Changing the strategy and culture of stroke awareness education in China: implementing Stroke 1-2-0

Global, regional, and national burden of ischemic stroke in older adults (≥60 years) from 1990 to 2021 and projections to 2030

Background

Ischemic stroke is a leading cause of disability and mortality among adults worldwide, particularly in the older population (≥60 years). With the accelerating global aging population, it is crucial to analyze the trends and influencing factors of the global, regional, and national burden of ischemic stroke and forecast future trends. These insights are essential for informing the formulation of public health policies.

Methods

Using data from the Global Burden of Disease (GBD) 2021 database, this study examined the age-standardized incidence, age-standardized prevalence, age-standardized mortality, and age-standardized disability-adjusted life years (DALYs) of ischemic stroke in individuals aged 60 years and above from 1990 to 2021. A combination of variables, including the socio-demographic index (SDI), sex, and age groups, was applied in regression analyses and Bayesian predictive models to examine trends and forecast the burden of ischemic stroke up to 2030.

Results

From 1990 to 2021, despite global population growth among older adults, the age-standardized incidence, age-standardized prevalence, age-standardized mortality, and age-standardized disability-adjusted life years of ischemic stroke demonstrated an overall declining trend (all EAPCs were negative). The decline in disease burden was most pronounced in high-SDI regions, while low-SDI regions faced a significantly higher disease burden and exhibited notable regional disparities. The overall burden of ischemic stroke was higher in males than in females; however, in the 80-84 age group, females exceeded males in disease burden. Projections indicate that by 2030, the burden of ischemic stroke in older adults globally will continue to decline. Nevertheless, due to the aging population, the absolute number of patients is expected to increase.

Conclusion

The global burden of ischemic stroke has significantly decreased, particularly in high-SDI regions with abundant healthcare resources. However, low-SDI regions face more substantial public health challenges. It is recommended to enhance the control of high-risk factors such as hypertension, smoking, and high BMI, and to optimize healthcare services in low-income regions to further reduce the burden of ischemic stroke and improve the quality of life for older adults.

Stroke 1-2-0-3-6: rapid identification and timely action for stroke in China

In 2016, doctors in China proposed the Chinese version of FAST, called Stroke 120, to improve stroke identification and response in the Chinese population. And we modified Stroke 120 by adding "3" and "6" which aimed to reduce the prehospital delays and improve the prognosis of patients with stroke.

Research progress on influencing factors and intervention measures of pre-hospital delays in acute ischemic stroke

BackgroundStroke, a leading cause of health impairment globally, sees intravenous thrombolysis as the primary treatment during the acute phase, yet delays persist due to pre-hospital and in-hospital factors. While research has reduced in-hospital delays significantly, pre-hospital delays remain a concern both domestically and internationally.ObjectiveThis article aims to provide a comprehensive review of the research progress on the influencing factors and intervention measures of pre-hospital delays in acute ischemic stroke.MethodsBy analyzing the literature, summarize the risk factors leading to treatment delay in acute ischemic stroke (AIS), and provide a review of potential improvement methods.ResultsPre-hospital delay in acute ischemic stroke (AIS) is influenced by both objective factors like age, gender, and regional economic status, as well as subjective factors such as stroke awareness. The introduction of "Stroke 120," a stroke education slogan tailored to Chinese language habits, aims to improve stroke awareness and address delayed treatment and low AIS venous thrombolysis utilization among the Chinese publicConclusionIn conclusion, collaborative efforts from the government, society, and hospitals are essential to enhance stroke education comprehensively. This will ensure widespread awareness of stroke knowledge, facilitating timely and effective treatment for AIS patients.

Health literacy in stroke disease: A systematic review

BACKGROUND

Health literacy has been demonstrated to be a factor that influences patients' ability to retain clinical education and counselling.

AIMS

To describe: (1) the importance of health literacy in the prevention of stroke; (2) the correlation of risk factors with health literacy; and (3) the importance of health literacy in post-stroke outcomes.

METHODS

A systematic review was conducted using the following databases: PubMed (via Medline), CINAHL (via EBSCO), PsycINFO (via EBSCO), and Web of Science (via EBSCO) for studies focused on health literacy in stroke. We included qualitative, quantitative and observational studies. The critical appraisal tool of JBI-Checklists was used to assess the methodological quality of the included studies.

