of Varna, Bulgaria
2 Clinic of Neurology, Acute Stroke Unit, University Hospital, Varna, Bulgaria
3 National Centre for Hygiene, Medical Ecology and Nutrition, Sofia, Bulgaria
4 Department of Public Health and Primary Care, Institute of Public Health, Cambridge, UK
Correspondence: Dr Klara Dokova, Department of Social Medicine, Medical University of Varna, 55 Marin Drinov str., Varna 9002, Bulgaria, tel./fax +359 52 644 166, Email: alpha{at}varna.net
Received August 24, 2004, accepted January 31, 2005
 |
Abstract |
|---|
 Top Abstract MethodsResultsDiscussionAcknowledgementsReferences |
|---|
Background: Knowledge of stroke risk factors is undocumented in Bulgaria. Methods: 188 subjects in 2000 and 447 in 2003 were asked: ‘Why do you think stroke is so common in this region?’ Results: Stress and poverty accounted for 69% of the first mentions in 2000 and 59% in 2003. There were no mentions of high blood pressure and no first mentions of smoking in 2000. High blood pressure appears only 10 times and smoking 12 times among 745 answers in 2003. Conclusion: Health education on the established causes of stroke is an urgent priority in Bulgaria.
Keywords: open-ended questionnaire, primary prevention, public awareness/knowledge, stroke risk factors
Stroke incidence in North-Eastern Bulgaria is amongst the highest yet reported for European populations,1 with age-adjusted rates in the rural areas being around three times those reported from the Oxford Vascular Study.2
Although there is continuing scientific uncertainty about why rates are so high in Bulgaria, responses to this public health challenge are needed now. Both established risk factors (high blood pressure, cigarette smoking, obesity, diabetes) and probable ones, such as high sodium consumption, low fruit and vegetable consumption and low physical activity level,3 are related to individual behaviours and thus accepted to be modifiable. Change in such risk factors is less likely when public knowledge of their contribution to stroke risk is low. International experience suggests that health education campaigns can increase public awareness of risk factors for stroke.4–6 Assessment of the current level of public knowledge can help in the design of education programmes and can also provide a useful baseline against which to judge the possible contribution of education programmes.
We have identified 10 population-based studies of public knowledge of stroke risk factors assessed by open-ended questions.7–16. We found no such studies for Bulgaria. Results suggest a ‘west–east’ gradient: The percent of respondents able to name at least one of the following established, modifiable stroke risk factors: raised blood pressure, cigarette smoking, diabetes or obesity was highest in Greater Cincinnati, Ohio, USA (51%)14 and lowest in Poland (27.8%)16 , with high blood pressure, smoking and obesity being recalled most often. A west–east gradient is also suggested by studies which asked participants to choose from a list of possible stroke risk factors;11,17–20 the proportion of people able to recognise at least one correct factor ranged from 96.8% in Georgia, USA to 66.7% in a Bulgarian study.18,20
We present here findings from two consecutive cross-sectional studies conducted in 2000 and 2003 among urban and rural populations in North-Eastern Bulgaria, a region where stroke risk is very high. Our objective was to gain insight into people's thoughts and understanding on the causes of high stroke rates in this region, to guide further research and action.
|
Methods |
|---|
|
TopAbstractMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Study design and populations
Consecutive cross-sectional surveys applying similar sampling and data collection methods were conducted in the North-Eastern region of Bulgaria between January and March 2000, and April and May 2003.
Subjects included in the first study were residents of the Primorski district of Varna city and the village of Grozdovo with stated ages between 45 and 74 years. Subjects included in the second study were residents of Varna city and Dobrich town, and of the villages Kichevo, Priseltzi and Bliznatzi (in Varna Region), and the villages of Rositza and Zhiten (in Dobrich region), in the same age range of 45–74 years.
Patient registration lists of cooperating general practitioners were sorted by age group and sex and used as sampling frames. Potential study subjects within each age–sex category were consecutively invited to take part until a common target number was reached. 188 (91 rural and 97 urban) participants took part in the first study and 447 (229 urban and 218 rural) in the second. The proportion agreeing to participate was around 70% in the second study (information not retained for first study).
Comparison with regional data from the 2000 census showed that persons with less schooling were under-represented in the study samples for the rural areas.
Data collection
During structured face-to-face interviews conducted in the volunteers' homes, covering many aspects of lifestyle and family circumstances, subjects were asked: ‘Why do you think stroke is so common in this region?’. Interviewers were instructed not to prompt responses and to record first and other reasons offered in summary verbatim form. All answers in both studies were post-coded with the same system: first into 102 initial categories, which were then combined into 29 higher categories and finally into seven more inclusive groups. These groups are:
- Social, political and economic environment: including stress, poverty, unemployment, etc.
