Volume 88, Issue 9 , Pages 1214-1216, September 2007
Stroke-Related Knowledge and Health Behaviors Among Poststroke Patients in Inpatient Rehabilitation
Article Outline
Abstract
Koenig KL, Whyte EM, Munin MC, O’Donnell L, Skidmore ER, Penrod LE, Lenze EJ. Stroke-related knowledge and health behaviors among poststroke patients in inpatient rehabilitation.
Objective
To measure stroke knowledge and prestroke personal health behaviors of stroke patients undergoing inpatient rehabilitation and their caregivers.
Design
Prospective cohort.
Setting
Academic rehabilitation hospital.
Participants
A total of 130 stroke patients and 85 caregivers interviewed after ischemic stroke.
Interventions
Not applicable.
Main Outcome Measure
The Stroke Education Assessment measured stroke knowledge and prestroke personal health behaviors.
Results
Large deficiencies in patient and caregiver stroke knowledge were found. Fifty-two percent of patients could not name any stroke risk factors, 52% were unable to name a stroke warning sign, and 35% were unable to identify appropriate actions to take in a stroke emergency. Older patients were less knowledgeable than younger patients. Caregivers were more knowledgeable than patients. Regarding prestroke personal health behaviors, 28% of patients reported medication nonadherence, 26% did not see their primary care physician in the preceding year, and less than 40% of patients with diabetes or hypertension reported diets consistent with these diagnoses.
Conclusions
Stroke patients participating in inpatient rehabilitation and their caregivers have large gaps in stroke knowledge and have suboptimal personal health behaviors, thereby putting patients at high risk for recurrent stroke. Our finding highlights the need to develop stroke-education programs for rehabilitating patients that are effective in closing these gaps in knowledge and personal health behaviors.
Key Words: Cerebrovascular accident, Education, Rehabilitation, Stroke
STROKE SURVIVORS ARE at risk for recurrent stroke. However, over one half of stroke survivors are unaware of their increased risk1 and many cannot identify any risk factors.2 Furthermore, many people do not know the signs or symptoms of stroke or what to do if stroke is suspected2, 3, 4, 5 and therefore present to a hospital too late to receive time-sensitive medications that would improve clinical outcome.6
We conducted this study to examine stroke knowledge in inpatients recently admitted to a rehabilitation hospital after stroke and their caregivers as well as to assess patients’ prestroke personal health behaviors. We hypothesized that we would find significant stroke-knowledge deficiencies consistent with those described previously. Furthermore, we used this study to explore patient and caregiver characteristics that correlated with stroke knowledge.
Methods
We prospectively interviewed stroke patients consecutively admitted to an inpatient rehabilitation facility and their caregivers. All patients had experienced an ischemic stroke (first-ever or recurrent) within the preceding 30 days. Patients who were unable to reliably answer interview questions were excluded.
We assessed patients at admission. Some patients had received stroke education in the acute hospital setting; however, this education was limited to the provision of written materials. We measured knowledge of stroke risk factors and warning signs, as well as the most appropriate response to a suspected stroke by using open-ended questions from the Michigan Behavior Risk Factor Survey7 and by using information approved by the American Heart Association. We measured medication adherence in the week before the index stroke by using a validated self-report question.8 We also assessed diet; smoking status; frequency of appointments with a primary care physician (PCP); and knowledge and treatment of hypertension, hyperlipidemia, and diabetes. Stroke location was derived from either the radiologist’s interpretation of any brain-imaging study or the attending neurologist’s clinical determination of lesion location.
Statistical analysis used SPSS.a We used 1-way analysis of variance tests and chi-square tests for continuous and categorical variables, respectively. The study was approved by the institutional review board.
Results
From October 2003 through March 2005, 295 patients were admitted for acute inpatient rehabilitation. One hundred thirty patients and 85 caregivers participated in this study (characteristics presented in table 1). Reasons for exclusion included primary hemorrhagic stroke (n=83); stroke more than 30 days before admission (n=23); administrative reason (n=23); subject unable to reliably answer questions because of medical instability (n=10), aphasia (n=7), severe cognitive impairment (n=7), deafness or blindness (n=4), or inability to speak English (n=3); and refusal of study participation (n=5). Fewer caregivers were interviewed as they were difficult to contact.