RESULTS

Thirty-three studies, involving 35,935 participants, were selected for this systematic review. Most of the studies (41 %) were cross-sectional. Health literacy levels among the general population and stroke patients were found to be relatively low, indicating the need for increased stroke education. Hypertension and stress were the most frequently identified risk factors while pregnancy and oral contraceptives, and anticoagulants were the least. People at risk of stroke have indicated a desire for more practical information and individually tailored behavioral interventions.

CONCLUSIONS

The results of this study highlighted the deficiency in health literacy among different populations. We noticed that even a simple educational intervention can help to improve health literacy. Targeting the general public is important in order to rapidly translate knowledge into action and to reduce the time from symptom onset to hospital arrival as time plays an important role in stroke.

Factors affecting stroke pre-hospital delay behavioral intention among community residents: A path analysis

BACKGROUND

Pre-hospital delay is the major cause of stroke treatment delay, and behavioral intention is considered to be the most direct predictor of behavior. Therefore, to effectively reduce stroke pre-hospital delay, it is essential to further understand the relationship between stroke pre-hospital delay intention (SPDBI) and its social-psychological influencing factors, namely personality traits, social support and coping style.

AIM

This study aims at examining the relationships among personality traits, coping style, social support, and SPDBI.

METHODS

A cross-sectional, self-administered questionnaire was distributed to 845 residents. The content of the questionnaire included demographic information, the knowledge of "Stroke 120", Ten-Item Personality Inventory-Chinese version, Simplified Coping Style Questionnaire, Perceived Social Support Scale and SPDBI Scale. Path analysis was used to investigate the relationship among SPDBI and its psychosocial influencing factors.

RESULTS

The final path model showed a good fit to the data (χ2/df = 2.981, RMSEA = 0.048, GFI = 0.936, CFI = 0.941). Extroversion (β = 0.106), positive coping (β = -0.110), negative coping (β = 0.150) and the knowledge of "Stroke 120" (β = -0.152) had only direct effects on SPDBI. While agreeableness (β = 0.113), openness (β = -0.121) and social support (β = -0.118) had direct effects on SPDBI, they also had indirect effects (β = -0.009; -0.022; -0.049) on SPDBI though positive coping.

CONCLUSIONS

Adequate social support and positive coping of health threat may reduce residents' SPDBI. Meanwhile, the interventions to reduce SPDBI should take personality differences into consideration.

Barriers to Effective Prehospital and Hyperacute Stroke Care in India: A Physician Perspective

Introduction

The incidence of stroke is increasing in India. Prehospital stroke care is crucial for reducing stroke morbidity and mortality, but its implementation in India faces several challenges. Limited original research exists on prehospital stroke care in India, making it essential to identify the problems in implementing effective prehospital stroke care.

Methods

A web-based survey was conducted among registered medical practitioners in India who treat acute stroke. The survey questionnaire was developed in English and included 26 questions divided into five parts: questions about the physician's practice setup/hospital in India, perception of community awareness, existing prehospital care/systems, in-hospital stroke care availability, and specific issues faced.

Results

Eighty-three doctors in India participated in the survey (43% response rate). Most of the respondents worked in private hospitals (68%) and urban areas (76%). While 89% of hospitals had ambulance services, over 33% reported that patients had to pay for ambulance transport. Among respondents, 12% reported a community stroke care network, with infrequent prehospital procedures such as random blood glucose measurement (22%), stroke identification (15.7%), "last seen normal" documentation (14.5%), and low prehospital notification to hospitals (5%). Delays in referral from peripheral centers were reported by 73% of respondents. Most hospitals had standard operating procedures (SOPs) (84%), computed tomography (CT) (94%), magnetic resonance imaging (MRI) (85%), and offered intravenous thrombolysis (IVT) (77%). However, 24 h availability of CT was reported only by 6%, MRI by 19% and IVT by 12%. Nearly half (45%) reported treatment with thrombolysis was not covered by insurance. Mechanical thrombectomy was available in 34% of hospitals and 63% of hospitals conducted in-hospital audits for stroke patients.

Conclusions

The capabilities of stroke-catering hospitals in urban settings are encouraging, with many having SOPs, imaging capabilities, and thrombolysis and mechanical thrombectomy services. However, there is much room for improvement, in making the essential stroke care services financially accessible to all and available around the clock.

