ABSTRACT
Background and Aim
Stroke is a leading cause of disability and mortality worldwide and represents an increasing public health concern in low‐ and middle‐income countries, including Palestine. Timely detection and immediate intervention are critical for reducing stroke‐related morbidity and mortality. The present study investigates the level of stroke knowledge and its determinants within the Palestinian community.
Methods
A cross‐sectional, structured, questionnaire‐based study of the Palestinian community was conducted from June to December 2025. Participants recruited through a convenience sample technique answered the questionnaire in both electronic and print versions. Stroke knowledge was scored from 0 to 35, with good knowledge defined as ≥ 50%. Statistical analysis included descriptive statistics, Chi‐square test, and binary logistic regression with stroke knowledge as a binary outcome (good vs. poor). Statistical significance was set at p < 0.05.
Results
Among 1539 participants (60.6% female; 58.2% aged 18–29), 54.1% demonstrated good stroke knowledge, with a mean score of 18.35 ± 8.97 out of 35. Notable knowledge gaps were identified regarding risk factors (40.4% with good knowledge), early symptoms (46.7%), and outcomes (47.7%). Hypertension (70.6%) and smoking (55.9%) were the most frequently recognized risk factors. Multivariate logistic regression analysis indicated that discussing stroke risk with a healthcare provider (aOR = 3.20, 95% CI = [2.34–4.37]; p < 0.001), higher education (aOR = 2.67, 95% CI = [1.37–5.20]; p = 0.004), higher income (aOR = 2.83, 95% CI = [1.79–4.47]; p < 0.001), and having a relative with stroke (aOR = 2.15, 95% CI = [1.64–2.83]; p < 0.001) were associated with greater stroke knowledge. In contrast, being married (aOR = 0.67, 95% CI = [0.46–0.97]; p = 0.036), being employed (aOR = 0.64, 95% CI = [0.47–0.87]; p = 0.004), or being a current smoker (aOR = 0.70, 95% CI = [0.52–0.95]; p = 0.02) were associated with lower odds of good stroke knowledge. The internet and social media were the primary sources of information (51.7%).
Conclusion
Stroke symptoms, risk factors, and treatment are poorly understood in the Palestinian community. These findings highlight the need for coordinated public health education and community‐based awareness measures.
Keywords: community, knowledge, Palestine, stroke
1. Introduction
Stroke is the second leading cause of disability and mortality globally [1]. It is characterized by a sudden disruption of blood flow to the brain, resulting in substantial neurological damage and long‐term physical, cognitive, and emotional impairments [2]. The damage caused by stroke extends beyond the affected individuals to families, communities, and healthcare systems. Globally, stroke remains a significant public health concern. Today, the situation is even more concerning, with more than 795,000 stroke incidents reported annually in the United States, including 185,000 recurrent strokes [3]. In Palestine, stroke has been a major and growing public health concern. According to Annual Health Reports of the Palestinian Ministry of Health, cerebrovascular diseases account for approximately 11%–13% of all registered deaths, consistently placing stroke among the five leading causes of mortality nationwide and among the top three causes of death in adults aged 60 years and older [4, 5, 6]. Beyond its contribution to mortality, stroke is a leading cause of long‐term disability, resulting in substantial physical, psychological, and economic burdens for affected individuals, their families, and the healthcare system [2].
Locally available evidence indicates that cerebrovascular diseases are one of the leading causes of morbidity and hospital‐associated mortality in Palestine. For example, a retrospective study on acute ischemic stroke in the West Bank of Palestine reported that hypertension and diabetes are identified as major contributing risk factors [6]. Stroke is responsible for one in every twenty deaths, which is approximately 140,000 deaths annually in the United States. Although stroke primarily affects the older population, it can occur at any age, which makes it extremely important for people across the country to be aware of stroke [7].
Prevention is a very important factor in reducing the global stroke burden, as evidence shows that up to 85% of strokes can be prevented by changing lifestyle and managing risk factors (such as hypertension, smoking, diabetes mellitus, and hyperlipidemia) [8]. Over the last three decades, developed countries have achieved a 42% decrease in stroke incidence following these changes, while developing countries have experienced a troubling increase, underscoring inequities in prevention strategies and public health education [8]. Notably, public awareness of stroke warning signs does not differ significantly between developed and developing countries, as demonstrated by a systematic review comparing these populations [9]. Therefore, to effectively prevent strokes, it is important to raise public awareness and education about their symptoms, risk factors, and the imperative need for prompt intervention. In many countries, efforts have been made to inform the public about the signs and symptoms of stroke and the critical need to seek emergency medical care [10, 11]. These knowledge‐based education campaigns have demonstrated success in reducing treatment delays and complications. In other parts of the world, especially low‐resource areas, awareness needs to be raised [12]. Overall, primary prevention through enhanced public awareness was found to be beneficial worldwide, but remains needed in many low‐ to middle‐income countries, such as Palestine.
