Awareness of Stroke Risk Factors, Warning Signs, and Preventive Behaviour Among Diabetic Patients in Al-Ahsa, Saudi Arabia

Objectives This study aims to measure the level of awareness about stroke symptoms, risk factors, and preventive health practices that could be taken to reduce the risk of stroke among diabetic patients in Al-Ahsa, Saudi Arabia. Methods A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia in 2020. The sample included a total of 202 male and female Saudi adults aged 18-65 years, with either type 1 or type 2 diabetes mellitus, and living in Al Ahsa, Saudi Arabia. The information was collected randomly through an online questionnaire distributed among patients after getting their contact information from relevant governmental and private diabetes clinics and after signing the informed consent. For awareness and knowledge items, each correct answer was scored one point and the total summation of the discrete scores of the different items was calculated. A diabetic patient with a score less than 60% of the total score was considered to have poor awareness while a score of 60% or more of the total score was considered a good level of awareness. Results A total of 87 (43.1%) participants had an overall good awareness level, while 115 (56.9%) had poor awareness levels. Around 40.6% of the study patients had heard about stroke, 61.9% knew that stroke affects the brain, and 24.3% reported that stroke is higher among males. As for factors associated with stroke, the most reported was high blood pressure (71.8%), followed by diabetes mellitus (69.3%). Exactly 65.8% of participants knew about the mechanism of ischemic stroke and 42.6% reported hemorrhagic stroke. A high percentage of patients (73.1%) realize that they could reduce their risk of stroke. Conclusion The findings of the current study showed that less than half (43.1%) of the Saudi patients with DM had a good awareness level regarding stroke and its related risk factors and warning signs. Older patients (aged 50-65 years) with high social levels (high education and income) and those with a family history of stroke had significantly higher awareness levels. Hypertension, DM, and smoking are the highest reported known risk factors of stroke, and speech disorders are the highest known stroke presentation to the respondents.


Introduction
Diabetes mellitus (DM) is a metabolic disorder characterized by either insulin resistance or the inability of the body to produce a proper amount of insulin or both, resulting in hyperglycemia [1,2]. The prevalence of DM is estimated to be 34% in the Saudi population, while the global prevalence of DM is about 9.3%. The Kingdom of Saudi Arabia has the seventh highest DM prevalence [3][4][5].
DM is considered an independent risk factor for stroke due to the fact that DM causes vascular aging, which leads to microvascular and macrovascular complications. Stroke is a neurological condition, which occurs abruptly due to a pathology in the vessels of the brain or in the vessels from or to the brain. DM is a chronic disease that does not only need medical attention but also requires self-care and a patient's knowledge about the potential secondary illnesses that might be caused by it [6][7][8][9][10][11].
DM is considered a major modifiable risk factor for stroke. Moreover, DM is highly associated with pathophysiological changes including vascular endothelial dysfunction, arterial stiffness, thickening of the capillary basal membrane, and systemic inflammation. Stroke is one of the highlighted macrovascular complications of DM and it is more likely to be associated with type-2 DM [6][7][8][9][10][11]. Furthermore, diabetic patients have twice the risk of developing both ischemic and hemorrhagic stroke compared with those who are non-diabetic, which makes DM accountable for almost one-quarter of all stroke cases [6][7][8][9][10][11]. In addition, diabetic patients who developed stroke have less favorable outcomes [9].
Worldwide, stroke and other cerebrovascular accidents are major health issues with a huge burden at the individual, family, and social levels [8]. Also, the financial burden is a significant issue with an estimated direct medical cost of $273-$818 billion between 2010 and 2030 in the United States alone [8]. Stroke is one of the most prevalent diseases in Saudi Arabia with a prevalence rate of 43.8 per 100,000 in Riyadh and 40 per 100,000 in the Eastern province. In Saudi Arabia, stroke is the third leading cause of death after ischemic heart disease and road injuries [12][13].
A previous study assessed the knowledge of stroke risk factors and warning symptoms among the Saudi general population and found that 63.8% of the participants had a poor knowledge level [14]. Another study conducted among stroke patients at King Abdulaziz Medical City, Riyadh, Saudi Arabia, has shown that more than 50% of the patients were unaware that they were having a stroke. Most of them sought medical care late because of failing to notice signs and symptoms [15].
Therefore, this study aimed to measure awareness levels about stroke symptoms, risk factors, and preventive health practices among patients with diabetes. Subsequently, this will lead to a reduction in the risk of stroke among these patients. The results of the study would be of help to the local health authorities in planning effective educational programs to increase the awareness of these patients. Eventually, this may reduce the burdens and costs caused by stroke.

Materials And Methods
A cross-sectional questionnaire-based study was conducted in Al-Ahsa, Saudi Arabia, from January 1, 2022, to December 31, 2022. The population included both male and female diabetic Saudi adults, 18-65 years of age, living in Al Ahsa, Saudi Arabia. All types of DM were included. The study was approved by the Research Committee of King Fahad Hospital, Hofuf, AI Ahsa, Kingdom of Saudi Arabia (Approval number: IRB KFHH (H05-HS-065) 46-33-2020).
The calculated sample size was 385 participants, determined by the Richard Geiger equation, with a margin of error determined as 5%, a confidence level of 95%, the population as 1,041,863, and 50% for response distribution. The information was collected randomly through an online questionnaire distributed among patients after getting their contact information from relevant governmental and private DM clinics. All patients signed approval to share in the study after being informed of the study details and its rationale. We obtained responses only from 202 participants.
After data were extracted, they were revised, coded, and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, New York, United States). All statistical analysis was done using two-tailed tests. A p-value less than 0.05 was considered statistically significant. For awareness and knowledge items, each correct answer was scored one point and the total summation of the discrete scores of the different items was calculated. A diabetic patient with a score less than 60% of the total score was considered to have poor awareness while a score of 60% or more of the total score was considered good awareness.
Descriptive analysis based on frequency and percent distribution was done for all variables including patients' demographic data, medical and family history, and smoking. Also, patients' awareness regarding stroke, risk factors, warning signs, and prevention with preferred sources of information were tabulated and graphed. Cross tabulation was used to assess the distribution of knowledge levels according to patients' personal data, medical data, and risk factors. Relations were tested using the Pearson chi-square test and exact probability test for small frequency distributions.