Knowledge and awareness of stroke in rural and urban communities

INTRODUCTION

The average stroke morbidity rate, especially in rural communities, is higher when compared to the national average.

OBJECTIVE

Identify the profile of knowledge and awareness of stroke in rural and urban communities and analyze the differences between the two.

METHOD

Respondents who met the requirements answered a questionnaire containing a total of 41 items regarding knowledge and awareness of stroke. Characteristic data obtained includes age, gender, education, occupation, and ethnicity. Differences in characteristics were analyzed using Mann-Whitney, and the profiles of knowledge and awareness of stroke in rural and urban groups were analyzed using independent t tests to see differences between the two.

RESULT

Differences in the characteristics of rural and urban groups were only in education (p = 0.036) and occupation (p = 0.021). The mean score of the knowledge domain for the rural group was 72.53 (SD = 11.04), for the urban group it was 81.06 (SD = 11.12). The mean score awareness of stroke domain in the rural group was 72.18 (SD = 11.01), the urban group was 85.51 (SD = 11.67). The profile of knowledge and awareness of stroke in rural communities was significantly lower than in urban communities. The significance value was (p = 0.004) for knowledge and (p = 0.002) for awareness of stroke.

CONCLUSION

Based on the findings, it is reasonable to suspect that educational and occupational factors contribute to differences in the profile of knowledge and awareness of stroke in the two groups. Therefore, the stroke awareness campaign strategy for rural communities needs to be specifically designed by emphasizing/considering educational and occupational factors.

mHealth App to improve medication adherence among older adult stroke survivors: Development and usability study

Background

Effective medication adherence is vital for older adult stroke survivors, yet 20-33% cease treatment within a year post-discharge, increasing risks of recurrent strokes and mortality. A mobile health (mHealth) app could be a novel tool to improve medication adherence among stroke survivors because of its potential to increase patient empowerment. A few stroke-related apps provide information and support to stroke survivors. However, none have focused on medication adherence and documented their development and evaluation process, particularly those focused on this older population.

Objective

This study aims to design and develop a smartphone app called OASapp to improve medication adherence among older adult stroke survivors and evaluate its usability.

Methods

OASapp was developed in a three-phase development process. Phase 1 is the exploration phase (including a cross-sectional survey, a systematic review, a search for stroke apps on the app stores of Apple App Store and Google Play Store, and a nominal group technique). In phase 2, a prototype was designed based on the Health Belief Model and Technology Acceptance Model. In phase 3, Alpha and Beta testing was conducted to validate the app.

Results

Twenty-five features for inclusion in the app were collected in round one, and 14 features remained and were ranked by the participants during nominal group technique. OASapp included five core components (medication management, risk factor management, health information, communication, and stroke map). Users of OASapp were satisfied based on reports from Alpha and Beta testing. The mean Usability Metric for User Experience (UMUX) score was 71.4 points (SD 14.6 points).

Conclusion

OASapp was successfully developed using comprehensive, robust, and theory-based methods and was found to be highly accepted by users. Further research is needed to establish the clinical efficacy of the app so that it can be utilized to improve clinically relevant outcomes.

Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team

BACKGROUND

Stroke is one of the leading causes of death worldwide, especially in developing countries. In China, there is an urgent need to educate people about stroke awareness and the importance of using emergency medical services (EMS) quickly after a stroke has occurred.

OBJECTIVE

We sought to explore the effects of the Stroke 1-2-0 Prehospital Stroke Education System based on the experience of a general practitioner team.

METHOD

We prospectively enrolled 119 community general practitioners to be trained in the procedures advocated by the Stroke 1-2-0 Prehospital Stroke Education System. The training content included early detection of ischemic stroke, first aid for stroke, and intravenous thrombolysis; The effects of the training were later evaluated via a before-and-after comparison. The 119 enrolled physicians formed a Stroke 1-2-0 lecturer group and taught stroke knowledge to community residents. The group remained active for 6 months, during which the medical treatment data of stroke patients (i.e., stroke onset time, prehospital delay, whether an ambulance was called, and whether thrombolytic therapy was performed) in each of 5 jurisdictions were recorded for the month before (January 2021) and that after (August 2021) the 6-month community education program. Finally, the effects of the community education program were evaluated.

