Knowledge and practices related to stroke prevention among hypertensive and diabetic patients attending Specialist Hospital, Sokoto, Nigeria

Introduction Stroke has become a problem of public health importance worldwide. Knowledge and practices related to stroke prevention among hypertensive and diabetic patients are important in the control of the disease. In Nigeria, recent reports indicate an emerging epidemic of stroke. This study aimed to determine the knowledge and practices related to stroke prevention among hypertensive and diabetic patients in Sokoto, Nigeria. Methods This was a cross-sectional study among 248 patients attending hypertension and diabetes clinic of Specialist Hospital, Sokoto, Nigeria, selected by systematic sampling technique. A semi-structured questionnaire was used to collect data on the research variables. Data were analyzed using IBM SPSS version 20 statistical package. Results The mean age of respondents was 48.21 ± 15.07 years and they were predominantly females (65.7%). The respondents had good knowledge of stroke (70.3%), organs or parts of body affected by stroke (89.1%), signs or symptoms of stroke (87.0%), stroke risk factors (86.6%) and stroke prevention (90.8%). Formal education was the sole predictor of good knowledge of signs or symptoms of stroke (aOR = 3.99, 95% CI = 1.58-10.13, p = 0.004), stroke risk factors (aOR = 4.24, 95% CI = 1.68-10.67, p = 0.002) and stroke prevention (aOR = 3.45, 95% CI = 1.09-10.93, p = 0.035). Stroke prevention practices were sub-optimal and significantly associated with formal education and being employed. Conclusion These findings suggest the need for all stakeholders to focus on both patients' education and empowerment in halting the rising burden of stroke across the globe.


Introduction
Stroke is a worldwide health problem and a major contributor to morbidity, mortality and disability in both developing and developed countries [1]. Stroke is the third most common cause of death in the world after heart diseases and cancers and the second leading cause of cardiovascular deaths worldwide after ischemic heart disease. The World Health Organization (WHO) estimates show that about 17.3 million people died of cardiovascular diseases (CVDs) in 2012, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart diseases and 6.7 million were due to stroke. Contrary to popular belief, four out of five of these deaths occurred in the low-and middle-income countries and men and women were equally affected [2,3].
According to the Centre for Disease Control and Prevention (CDC), stroke is the leading cause of preventable disability worldwide [4]. It is a major cause of long term disability and has potential enormous emotional and socioeconomic burden for patients, their families and health services. The often long term disabilities that accompany the disease are known to have far-reaching consequences on the wellbeing and quality of life of stroke survivors and their caregivers [5].
In Nigeria, stroke has been reported to account for the majority of medical admissions, with 30-day case fatality rates ranging from 28 to 37% and functional disability rates as high as 60.9% [6][7][8].
Although most of the stroke data in the country are hospital-based due to identified challenges in conducting community-based studies, the high burden of stroke in the Nigerian population, as with populations in other developing countries, has been widely acknowledged. The resultant permanent physical, cognitive and emotional changes from stroke affliction create pressure and lifechanging demands for families and caregivers of its survivor and they are the ones who often bear the brunt of long-term care of stroke survivors, thus making them more likely to experience stress, burden and psychological morbidity [9].
Epidemiological studies have indicated that a stroke does not occur at random, there are risk factors which precede stroke by many years, therefore awareness and good knowledge of these risk factors are very crucial to its prevention. The good news is the fact that 80% of premature heart attacks and strokes are believed to be preventable when necessary precautions and actions are taken [10].
Hypertension is the most important modifiable risk factor for stroke worldwide and the risk of all stroke sub-types increases with increasing blood pressure [11,12]. Hypertension is highly prevalent in Nigeria as in other African countries and constitutes the major risk factor for stroke in the country [13][14][15]. Diabetes is also a modifiable risk factor for stroke; people with diabetes are believed to have a 1.5 to 3 fold risk of stroke compared to non-diabetic subjects [16]. The prevalence of diabetes has been on the increase in many developing countries including Nigeria in recent times, owning in part to growing preference for diet comprising fatty and refined carbohydrates and obesity [15]. One of the main reasons for the rise in stroke as a cause of death is patients' lack of knowledge of the risk factors involved [17]. In addition, there is lack of patients' participation in the management of the disease. This participation demands motivation, knowledge and compliance from the patients since it is a complex lifetime regimen that needs to be followed. Patients who do not have knowledge of the risk factors of stroke are less likely to engage in stroke prevention practices like controlling their blood pressure, and behavioral pattern change such as smoking cessation and consuming a low-salt diet [18].  [20], an 81.1% prevalence of knowledge of risk factors of stroke from a previous study [21], a precision level of 5% and an anticipated response rate of 95%. The eligible study participants were selected by systematic sampling technique. The Internal Medicine Department of the hospital runs the hypertension and diabetes clinic twice a week (Tuesdays and Thursdays), seeing an average of 200 patients per day. One in every 7 consecutive patients presenting at the clinic was selected over a period of 8 clinic days until the required sample size was obtained. If a selected patient declined participating in the study, then the next patient was considered.
A pretested and validated semi-structured, interviewer-administered questionnaire adapted from instruments used in previous studies [5,22] was used to obtain information on study participants' sociodemographic characteristics; knowledge of stroke, its risk factors and prevention; and participants stroke prevention practices. The  (Table 1).
Respondents' perception of stroke: Although, majority, 209 (87.4%) of the 239 respondents knew stroke as a disease of the blood vessels in the brain, about a quarter of respondents (25.5%) misperceived it as a disease of the blood vessels in the kidney, while a few also attributed it to germs (11.7%) and spiritual attack of respondents knew that sudden loss or reduced sensation all over the body (30.5%), and sudden weakness or paralysis all over the body (38.1%) weren't symptoms or signs of stroke (Table 2).  Table 4.