Table 1. Patient and Caregiver Demographic and Clinical Characteristics
| Characteristics | Patient (n=130) | Caregiver (n=85) |
|---|---|---|
| Age (y) | 69.7±14.2 (73) | 59.3±15.7(61) |
| % Male | 46.9(61) | 21.5(17) |
| % White | 76(98) | 74.1(63) |
| Marital status (% married) | 74.6(79) | 49.4(42) |
| Length of stay (d) | 16.3±9.5(14) | NA |
| Stroke location | NA | |
| Cortical only | 36.9(48) | |
| Subcortical only | 44.6(58) | |
| Cortical/subcortical | 3.9(5) | |
| Brainstem | 7.7(10) | |
| Unknown | 6.9(9) | |
| No. of subjects with first ever stroke | 110 | NA |
| Insurance type | NA | |
| Commercial insurance: non-MCO | 10.8(14) | |
| MCO or HMO | 15.4(20) | |
| Medicaid: non-MCO | 2.3(3) | |
| Medicaid: MCO | 3.1(4) | |
| Medicare: non-MCO | 51.5(67) | |
| Medicare: MCO | 15.4(20) | |
| Unknown | 1.5(2) | |
| Education (y) | 12.7±2.9(12) | NC |
| Caregiver’s relationship to subject | NA | |
| Spouse | 47.4(40) | |
| Adult child | 38.2(33) | |
| Relative (eg, aunt, uncle) | 1.3(1) | |
| Friend | 2.6(2) | |
| Other (eg, cohabitant) | 10.5(9) |
Knowledge of Risk Factors
Fifty-two percent of patients were unable to name any stroke risk factors. Age (but not race, sex, education, or type of medical insurance) was significantly associated with number of risk factors named (F3,126=6.966, P<.001). Older patients were more likely to name zero (Tukey honestly significant difference [HSD] post hoc, P<.001) or 1 (Tukey HSD post hoc, P=.002) stroke risk factors versus 2 or more risk factors. Among caregivers, 17% were unable to name at least 1 risk factor for stroke. No demographic or clinical characteristics correlated with caregiver knowledge (data not shown).
Knowledge of Warning Signs and Emergent Treatment
Although 99% of patients acknowledged the importance of seeking medical attention, only 65% stated they would call 911 or go to an emergency department if they thought they were having a stroke. Furthermore, 52% were unable to name any warning signs other than symptoms of their index stroke. Twenty percent of caregivers were unable to name at least 1 warning sign for stroke. There was no significant effect of age, race, sex, education, or type of insurance on knowledge of warning signs or of need for emergent treatment for either patients or caregivers (data not shown).
Health Behaviors
Among patients with hypertension (n=94) or type 2 diabetes mellitus (n=44), less than 40% reported following any dietary recommendations before their stroke.
Regarding medication adherence, 14% of patients were not taking any prescribed medications before the stroke, and an additional 8% could not remember if they had missed any doses. Of the remaining 102 patients, 28% reported missing at least 1 pill in the week before their stroke. Eighteen percent of caregivers were unable to comment on the patients’ medication adherence. Of the remaining 70 caregivers, 21% endorsed patient nonadherence in the week before their stroke. Twenty-six percent of patients reported not seeing their PCP in the previous year. Age, race, sex, and type of insurance were not significantly associated with medication adherence or annual PCP visit.
Discussion
We found significant deficiencies in stroke-related knowledge and prestroke health behaviors in patients undergoing inpatient rehabilitation after ischemic stroke. These patients are at risk for poor long-term outcomes because of a lack of knowledge regarding modifiable stroke risk factors and the need to obtain prompt medical attention for subsequent strokes.
Study Limitations
Study limitations include the exclusion of patients with severe cognitive impairment as well as the lack of cognitive assessment; therefore, we cannot comment on the relation of milder cognitive impairment with stroke knowledge and personal health behaviors. We acknowledge that patients’ knowledge could have been greater than what they reported and that recall bias may have affected patients’ descriptions of prestroke personal health behaviors. This study was carried out in a single site, thereby limiting the results’ generalizability. Finally, we do not know which subjects received stroke education during their acute inpatient hospitalization; therefore, we cannot comment on the impact of this education on stroke knowledge.
Our findings show the need for establishing effective patient-education programs. Inpatient rehabilitation offers an opportunity to provide education to stroke patients and families; however, given decreasing length of stay, the best ways to conduct this education, including when, where, and by whom, requires further study.
Conclusions
Patients undergoing inpatient rehabilitation after ischemic stroke show large gaps in stroke-related knowledge and shortcomings in prestroke health behaviors. Patients’ primary caregivers also show poor stroke-related knowledge. Patient and caregiver education programs are needed as a means of promoting patients’ health.
Suppliers
Acknowledgment
We thank Grace Campbell, BSN, RN, CRRN, CBIS, for her help with this research and quality assurance project.
References
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- Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med. 1999;33:3–8
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- . Helping patients follow prescribed treatment. JAMA. 2002;288:2880–2883
- a SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
Supported by the National Institute of Mental Health (grants no. K23 MH 64196, K23 MH 67710).
A commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit upon the author or 1 or more of the authors. Koenig, Whyte, Munin, and Lenze have received consulting fees from Fox Learning Systems Inc.
PII: S0003-9993(07)00388-7
doi:10.1016/j.apmr.2007.05.024
© 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Volume 88, Issue 9 , Pages 1214-1216, September 2007