RESULTS

The participants' understanding of intravenous thrombolysis in the treatment of acute ischemic stroke improved significantly after the training as compared with their earlier understanding (96% vs. 78.99%; P < .001), and their understanding of the time window for intravenous thrombolysis increased from 26.05% before to 72% (P < .001) after the training. Most of the participants (90% vs. 67.23%; P < .001) said that they would immediately call the 120 emergency number of China's emergency phone system if they encountered individuals who appeared to be victims of acute stroke. A total of 82 stroke patients were seen before and 67 after the community education program. As for the use of the emergency call system, more patients with stroke activated that system after the program versus before (21.95% vs. 37.31%; P = .04). The 3-hour arrival rate after the program was nearly three times higher than that before the program (62.69% vs. 19.51%; P < .001). Also, regarding receiving thrombolysis after the occurrence of a stroke, the program triggered a substantial increase compared with the total earlier (19.4% vs. 6.1%; P = .013).

CONCLUSION

We found that the Stroke 1-2-0 Prehospital Stroke Education System significantly improved community residents' knowledge regarding stroke.

Evaluation of stroke health education for primary school students in Dali, China

Objectives

To provide us with some evidence to develop more targeted stroke intervention strategies, improve the health awareness of stroke among children, and advocate the health promotion campaign of “small hands holding big hands” among parents and children, we have conducted a health education program on stroke among primary school students in Dali.

Methods

This study has applied stratified random cluster sampling in Dali of Yunnan, China. We compared the improvement of students' knowledge of stroke before and after our health education program in primary school students of Dali in October 2020. Data were collected through 3 rounds of survey by using the same questionnaire.

Results

There were 215 participants aged 7–8 years old sampled in the first phase of the study and 145 participants in the follow-up study. The knowledge of stroke among the participants was relatively low in the pre-intervention survey. After the health education, all the indicators on stroke knowledge were improved. The correct rates in stroke definition, sequelae, and “1-2-0” identification were increased from 0 to 66.05%, to 53.95% and 64.19%, respectively, in both pre-intervention and post-intervention surveys. The correct rate of stroke knowledge was about 4.83–92.41% 3 months after the intervention. The mean score of the questionnaire was 4.25 ± 0.19 in the pre-intervention survey, and that was 15.85 ±0.27 in the post-intervention one. The mean score was 14.02 ± 0.28 post-3-month test. The score in the 3-month survey after the intervention was 11.55% lower than that in the post-intervention score.

Conclusions

The effect of stroke-related knowledge in the health education program for children is improved significantly and this can last for 3 months but it also had attenuation. We should repeat pertinent health education among students.

Design and validation of a new scale for prehospital evaluation of stroke and large vessel occlusion

Background

Rapid recognition of acute stroke and large vessel occlusion (LVO) is essential in prehospital triage for timely reperfusion treatment.

Objective

This study aimed to develop and validate a new screening tool for both stroke and LVO in an urban Chinese population.

Methods

This study included patients with suspected stroke who were transferred to our hospital by emergency medical services between July 2017 and June 2021. The population was randomly partitioned into training (70%) and validation (30%) groups. The Staring-Hypertension-atrIal fibrillation-sPeech-weakneSs (SHIPS) scale, consisting of both clinical and medical history information, was generated based on multivariate logistic models. The predictive ability of the SHIPS scale was evaluated and compared with other scales using receiver operating characteristic (ROC) curve comparison analysis.

Results

A total of 400 patients were included in this analysis. In the training group (n = 280), the SHIPS scale showed a sensitivity of 90.4% and specificity of 60.8% in predicting stroke and a sensitivity of 75% and specificity of 61.5% in predicting LVO. In the validation group (n = 120), the SHIPS scale was not inferior to Stroke 1-2-0 (p = 0.301) in predicting stroke and was significantly better than the Cincinnati Stroke Triage Assessment Tool (C-STAT; formerly CPSSS) and the Prehospital Acute Stroke Severity scale (PASS) (all p < 0.05) in predicting LVO. In addition, including medical history in the scale was significantly better than using symptoms alone in detecting stroke (training group, 0.853 versus 0.818; validation group, 0.814 versus 0.764) and LVO (training group, 0.748 versus 0.722; validation group, 0.825 versus 0.778).

Conclusion

The SHIPS scale may serve as a superior screening tool for stroke and LVO identification in prehospital triage. Including medical history in the SHIPS scale improves the predictive value compared with clinical symptoms alone.