- Lifestyle: including unhealthy lifestyle in general, smoking, physical activity and alcohol consumption.
- Physical and natural environment: encompassing air, water pollution, chemical pollution from agriculture and other sources, climate and atmospheric conditions and physical conditions at work, etc.
- Diet: including diet without further specification, poor diet, inadequate diet with lack of variety and insufficient food, overeating, overweight along with more specific categories such as too much salt, insufficient fruits, vegetables and vitamins, too much animal fat and insufficient unsaturated fat, etc.
- Medicine: including categories such as lack of public knowledge about health, lack of trust in modern medicine etc. and quality and availability of medical services including lack of preventive services, poor quality of services, poor quality of hypertension control and poor management of cardiovascular diseases, etc.
- Biological: including inheritance, high blood pressure, atherosclerosis, diabetes, blood cholesterol and atrial fibrillation.
- Other: such as irregular sexual life, Balkan temperament, egotism, etc.
Descriptive statistical analyses were performed using SPSS version 11.0.
Ethical approval was granted by the ethical committee of Varna Medical University and written informed consent was obtained from all subjects.
|
Results |
|---|
|
TopAbstractMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The participants in the first study suggested 494 possible answers in total and those in the second study gave 745 answers to the question ‘Why do you think stroke is so common in this region?’. 179 (95.2%) of the respondents in 2000 and 100% from the respondents in 2003 offered at least one explanation.
Answers from the group of social, political and economic environment (such as stress and poverty) were most common representing 69% of the first mentions and 48% of all mentions in 2000 and 59% of the first mentions and 55% of all mentions in 2003 (table 1). They were followed by the group of dietary causes for stroke in both studies.
|
High blood pressure was not mentioned at all by the participants in the first study in 2000, and it appears only 10 times among 745 suggested answers in the second study from 2003.
Smoking was mentioned 11 times (among 494 answers) in 2000 and 12 times (among 745 answers) in 2003.
Although dietary causes of stoke constituted 31% of all mentions in 2000 and 25% of all mentions in 2003, low consumption of fresh fruits and vegetables was mentioned only four times among all 494 answers in 2000 and three times among 745 answers in 2003. High salt consumption was mentioned only 14 times in 2000 and eight times in 2003.
More urban dwellers than rural dwellers were able to nominate an accepted stroke risk factor (30% compared with 5%, for all mentions, P < 0.001) in the study in 2000. In the second study in 2003 this urban/rural gradient in stroke knowledge was not observed.
|
Discussion |
|---|
|
TopAbstractMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The most important result of these two studies is the very low proportion of participants mentioning high blood pressure and cigarette smoking—the two established causes of stroke likely to be causing the largest population attributable risks.
Also notable is the high percentage of participants nominating stress and poverty as causes of stroke. Both studies were performed in a period when the ‘transition’ to a market economy was imposing enormous economic burdens on the population, inevitably affecting diet and other lifestyle factors. While the popular identification of poverty as a cause of stroke is consistent with epidemiological research identifying it as a (distal) cause,21 the evidence relating stress to stroke is inconclusive.22
Known biases in the composition of our study populations (under-representation of those with less schooling) would be likely to bias our results in a ‘better informed’ direction. Comparability of our results with those from other studies employing open-ended questions is limited by the fact that in the other studies, reasons for variation in individual risk were sought, whereas in our study it was reasons for regional variation. Bearing this difference in mind it remains notable that the proportions nominating blood pressure and smoking as causes of stroke were substantially higher in these other studies (table 2).
|
Efforts so far made to educate the Bulgarian public about risk factors for stroke appear to have had little effect. Concerted national programmes of public education about the established modifiable causes of stroke should be adopted as a public health priority. Epidemiological research is also needed into the specific reasons for the high level and geographic distribution of stroke risk in Bulgaria.
More generally, in debates about the causes of the west–east gradient in vascular disease, little attention has so far been given to the potential contribution of differences in public knowledge of risk factors. Insufficient knowledge of risk factors deserves recognition as a potentially important contributor to excess vascular mortality in former socialist countries in Europe.
|
Acknowledgements |
|---|
|
TopAbstractMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The ‘Varna Diet and Stroke Study’ is supported by the Wellcome Trust, London, UK. The ‘Salt and Health Study’ is supported by the Open Society Foundation, Sofia, Bulgaria.
