Original Paper

Received: May 22, 2012

Accepted: September 7, 2012
Published online: November 16, 2012

Eur Neurol 2013;69:8994

DOI: 10.1159/000343805

Stroke Awareness in Two Estonian Cities:

Better Knowledge in Subjects with
Advanced Age and Higher Education
Riina Vibo a Liisa Krv a Merle Vli a Kadi Tomson a Erika Piirsoo a
Siim Schneider b Janika Krv a
a

Department of Neurology and Neurosurgery, University of Tartu, Tartu, and b North Estonia Medical Centre,
Tallinn, Estonia

Key Words
Stroke Awareness Prevention Risk factors

Abstract
Objectives: This study was undertaken to assess stroke
awareness of the Estonian population. Methods: Investigators were asked to fill in an original, closed-ended multiplechoice questionnaire about the definition, risk factors, symptoms and behavior at the onset of stroke by randomly selected subjects in public places of the two biggest cities in
Estonia (Tallinn and Tartu). Results: The study included 355
persons. Most of the respondents knew that stroke is an
acute disease and that one should call the ambulance at the
onset of a stroke. Speech disorder and paresis were the best
known symptoms, while hypertension was the best known
risk factor. There were no differences between the sexes, but
advanced age and higher level of education were related to
higher awareness. Conclusions: The overall knowledge was
better compared to many other studies. Future awareness
campaigns should be addressed to younger subjects with
lower education.
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Introduction

It has been estimated that even with stable stroke incidence rates there will be a marked increase in the number
of stroke events from approximately 1.1 million per year
in 2000 to 1.5 million cases per year in 2025 in Europe [1].
In Estonia, the age- and sex-adjusted incidence of stroke
has declined from 230 per 100,000 in 19911993 to 188
per 100,000 in 20012003 and it is comparable to other
European regions [2, 3].
Early arrival at the hospital is essential for a good outcome [4]. However, several studies have shown that only
about 3040% of ischemic stroke patients arrive at the
hospital within 3 h of stroke onset [57] and approximately 5% of all stroke patients can be treated with intravenous thrombolysis acute stroke treatment with proven efficacy. For those not qualifying for thrombolysis,
early treatment in a stroke unit ensures a better outcome
[8]. The main reason for treatment failure is the patients
late arrival at the hospital [9]. The reasons for late arrival
may be associated with different factors, such as the
awareness of stroke symptoms, knowledge of stroke treatment possibilities, availability of ambulance service and
local medical services [1012]. Numerous studies using
different methods (telephone interviews, face-to-face
Riina Vibo, MD, PhD
8, L. Puusepa St
EE51014 Tartu (Estonia)
E-Mail Riina.Vibo@kliinikum.ee

Table 1. Mean values of answers by gender, educational level and age groups

Gender
Male
Female
Education
Basic/primary
Secondary
Vocational
Higher
Age groups
1019 years
2939 years
4059 years
60 years

Subjects, n (%)

Etiology

Acute onset

Symptoms

Risk factors

Action at onset

109 (31)
240 (69)

0.73
0.66

0.73
0.80

0.42
0.42

0.33
0.42

0.57
0.59

52 (15)
105 (30)
64 (18)
128 (37)

0.34
0.67
0.72
0.81

0.69
0.77
0.78
0.84

0.08
0.39
0.44
0.56

0.22
0.37
0.48
0.44

0.49
0.69
0.61
0.55

81 (23)
112 (32)
90 (26)
68 (19)

0.53
0.62
0.83
0.77

0.72
0.73
0.86
0.88

0.23
0.43
0.54
0.45

0.26
0.40
0.42
0.50

0.59
0.50
0.62
0.72

questioning, internet-based surveys, etc.) have confirmed

low public awareness of stroke warning signs and stroke
risk factors which contribute to late arrival and limited
use of thrombolysis [9, 1321]. A recent study of risk factor awareness among stroke survivors showed that older
patients and those with excellent recovery are at risk for
poor awareness even after stroke [22]. Most frequently,
stroke symptoms are mistaken for those of myocardial
infarction and better knowledge is usually seen among
respondents with a higher educational level [1315].
The aim of the present study was to assess the knowledge of stroke risk factors and symptoms among the Estonian population and to compare the results with data
from other studies.