Analysis of Time to the Hospital and Ambulance Use Following a Stroke Community Education Intervention in China

Importance

Prehospital delay (time from symptom onset of stroke to the door of a hospital) in patients with stroke is long in China. With the goal of improving public awareness and knowledge of stroke recognition, Stroke 1-2-0 was developed in China as an education program to prompt rapid response to the onset of stroke based on clinical practice in China, and examination of its outcomes is needed.

Objective

To investigate the association of the Stroke 1-2-0 educational campaign with prehospital delay for patients with ischemic stroke.

Design, Setting, and Participants

In a population-based cross-sectional study, all patients with ischemic stroke events were admitted to the Minhang Hospital, which is the only tertiary care hospital with a stroke center that provides acute stroke care in Xinzhuang county, Shanghai, China. The study period was from January 1, 2016, to December 31, 2019, and data analysis was performed from January 1 to July 31, 2021.

Exposures

A multifaceted Stroke 1-2-0 educational campaign comprising slides, videos, brochures, and posters distributed in the community.

Main Outcomes and Measures

Proportion of patients with hospital arrival within 3 hours and use of an ambulance to seek medical care, as well as the odds of seeking medical attention within 3 hours after the stroke before vs after initiation of the multifaceted educational campaign.

Results

A total of 2857 patients (1774 men [62.1%]; mean [SD] age, 69.83 [12.66] years) with stroke were identified, including 503 in the precampaign period and 2354 in the postcampaign period. Following the multifaceted campaign, the median (IQR) prehospital delay time decreased from 18.72 (7.44-27.84) hours to 6.00 (2.00-16.35) hours (P < .001). After the implementation of the Stroke 1-2-0 campaign, the proportion of patients with hospital arrival time within 3 hours increased from 5.8% to 33.4% (P < .001) and use of an ambulance increased from 3.2% to 30.6% (P < .001). In an interrupted time series analysis, the initiation of the Stroke 1-2-0 campaign was associated with significantly increased odds of arriving at the hospital within 3 hours (odds ratio, 8.01; 95% CI, 7.17-8.95; P < .001) and use of an ambulance (odds ratio, 9.41; 95% CI, 8.24-10.74; P < .001).

Conclusions and Relevance

The persistent multifaceted campaign using the Stroke 1-2-0 program was associated with reduced prehospital delay and improved timely arrival rate and ambulance arrival rate for patients with stroke. These findings suggest that Stroke 1-2-0 can be adopted in other regions of China to possibly improve health outcomes and reduce clinical burdens for all patients with stroke.

Impact of a health campaign on Chinese public awareness of stroke: evidence from internet search data

INTRODUCTION

Health campaigns have the potential to improve public awareness, but their impact can be difficult to assess. Internet search data provide information concerning online health information-seeking behaviour in the population and may serve as a proxy for public awareness to evaluate health campaigns. This study aimed to measure the impact of World Stroke Day (WSD) in China using Baidu search data.

METHODS

Daily search index values (SIV) for the term 'stroke' were collected from January 2011 to December 2019 using the Baidu Index platform. We examined the mean difference in SIV between the 4 weeks surrounding WSD (period of interest) and the rest of the year (control period) for each year by t-test analysis. The mean difference between the period of interest and the control period was also calculated. The joinpoint regression model was used to analyse the trends of internet search activity 30 days before and after WSD for each year (2011-2019). Finally, the top and rising queries related to stroke during the week of the campaign in 2020 were summarised.

RESULTS

A significant mean increase in SIV of 418.5 (95% CI: 298.8 to 538.2) for the period of interest surrounding WSD was observed, 36.2% greater than the SIV during the control period (2011-2019). Short-term joinpoint analysis showed a significant increase in SIV 3 days before WSD, a peak on WSD and a decrease to the precampaign level 3 days after WSD. The rising related queries suggested that the public had increasing concerns about stroke warning signs, stroke prevention and stroke recovery during the campaign.

CONCLUSIONS

The WSD campaign increased internet search activity. These research techniques can be applied to evaluation of other health campaigns. Advancing understanding of public demand will enable tailoring of the campaign and strengthen health management.