We are indebted to all participants of the study, their families and their general practitioners for the cooperation.
Key points
|
|
References |
|---|
|
TopAbstractMethodsResultsDiscussionAcknowledgementsReferences |
|---|
1 Powles JW, Kirov P, Feschieva N, Stanoev M, Atanasova V. Stroke in urban and rural populations in north-east Bulgaria: incidence and case fatality findings from a ‘hot pursuit’ study. BMC Public Health 2002:2:24.[CrossRef][Medline]
2 Rothwell PM, Coull AJ, Giles MF, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004;363:1925–33.[CrossRef][Web of Science][Medline]
3 Tanaka H, Iso H, Yokoyama T, Yoshiike N, Kokubo Y. 9.3 Cerebrovascular disease. In: Detels R, McEwan J, Beaglehole R, Tanaka H, Editors. Oxford Textbook of Public Health. Vol 3. Oxford: Oxford University Press, 2002:1193–226.
4 Becker K, Fruin M, Gooding T, Tirschwell D, Love P, Mankowski T.Community-based education improves stroke knowledge. Cerebrovasc Dis 2001;11:34–43.[CrossRef][Web of Science][Medline]
5 Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on cardiovascular disease risk factors. The Stanford Five-City Project. J Am Med Assoc 1990;264:359–65.
6 Stern EB, Berman M, Thomas JJ, Klassen AC. Community education for stroke awareness: An efficacy study. Stroke 1999;30:720–3.
7 Hux K, Rogers T, Mongar K. Common perceptions about strokes. J.Community Health 2000;25:47–65.
8 Kim JS, Yoon SS. Perspectives of stroke in persons living in Seoul, South Korea. A survey of 1000 subjects. Stroke 1997;28:1165–9.
9 Miller JE. Knowledge of stroke risk factors, symptoms, and treatment among New Jersey adults. N J Med 2001;98:47–53.[Medline]
10 Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. J Am Med Assoc 1998;279:1288–92.
11 Parahoo K, Thompson K, Cooper M, Stringer M, Ennis E, McCollam P. Stroke: awareness of the signs, symptoms and risk factors-a population-based survey. Cerebrovasc Dis 2003;16:134–40.[CrossRef][Medline]
12 Ramsden VR, Shuaib A, Reeder BA, Khan K, Liu L. Risk factor awareness: a randomized telephone survey of public knowledge. Can J Public Health 1994;85(Suppl 2):S57–S60.
13 Reeves MJ, Hogan JG, Rafferty AP. Knowledge of stroke risk factors and warning signs among Michigan adults. Neurology 2002;59:1547–52.
14 Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledge of the warning signs and risk factors for stroke. J Am Med Assoc 2003;289:343–6.
15 Sug YS, Heller RF, Levi C, Wiggers J, Fitzgerald PE. Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population. Stroke 2001;32:1926–30.
16 Wiszniewska M, Swiderski W, Fryze W, et al. [Knowledge of stroke problems among adults in Poland]. Neurol Neurochir Pol 2000;34:1129–36.[Medline]
17 Cheung RT, Li LS, Mak W, et al. Knowledge of stroke in Hong Kong Chinese. Cerebrovasc Dis 1999;9:119–23.[CrossRef][Medline]
18 Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement. South Med J 2001;94:613–8.[Web of Science][Medline]
19 Segura T, Vega G, Lopez S, Rubio F, Castillo J. Public perception of stroke in Spain. Cerebrovasc Dis 2003;16:21–6.[CrossRef][Medline]
20 Tulevski B, Vasilevski N, Vukov M, Kostova S, Ivanova V. Risk factors and health of the population aged 25 to 64 years in the demonstration area Lovech of the Programme CINDI-Bulgaria (in Bulgarian). Promotsia na Zhdrave (Health Promotion, Sofia) 1998;3:1–90.
21 Davey Smith G, Hart C, Blane D, Hole D. Adverse socioeconomic conditions in childhood and cause specific adult mortality: Prospecitve observation. Br Med J 1998;316:1631–5.
22 Truelsen T, Nielsen N, Boysen G, Gronbaek M. Self-reported stress and risk of stroke: the Copenhagen City Heart Study. Stroke 2003;34:856–62.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  J. Joubert, L. F. Prentice, T. Moulin, S.-T. Liaw, L. B. Joubert, P.-M. Preux, D. Ware, E. Medeiros de Bustos, and A. McLean Stroke in Rural Areas and Small Communities Stroke, June 1, 2008; 39(6): 1920 - 1928. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||