Results
A total of 202 diabetic patients completed the study questionnaire. Patients were aged 18 to 65 years with a mean age of 45.1 ± 16.6 years old. A total of 101 (50%) patients were females and 50% were males. A total of 137 (67.8%) patients were married and 73 (36.1%) were university educated while 66 (32.7%) had a secondary level of education. Considering work, 102 (50.5%) were non-healthcare workers, healthcare workers represented only 5% of the samples, and the rest are students or not working; a monthly income of less than 3000 SR was reported by 77 (38.1%) participants ( Table 1).

FIGURE 1: Overall awareness regarding stroke risk factors, warning signs, and preventive behaviors among the study participants
Exactly 52.3% of the older patients (aged 50-65 yers) had a good awareness level compared to 47.1% of the younger age group, which was was statistically significant (P-value=0.021). Also, 67.5% of patients with high income showed a good awareness level (P-value=0.004). A total of 50.5% of patients with hypercholesterolemia had a good awareness of stroke (P-value=0.044). Additionally, 51.4% of patients with a family history of stroke had a good awareness of the disease (P-value=0.012) ( Table 4). The most preferred source was healthcare personnel (53.2%), followed by the internet (51.7%), family/friends (26.9%), books (19.4%), and television and radio (18.9%) ( Figure 2).

Discussion
The current study aimed to assess diabetic patients' awareness regarding stroke risk factors, warning signs, and prevention in Al-Ahsa, Saudi Arabia. The study showed that less than half (43.1%) of the patients had a good awareness level regarding stroke and its related risk factors and warning signs. More specifically, less than half (40.6%) of the study patients had heard about stroke. About two-thirds (61.9%) of the patients knew that stroke affects the brain, but only one-fourth of them reported that stroke is higher among males.
The literature showed that the prevalence of stroke is higher among men till the age of 80 years, after that it is higher in women. Most of the studies concluded that the case fatality rate is higher in female than in male stroke patients; there is also some evidence, albeit relatively weak, indicating a better functional outcome in men. As for factors associated with stroke, the most reported was high blood pressure, DM, cigarette smoking, and high cholesterol level [16][17][18][19].
Regarding knowing stroke different clinical presentations by the study group, 70.8% reported knowing about speech disorders, 69.8% knew about weakness or disability to move one-half of the body, 64.4% knew about decreased vision, and 62.9% reported knowing about decreased sensation or inability to feel things. A total of 73.1% of the patients knew that they could reduce the risk of stroke. The study also revealed that older patients (aged 50-65 years) with high social levels (high education and income) and those with a family history of stroke had significantly higher awareness levels.
Arisegi et al. showed that 70.3% of diabetic patients had good knowledge of stroke, organs or parts of the body affected by stroke (89.1%), signs or symptoms of stroke (87.0%), stroke risk factors (86.6%), and stroke prevention (90.8%) [20]. Formal education was the sole predictor of good knowledge of the signs or symptoms of stroke. Studies in Nigeria [21,22], the United States [23], and Australia [24] also showed that the majority of the participants had good knowledge of stroke as a disease of the blood vessels in the brain.
Regarding warning signs and clinical presentation, a study in Ghana reported numbness or paralysis as the most common stroke warning sign known to participants [25]. While it also concurs with the findings in studies conducted in Osogbo, Nigeria [22], Benin [26], and Nigeria [27]. It differs from the findings in studies conducted in Australia [24] and Ireland [28] that reported visual problems and slurred speech, respectively, as the most common stroke signs identified. In Saudi Arabia, Alhazzani et al. found that 63.6% and 43.7% of primary health center patients correctly identified thrombosis and hemorrhage, respectively, as types of strokes. The most reported risk factors were hypertension (55.8%), dyslipidemia (45.8%), and smoking (41.9%). Sudden severe headache (54.1%), dizziness (51.0%), and difficulty in speaking (44.3%) were the most frequently recognized symptoms [29]. Another study revealed that the mean knowledge of stroke risk among hypertensive patients was 10.73 ±3.53 while the mean knowledge of warning signs was 9.276±2.99 [30].
The main limitation was the smaller than desired sample size.

Conclusions
The findings of the current study showed that less than half (43.1%) of the patients had a good awareness level regarding stroke and its related risk factors and warning signs. Older patients with high social levels (high education and income) and those with a family history of stroke had significantly higher awareness levels. As for factors associated with stroke, the most reported was high blood pressure, DM, cigarette smoking, and high cholesterol level. Regarding the awareness of stroke clinical presentations, 70.8% knew about speech disorders, 69.8% knew about weakness or disability to move one-half of the body, 64.4% know about decreased vision, and 62.9% knew about decreased sensation or inability to feel things. Finally, formal education was the sole predictor of good knowledge of the signs or symptoms of a stroke. So, further emphasis on the importance of formal education is required.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Research Committee of King Fahad Hofuf, AI Ahsa, Kingdom of Saudi Arabia issued approval IRB KFHH (H05-HS-065) 46-33-2020. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.