Poor awareness of stroke educational tools among older adults in China

BACKGROUND

Stroke 1-2-0 and FAST (Face, Arm, Speech, Time) are two popular stroke educational tools that have been used in many stroke promotion campaigns. However, few researchers have investigated awareness of these tools among older adults in communities.

METHODS

This study was a cross-sectional survey of community-living older adults. Two family physicians conducted face-to-face interviews with older adults living in Minhang district, Shanghai, between October 1, 2020 and November 31, 2020. The survey comprised three parts: basic information, prior medical history, and stroke awareness knowledge. We focused on the awareness of FAST and Stroke 1-2-0 and investigated factors associated with awareness of these stroke educational tools.

RESULTS

The sample of this study was 466 older adults. Their mean age was 73.45 years. Male respondents accounted for 46.14% of the total sample. More than half of the older adults surveyed had an educational background of less than 6 years. Over 90% of the older adults surveyed had never heard about Stroke 1-2-0 or FAST. The awareness rate of Stroke 1-2-0 and FAST was 7.94%, with awareness of Stroke 1-2-0 being higher than that of FAST (6.01% vs. 0.43%, p < .05). None of the respondents who had heard about the two stroke educational tools could explain the utility of either tool fully. Having a background in higher education was associated with awareness of stroke educational tools independently, with an odds ratio (OR) of 10.07, 95% confidence interval (CI) of 3.7-27.4, p < .001. In addition, Wechat (OR 6.57, 95%CI 2.65-16.27, p < .001) and the community bulletin board (OR 2.95, 95%CI 1.37-6.33, p = .005) were found to be important sources for acquiring knowledge of stroke awareness tools.

CONCLUSION

The limited awareness of Stroke 1-2-0 and FAST displayed among older adults in the community indicates that we must take action to improve education on stroke among the elderly.

Age-Related Disparities in Stroke Knowledge Among Community Older Adults

Background: This study aimed to investigate the disparities in stroke knowledge between older adults and the oldest old. Methods: Family physicians conducted a cross-sectional survey through face-to-face interviews with the older and oldest old adults of two suburban communities in the Minhang district, Shanghai between October 1, 2020, and November 30, 2020. All participants were classified as oldest old (age ≥80 years) and older adults (age 60-79 years). Between-group differences in stroke knowledge were investigated by multivariate logistic regression analysis. Results: Overall, 466 older adults including 101 (21.67%) oldest old persons were qualified. Older adults were more familiar with the risk factors and symptoms of stroke than the oldest old. By multivariable logistic regression analysis, older adults were more familiar with the following risk factors: smoking [odds ratio (OR) 0.32, 95% confidence interval (CI) 0.16-0.61], alcohol abuse (OR 0.45, 95% CI 0.23-0.87), dyslipidemia (OR 0.51, 95% CI 0.31-0.85), and obesity (OR 0.30, 95% CI 0.17-0.53) than the oldest old. Regarding stroke symptoms, older adults were more aware regarding vision alteration (OR 0.42, 95% CI 0.25-0.69) and face-drop (OR 0.57, 95% CI 0.35-0.95) than the oldest old. The oldest old were less aware of acute stroke therapy (OR 0.11, 95% CI 0.02-0.48) and calling the emergency medical service (OR 0.30, 95% CI 0.12-0.70) than older adults. Finally, the older adults used television (OR 0.53, 95% CI 0.28-1.0), WeChat (OR 0.21, 95% CI 0.05-0.89), and the community bulletin board (OR 0.43, 95% CI 0.23-0.80) as knowledge sources more than the oldest old. Conclusion: The older adults and the oldest old had significantly high disparities in stroke knowledge. Given the aging population across China, the life expectancy is expected to be longer in future decades. These differences should be addressed in stroke educational campaigns targeting the oldest old.

Impact of regional differences in stroke symptom awareness and low-income status on seeking emergency medical service in China

BACKGROUND

Unawareness of stroke symptoms and low income are two barriers that affect the seeking of emergency medical service (EMS). This study aimed to assess the effect of unawareness and low income on seeking EMS and to investigate the regional distribution of the unawareness and low-income status and their associations with failing to call EMS in China.

METHODS

A total of 187,723 samples from the China National Stroke Screening Survey was interviewed cross-sectionally. Four status of awareness and annual income were identified: unaware and low-income, unaware-only, low-income-only, and aware and regular income. The outcomes were whether they intended to call EMS or not. The regional distribution of each status and their associations with not calling EMS were presented.