Results

Methods
An observational study for the assessment of appreciation of
stroke symptoms and risk factors among the Estonian population
was undertaken. For this purpose, an original closed-ended questionnaire was developed. This questionnaire included five questions about the stroke definition, risk factors, symptoms and behavior at the onset of stroke (see Appendix). Several statements
were given in every question block and the respondents had to
choose between correct or incorrect for every statement. Respondents remained anonymous, only age, sex, place of residence, and
level of education were recorded. None of them were medical professionals and no one had previously had a stroke themselves.
Investigators were asked to fill in an original, closed-ended
multiple-choice questionnaire by randomly selected subjects in
streets, shopping centers, libraries and other public places of the
two biggest cities in Estonia (Tallinn and Tartu) among the Estonian-speaking population between October 2008 and February
2009.

90

Every subject received an informative flyer describing stroke

symptoms and risk factor management after completing the selfadministered questionnaire.
For each questionnaire item the distribution of correct/incorrect/unanswered responses is given in proportions. Additionally,
mean values for items are calculated considering the correct answer as value 1, incorrect as value 1 and no answer as zero.
Accordingly, negative mean values indicate a tendency to answer
incorrectly, positive to answer correctly. Differences between
group distributions are tested using the 2 or Fisher test. Group
means are compared using the t test, ANOVA or Kruskal-Wallis
test. The significance level used is 0.05 with Bonferroni correction
for number of questionnaire items and compared groups. Analysis is performed using R [23].
This study was approved by the Ethics Review Committee on
Human Research of the University of Tartu.

Eur Neurol 2013;69:8994

A total of 355 subjects, 232 (65%) in Tartu and 123

(35%) in Tallinn, filled in the questionnaire. The age distributions of patients from the two cities included were
significantly different and therefore the comparison is
not shown. The mean age for men was 40.6 years (SD
19.7) and 39.6 years (SD 21.2) for women. The proportions
and mean values of correct/incorrect/unanswered questions are shown in figure 1. Proportions of patients in
different groups and the mean values of answers by questions according to age and education are shown in table1.
Of the respondents, 85% identified stroke as cerebrovascular disease and they knew it occurs suddenly. The
best known symptoms of stroke were speech disorder (84%
correct) and hemiparesis (83% correct). However, 29% of
Vibo /Krv /Vli /Tomson /Piirsoo /
Schneider /Krv

0.5

Stroke is:

A heart disease
A disturbance in the brains blood supply
A lung disease

Stroke appears suddenly:

Stroke onset is acute

Stroke symptoms are:

Speech disorder
Sudden strong pain in the chest
Paralysis of a limb or side of the body
Palpitation
Shortness of breath

Paralysis of one side of the face, corner of the mouth drops down

The risk factors of stroke are:

Cigarette smoking
High blood pressure
Drinking coffee
Cardiac arrhythmia
Diabetes
Excessive alcohol consumption
Low level of cholesterol in the blood
Insufficient physical activity

When stroke symptoms appear

Wait until the signs subside
one must:
Call the ambulance immediately
Call the family physician
Call a family member or friends who could help
Incorrect
No answer
Correct

0.2

0.4

0.6

0.8

1.0

Fig. 1. Proportions and mean values of correct/incorrect/unanswered questions.

respondents thought that sudden pain in the chest and palpitations are a symptom of stroke and a further 42% identified shortness of breath as a symptom of stroke (fig.1).
Hypertension was the best recognized risk factor for
stroke. Of the respondents, 45% believed that coffee
drinking increases the risk of stroke. When asking for the
action at stroke onset, 99% of the respondents knew that
one should call an ambulance immediately if a stroke has
occurred. However, in addition to the ambulance call,
21% also indicated they would call their general practitioner and 33% would call a friend.
Comparing the distributions of answers from men
and women, no statistically significant differences were
found in any of the 22 questionnaire items.
Considering respondents educational level there were
some differences in response pattern. In the etiology