Predictors of good knowledge of signs or symptoms, risk factors and prevention of stroke among the respondents:
Although, there was significant association (p < 0.05) between good knowledge of the signs or symptoms of stroke and age below 50 years, having formal education, and being employed (Table 5), the sole predictor of good knowledge of the signs or symptoms of stroke was having formal education ( Table 6). Respondents that had formal education were approximately four times likely to have good knowledge of the signs or symptoms of stroke as compared to those with none or qurranic education only (aOR = 3.99, 95% CI = 1.58-10.13, p = 0.004). Although, there was significant association (p < 0.05) between good knowledge of stroke risk factors and age below 50 years, having formal education, and being employed (Table 5), the sole predictor of good knowledge of stroke risk factors was having formal education (Table 6). Respondents with formal education were more than four times likely to have good knowledge of stroke risk factors as compared to those with none or qurranic education only (aOR = 4.24, 95% CI = 1.68-10.67, p = 0.002). Although, there was significant association (p < 0.05) between good knowledge of stroke prevention and age below 50 years, female sex, having formal education and being employed (Table 5), the predictors of good knowledge of stroke prevention were having formal education and being employed ( Table 6).
Respondents with formal education were approximately three times likely to have good knowledge of stroke prevention as compared to those with none or qurranic education only (aOR = 2.983, 95% CI = 1.351-6.588, p = 0.007). Similarly, respondents that were employed were more than three times likely to have good knowledge of stroke prevention as compared to those that were unemployed (aOR = 3.45, 95% CI = 1.09-10.93, p = 0.035).  Table 7. Compliance with stroke prevention practices was found to be associated with having formal education (X 2 = 17.327, p < 0.001) and being employed (X 2 = 11.658, p = 0.001).