RESULTS

The status of unaware and low-income, unaware-only, and low-income-only accounted for 6.3% (11,806/187,673), 11.9% (22,241/187,673), and 21.5% (40,289/187,673) of the total sample, respectively. Not calling EMS was significantly associated with the status of unaware and low-income (odds ratio [OR]: 3.21, 95% confidence interval [CI]: 3.07-3.35), unaware-only (OR: 2.38, 95% CI: 2.31-2.46), and low-income-only (OR: 1.67, 95% CI: 1.63-1.71), compared with the aware and regular income status. The Midwest regions had higher percentages of people in the unaware and low-income status; the East, South, and Central had higher percentages of unaware-only status; the North and Northeast regions had a higher percentage of low-income-only status, compared with other regions.

CONCLUSION

The existence of the regional difference in unawareness and low income justifies the specific stroke education strategies for the targeted regions and population.

Cluster-randomised controlled trial of Stroke 1-2-0 education programme to reduce stroke prehospital delay in China: a study protocol

INTRODUCTION

Stroke is the leading cause of death and disability in China. The median time of stroke pre-hospital delay is more than 15 hours, mainly due to the lack of awareness on stroke symptoms and calling emergency services. We developed Stroke 1-2-0 recognition tool in China, by adapting Face, Arm, Speech and Time. Our preliminary findings suggested that Stroke 1-2-0 can improve public's knowledge of the stroke symptoms, but its impact on the prehospital delay is still unclear. Furthermore, these findings were mainly obtained from Shanghai, one of the largest metropolises in China. However, more than half of population in China lives in the rural area. Given the striking disparities in socioeconomic status and quality of stroke care across the nation, a multicentre trial is warranted.

METHODS AND ANALYSIS

Stroke 1-2-0 education programme will adopt a multicentre, cluster-randomised controlled design. We aimed to recruit 32 communities from 16 counties across China. Each county includes two communities having more than 100 000 residents. The two communities sampled in the same county will be randomly assigned to receive either Stroke 1-2-0 education programme or usual care. The primary objective of this study is to evaluate the impact of Stroke 1-2-0 public education programme in reducing stroke prehospital delay among adults residing in the community, compared with the usual care. The intervention will be implemented for 1 year. The primary outcomes are the symptom onset to hospital arrival time ('onset-to-door time', ODT) and 3-hour hospital arriving rate. We will use an intention-to-treat approach. A linear mixed model will be used to control for potential cluster effects.

ETHICS AND DISSEMINATION

This study is approved by the Shanghai Minhang District Central Hospital Institutional Review Board (Shanghai, China). The findings will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2000040782.

Risk Factors Influencing Seeking Emergency Medical Service in Urban and Rural China Among Participants With a Previous Transient Ischemic Attack

Objective: It is critical to identify factors that significantly impede the correct action of calling emergency medical service (EMS) in the high-risk population with a previous history of transient ischemic attack (TIA) and further explore the urban–rural difference in China.

Methods: Participants with previous TIA from the China National Stroke Screening Survey and its branch study (FAST-RIGHT) were interviewed cross-sectionally (n = 2,036). The associations between the outcome measure of not calling EMS and multiple potential risk factors were examined, including demographic information, live (or not) with families, medical insurance type, urban or rural residence, awareness of stroke symptoms, annual personal income, presence of cardiovascular disease or risk factors, and stroke history in family members or friends. The sample was further stratified to explore the urban–rural difference by their residency.

Results: The proportion of not calling EMS was 36.8% among all participants with previous TIA, and these were 21.7 and 48.4% among urban and rural participants, respectively. Among rural participants, risk factors that were significantly associated with not calling EMS included primary school education [odds ratio (OR) 2.50, 95% confidence interval (CI) 1.89–3.33], living with family (OR 2.09, 95% CI 1.33–3.36), unaware stroke symptoms (OR 2.60, 95% CI 1.81–3.78), and low income (OR 1.57, 95% CI 1.19–2.07). Among urban participants, only low income was significantly associated with an increased risk of not calling EMS (OR 1.74, 95% CI 1.10–2.72).

Conclusions: Rural residents with previous TIA in China had a higher percentage of not calling EMS. Multiple risk factors have been identified that call for targeted intervention strategies.