question the response distribution was different in items

Stroke is a heart disease and Stroke is a disturbance in
the brains blood supply (both p ! 0.001). Differences
were found in the Symptoms question for items speech
disorder, sudden strong pain in the chest, paralysis of a
limb or one side of the body, palpitation and paralysis
of one side of the face, corner of the mouth drops down
(all p ! 0.001). Among the presented eight risk factors,
four were answered differently, namely smoking, high
blood pressure, low level of cholesterol and insufficient
physical activity (all p ! 0.001). In all cases the biggest
discrepancies were between respondents with a higher
education and with a basic/primary education.
When items in the questionnaire were aggregated and
summarized by one question mean value, the group with
the lowest results in each question is the group with the

Stroke Awareness

Eur Neurol 2013;69:8994

91

lowest level of education and the best results were achieved

by respondents with a higher educational level (in questions 13) but also by respondents with vocational education (in question 4) and secondary education (in question
5). Comparing the group with highest education to other
educational levels, the results for questions 1, 3 and 4 are
significantly better than those of basic/primary education (all p ! 0.001).
While comparing the oldest respondents (age group
160) with the three younger age groups, the questions
mean values for the oldest are significantly higher than
for the age group 1020 years for questions 1 and 4 (both
p ! 0.001) and higher than for the age group 2140 years
for question 5 (p = 0.008). For question 3, the results were
significantly different between the age groups (p = 0.006),
but the best results were obtained by the age group 4160
years and the superiority of the oldest group over the
younger age group was non-significant.
About half of the subjects (56 and 51%, respectively)
aged 20 years or younger thought that cigarette smoking
and alcohol abuse are risk factors for stroke whereas 80%
of respondents aged 120 years answered correctly. Only
5 subjects (1.4%) answered all the questions correctly. All
of them were women and 3 of them had higher education.

Discussion

This study, using an original questionnaire for the assessment of public awareness of stroke-related knowledge, showed that the overall awareness of stroke is good
in Estonia and that most people would act correctly if
stroke would occur. The knowledge was best in the age
group 160 years and the lowest among the youngest (10
20 years). The majority of respondents (85%) knew that
stroke is a disturbance in the brains blood supply. This is
comparable with the studies from Australia [9] and the
Czech Republic [21, 23]. The respondents were aware that
stroke occurs suddenly.
In most of the published studies, hypertension is the
best known risk factor for stroke with the exception of a
Bulgarian study [19]. While earlier studies have reported
that 2972% of the respondents answer correctly [1314,
16, 24, 25], 95% of Estonian respondents knew that hypertension is a risk factor for stroke. Similar results were reported by the recent study from the Czech Republic [21].
Also, the questions regarding excess alcohol consumption, cigarette smoking and low physical activity were answered well in our sample. Nevertheless, almost half of
the teenagers did not know that alcohol and cigarette
92

Eur Neurol 2013;69:8994

smoking are risk factors for stroke. This is of crucial importance, because the incidence of stroke in younger ages
in Estonia is two to three times higher compared to other
European countries [7].
Knowledge about diabetes and cardiac arrhythmias,
as stroke risk factors, was lower compared to other risk
factors, but still better than in other similar studies. We
suspect that many of the respondents answering correctly the cardiac arrhythmia question thought that stroke is
a heart disease. This is also confirmed by the fact that a
third of the respondents (mostly younger subjects)
thought that shortness of breath and chest pains are the
symptoms of stroke.
In studies where the respondents have to give the answer by themselves (open-ended questionnaire), the
knowledge of stroke warning signs are usually worse. In
the Michigan study, 80% of the respondents could name
at least one stroke symptom, whereas in Nigeria this
proportion was only 40% [15, 17]. In the Bulgarian study,
only a very small group of respondents was aware about
stroke risk factors like hypertension or smoking [19].
This expresses the significant difference of public
knowledge between developed and developing countries. Speech disorder and one-sided paralysis of a limb
were the best reported stroke symptoms (84 and 83%,
respectively) in our study. Speech disorder also seems to
be the best known symptom of stroke in other series [15,
16, 25].
Previous studies have shown that only about 2729%
of respondents would call an ambulance at the stroke
onset [13, 24]. The best result of our survey was that
nearly all of our respondents would call an ambulance
in the case of a stroke. However, about 54% of respondents with basic and secondary education would additionally call a general practitioner. This may indicate
that those respondents could not finally decide which
action is correct, but still the majority also answered
that they would call an ambulance. This may have been
influenced by the fact that availability of ambulance service is very good in Estonia and is not related to an economic context.
As has been shown by several other studies, stroke
awareness is better among subjects with a higher educational level [1316] and this was also confirmed in our
study.
There are a few limitations of this study. First, we did
not record whether the respondents had any health problems or risk factors themselves (but they had never had a
stroke). The knowledge about stroke risk factors was significantly better for subjects 160 years. Perhaps this
Vibo /Krv /Vli /Tomson /Piirsoo /
Schneider /Krv