Discussion
The ages of the respondents in this study ranged from 20 to 91 years with a mean age of 48.21 ± 15.07 years, this compares well with the findings in a study conducted in south-western Nigeria by Komolafe et al [24], in which the ages ranged from 16 to 95 years with a mean age of 53 ± 16 years. Another study by Wahab et al [25], also reported a mean age of 56.4 ± 12.6 years. On the contrary, a younger population with a mean age of 36.8 ± 14 years was observed in a study conducted in Ghana [26]. The preponderance of females in this study (65.7%) could be related to the fact that females have been identified to have good healthseeking behavior compared with males [27]. This is similar to the finding in a study in Uganda where 68% of the study participants were women [28] and another study by Nakibuuka et al [29], where 71.9% of the respondents from urban area and 59.6% from rural area were females. In contrast to the finding in this study, in a study done in Ghana, most of the respondents were males [26].
Unlike the poor perception of stroke reported in previous studies among patients in Nigeria [30,31] and even in community based Page number not for citation purposes 5 studies in the developed countries like United States [16] and Australia [32], majority of the respondents in this study (87.4%) knew stroke as a disease of the blood vessels in the brain. Majority of the respondents in this study were aware of the organ or parts of body affected by stroke (89.1%). Majority of them also had good knowledge of the signs or symptoms of stroke (87.0%), with sudden and severe headache and sudden weakness or paralysis on one side of the body being the most commonly known signs or symptoms of stroke. This is in agreement with the finding in a study in Ghana that reported numbness or paralysis as the commonest stroke warning sign known to respondents [26]. While it also concurs with the findings in studies done in Osogbo, Nigeria [25] and Benin, Nigeria [33], it differs from the findings in studies conducted in Australia [32] and Ireland [34], that reported visual problems and slurred speech respectively as the commonest stroke signs identified. The gaps identified in the knowledge of the signs and symptoms of stroke among the respondents in this study underscore the need for healthcare providers to give sufficient attention to educating their patients on the signs and symptoms of the disease at every clinic visit.
This would enable them seek care early enough, prevent disease progression, and avert fatal complications. Knowledge of stroke risk factors, especially identification of one's personal risk, is believed to play an important role in stoke prevention [35,36]. This study showed good knowledge of stroke risk factors among the respondents (86.6%), with hypertension being the most commonly reported risk factor (92.0%). This finding corroborates the findings in several studies that had consistently identified hypertension as the most important modifiable stroke risk factor or cause of stroke [37][38][39][40]. In contrast to the findings in this study, poor community awareness of stroke causes or risk factors has been reported in studies conducted both in Nigeria [31,34] and other countries across the globe including Brazil [41], Ireland [34], Pakistan [42] and the United States [43]. Although, most of the respondents in this study had good knowledge of stroke risk factors (86.6%) and stroke prevention (90.8%), the fact that only about half of them (54.8%) knew family history as a risk factor for stroke is of serious concern, as it shows that those whose first degree relatives have had stroke are unlikely to perceive themselves to be at an increased risk of the disease, or comply with stroke prevention practices. The importance of first-degree relatives of stroke survivors being aware of being at an increased risk of stroke is supported by the finding of the Lund Stroke Register study that reported higher prevalence of stroke or TIA (12.3%) among first-degree relatives of stroke patients as compared with first-degree relatives of control subjects (7.5%); Odds Ratio (OR) = 1.74, 95% Confidence Interval (CI): 1.36-2.22 [44]. In another large cohort study in China, in addition to family history of stroke being an independent risk factor for stroke, the more first-degree relatives are affected by stroke, the higher the individuals' risk of suffering from stroke [45]. Data from the Nigeria  [48], that reported that knowledge of stroke risk factors was influenced by educational level. Similar to the findings in this study, income and education were also found to be the determinants of knowledge of stroke risk factors in studies conducted in Australia [32], Brazil [41] and Ireland [34]; but this was not the case in a study conducted in Ghana [26]. The good knowledge of stroke prevention demonstrated by most of the respondents in this study (90.8%) with most of them identifying appropriate treatment of hypertensive and diabetes as preventive measures for stroke is reassuring and it is expected to facilitate adherence to treatment among those with these disease conditions.
The significance of adherence to treatment was shown in the findings in studies by Neal et al [49], that reported 35-44% reduction in the incidence of stroke with appropriate treatment of hypertension and Colhoun et al [50], that reported reduction in risk of stroke with appropriate treatment of diabetes. Also, behavioral/lifestyle modifications have been shown to contribute up to 80% reduction in the risk of stroke [51]. Despite the good knowledge of stroke prevention among the respondents in this study, the practice of stroke prevention was sub-optimal among them. Only about half of respondents (50.2%) attend follow up visits at the clinic regularly, approximately two-thirds (66.5%) take Page number not for citation purposes 6 prescribed medication for hypertension or diabetes regularly and just a few (16.7%) take prescribed drugs for heart disease regularly.
The poor adherence to treatment of hypertension and diabetes among the respondents in this study despite knowing the diseases to be risk factors for stroke is of serious concern as it suggests a wide gap between knowledge and practice of stroke prevention among them. Contrary to the finding in this study, another study conducted to evaluate the adherence to anti hypertensive therapy (AHT) and its implications on mortality rate and cardiovascular morbidity in a large cohort of patients in a clinical practice reported significantly lowered risk to death, stroke disabilities or acute myocardial infarction in patients with good and excellent adherence to AHT. Thus, the researchers concluded that the preliminary evidence underline the need to monitor and improve medication adherence in clinical practice [52]. The compliance by majority of the respondents in this study with behavioral/lifestyle measures for stroke prevention such as smoking cessation (85.4%), and reduction in alcohol intake (75.7%) is noteworthy in view of its benefits as reported in a study by Zhang et al [53], that found that adherence to more of elements of healthy lifestyles reduced the incidence of total, ischemic, and hemorrhagic stroke. The significant association between having formal education and compliance with stroke prevention practices in this study differs from the finding in a study in Iran [54], which reported that illiterate people surprisingly had a higher awareness of stroke and were engaged in stroke prevention practices, thus lowering stroke incidence. This finding underscores the need for policymakers, human resource managers and other stakeholders to make education of patients (particularly those with chronic diseases) an essential component of the management protocols at all levels of healthcare services provision; and it should be complemented by public health education through the mass media. Likewise, the significant association between being employed and compliance with stroke prevention practices, particularly adherence to medication, brings to the fore the need for government to alleviate poverty through job creation and provision of credit facilities for small scale enterprises; this would empower the patients to access healthcare services, facilitate compliance with stroke prevention practices, and invariably halt the rising burden of stroke across the globe.
Limitations of the study: Generalization of the findings of this study to the general populace is limited, being a hospital based study among patients accessing care for diseases that are closely related to stroke. The use of questionnaire to obtain information on the participants' self-reported stroke prevention practices seems not to provide enough evidence of their actual practices.

Competing interests
The authors declare no competing interests.  Table 1: Socio-demographic profile of respondents