3.1 Public knowledge of stroke as an emergency

Public knowledge of stroke symptoms and awareness that stroke is a medical emergency and a treatable condition is poor. Nearly one in five people (19%) were unable to identify any stroke symptom, according to a large survey covering Austria, France, Germany, Italy, the Netherlands, Poland, Russia, Spain, and the UK.  Of the 14 symptoms presented, no one symptom was recognised by more than half of the respondents. Only 51% would call an ambulance when someone has a stroke[188].

Numerous country-level or regional studies from across all of Europe support these findings of poor stroke symptom knowledge (Bulgaria[189], Croatia[88], Czech Republic[96, 190], Denmark[89], Estonia[90], France[191], Germany[91], Greece[92], Ireland[192], Italy[193], Lithuania[194], Portugal[195], Spain[196], Sweden[197], UK[198]). Two studies found a higher level of education related to higher awareness[90, 197]). There was no difference between urban and rural populations in a Croatian study[88]). Men were found to have poorer knowledge of stroke symptoms than women[89].

Poor public awareness is a common cause of pre-hospital delays. An Italian study found underestimation of symptoms to be responsible for 49% of late admissions to their stroke unit[199]. A Dutch study found that, for their patients, most of the pre- hospital delay was due to patients delaying contacting emergency services. That study estimated that 24% of stroke patients could receive thrombolysis if delays were avoided, compared to 7% actually receiving treatment[187].

The European Stroke Organisation(ESO) guidelines recommend awareness raising programs and most countries have undertaken public campaigns to improve the public knowledge of stroke symptoms and the appropriate response.

One of the best known national campaigns is the award-winning Act FAST public health campaign launched by  the  Department of Health in the UK in 2009, including  mass media advertisements aimed at the general population as well as primary care physicians.

This campaign  subsequently  served  as a template for similar campaigns in other European countries (Austria, Belgium, Ireland, Macedonia, Malta, Serbia, Slovenia, and Spain). Many European countries have introduced awareness-raising activities around a national  Stroke  Awareness Day, often linked to World Stroke Day (https://www.worldstrokecampaign.org).

Example from Czech Republic: HOBIT Programme
“We have initiated and conducted the HOBIT program (acronym for HOdina BIologie pro živoT) to increase the response to stroke and heart attack symptoms in school children. HOBIT 1 started in 2009 and finished in July 2015 and confirmed excellent feasibility and sufficient efficacy of the innovative web-based multimedia education program for children. We now propose a population-based intervention (HOBIT 2), which will educate[…] also their adult relatives. The intervention tool will be the existing e-learning programme customised for adults. Efficacy will be tested by randomizing adult into target group (education + testing) and control group (testing). HOBIT 2 will result in a scientifically proven educational platform and communication strategy that can be applicable nation-wide”.[9]

There is little research that measures the impact of these campaigns. Some studies use a reduction of pre-hospital  delays as a proxy for the campaign’s impact. Evaluating the UK Act FAST campaign, a marked improvement in early presentation was seen, coinciding with the start of the campaign, as well as increased awareness of stroke symptoms[200, 201].

The Irish FAST campaign showed an initial impact on emergency department attendance of stroke patients, but these effects were not sustained in the long term[202].  While  some  found  improvements in stroke symptom awareness following their campaign[91, 203, 204], others had negative results[96].

Overall, evaluation of public awareness programs tends to be poor and often doesn’t include their impact on people’s behaviour[205]. However, literature reviews on the effectiveness of stroke educational campaigns, including some European studies, generally found the potential to improve knowledge and change behaviour[205, 206]. There is therefore a need to systematically assess the public health campaigns undertaken across Europe, in order to prove their respective effectiveness and improve their impact accordingly.