might also be related to personal health problems. However, it has been shown that awareness about stroke risk
factors and symptoms among the cardiovascular patients
is about the same as among the ordinary population [18]
and plausibly this shortage did not significantly influence
our results. Secondly, it should be noted that we used a
closed-ended questionnaire where the respondents had
to choose correct answers. It has been shown that this
type of survey gives better results compared to those
where the respondents have to give the answers by themselves [9]. Another possible limitation may be that that
those with smallest awareness of stroke declined to participate in the study while people with reasonable or good
stroke awareness were more likely to participate. However, using the methodology of a face-to-face interview
where respondents did not know in advance the topic of
the questionnaire, there was no possibility to use additional help to answer correctly (as in the case of postal
questionnaires or internet-based surveys). The sample
size of our study is relatively small, because face-to-face
interviews in larger samples are difficult and time-consuming. We conclude that this questionnaire was easy to
use and it well describes the respondents knowledge of
stroke. If the multiple-choice answers are not provided,
the same questionnaire can also be used as an open-ended questionnaire.
A few studies about the time trends of stroke awareness have been published to evaluate the effect of public
campaigns on the knowledge of stroke in a certain population [16, 17, 19]. It was shown that the knowledge of
stroke symptoms was significantly improved, whereas
the awareness regarding stroke risk factors remained unchanged over a 5-year period [16, 17, 19]. Moreover, one
recent survey has proposed that there is a discrepancy
between theoretical stroke knowledge and the reaction in
an acute situation which could mostly depend on the severity of initial symptoms [26].

Appendix
The Questionnaire
Age:
Sex: male/female
Level of education: Primary school/secondary education/
vocational education/higher education
Place of residence: Tallinn/Tartu
Please decide which answer is correct.
Mark the right box in front of every statement.
True False
)
)
)

)
)
)

)
)
)
)
)
)

)
)
)
)
)
)

)
)
)
)
)
)
)
)

)
)
)
)
)
)
)
)

)
)
)
)

)
)
)
)

1. Stroke is:
A heart disease
A disturbance in the brains blood supply*
A lung disease
2. Stroke appears suddenly:
Appears suddenly*
3. Stroke symptoms are:
Speech disorder (dysphasia/aphasia)*
Sudden strong pain in the chest
Paralysis of a limb or hemiplegia*
Palpitation
Shortness of breath/dyspnea
Paralysis of one side of the face, corner of the
mouth drops down*
4. The risk factors of stroke are:
Cigarette smoking*
High blood pressure*
Drinking coffee
Cardiac arrhythmia/atrial fibrillation*
Diabetes*
Excessive alcohol consumption*
Low level of cholesterol in the blood
Low physical activity*
5. When stroke symptoms appear one must:
Wait until the warning signs pass
Immediately call the ambulance*
Call the family physician
Call a family member or friend who can help

* Correct answers.

Conclusion

The overall knowledge of stroke risk factors and symptoms is good in Estonia. However, it is important to organize public campaigns to further improve the awareness
of stroke, especially of younger age groups and subjects
with a lower educational status and thereby increase the
availability of acute stroke treatments, particularly
thrombolysis. National stroke awareness campaigns were
started in 2008 and cardiovascular disease prevention is
a public health priority in Estonia.
Stroke Awareness

Eur Neurol 2013;69:8994

93

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