While stroke knowledge has been assessed in several Middle Eastern countries, Palestine presents a unique socio‐political and healthcare context that may influence public awareness. The Palestinian healthcare system operates under fragmented governance, limited resources, and frequent disruptions due to occupation‐related factors (e.g., travel restrictions, checkpoints, and delayed emergency response). Consequently, stroke recognition and timely access to acute care may be disproportionately compromised compared to other regional settings. Therefore, this study fills that gap by providing baseline data on stroke literacy in a conflict‐affected, low‐ to middle‐income setting. Understanding these gaps can help guide targeted public health education strategies aimed at increasing early recognition of stroke and decreasing long‐term disability and morbidity.
2. Methodology
2.1. Study Design and Setting
A cross‐sectional study was conducted among the Palestinian community in the West Bank, Palestine. Participants were recruited from outpatient waiting rooms and public places in the community. This survey‐based study used an anonymous electronic and paper questionnaire. The electronic questionnaire was created using Google Forms and distributed via social media, while the paper questionnaire was distributed in hospital waiting rooms and public places between June 2025 and December 2025.
2.2. Study Population, Inclusion, and Exclusion Criteria
The study population comprised Palestinian adults residing in the community. The inclusion criteria were: (1) age 18 years or older, (2) residence in the West Bank, and (3) willingness to participate and complete all sections of the questionnaire. The exclusion criteria were: (1) age under 18 years, (2) inpatient status, (3) refusal to provide informed consent, or (4) failure to complete all questionnaire sections.
2.3. Sample Size and Sample Techniques
The sample size was calculated using Raosoft, an online sample size calculator (www.raosoft.com), based on the Palestinian population aged 18 and over as reported by the Palestinian Central Bureau of Statistics [13], with a reference percentage of 50%, a 95% confidence level, and a 2.5% margin of error. The minimum sample size was calculated to be 1536 participants. Data were collected from June 2025 to December 2025 using convenience sampling, yielding 1539 eligible responses for analysis. A large sample size was chosen to enhance analytical power and improve the quality of the results by recruiting a sample that resembles the community characteristics. An electronic and paper questionnaire was designed and distributed clearly and unambiguously to adults aged 18 and over. Data collectors ensured that all questionnaires were fully completed, thereby ensuring data completeness.
2.4. Study Variables
The dependent variable was participants’ knowledge of stroke, assessed using a structured questionnaire comprising multiple questions. Each correct response was scored as one point. The total knowledge score was calculated by summing the correct responses and converting the score into a percentage. A binary threshold of 50% was used to categorize participants as having “good” or “poor” knowledge. This cutoff was selected as an accepted standard in stroke knowledge research for defining adequate awareness and has been consistently applied in prior studies that used similar questionnaires to ensure comparability of findings [10, 14, 15]. In these studies, participants scoring at least 50% of the total attainable score were categorized as having good knowledge findings [10, 14, 15]. Although the total knowledge score was originally measured as a continuous variable, dichotomization was performed to facilitate comparison with previous stroke‐awareness studies that classified participants into adequate and inadequate knowledge groups using predefined cutoffs. Nevertheless, we acknowledge that dichotomization may result in some loss of information and should be interpreted accordingly. Based on this approach, participants who answered at least 50% of the 35 items correctly (i.e., a score of ≥ 17.5, rounded up to ≥ 18 points out of 35) were categorized as having “good” stroke knowledge, while those scoring ≤ 17 were categorized as having “poor” knowledge.
All independent variables in this study were treated as categorical variables. These variables included gender (male/female), marital status (single, married, divorced, or widowed), place of residence (urban, rural, refugee camps), smoking status (smoker, non‐smoker, ex‐smoker), educational level (primary, secondary, higher education), occupation (employed, unemployed), income level (low: Less than 3000 NIS (approximately < 830 USD), medium: 3000–9000 NIS (approximately 830–2500 USD), high: more than 9000 NIS (approximately ≥ 2500 USD), family history of stroke, and previous medical conditions. Age was the only continuous variable collected, recorded in completed years, and subsequently categorized into age groups for statistical analysis.
2.5. Study Tool, Validity, and Reliability
The questionnaire was adapted from previously published stroke awareness surveys conducted in Jordan and Lebanon [10, 16]. Since the primary objective of the present study was to assess stroke knowledge rather than develop or validate a new measurement instrument, exploratory factor analysis was not performed. Instead, a panel of expert neurologists reviewed the questionnaire of items to ensure content validity, clinical relevance, and accuracy. The instrument was pilot tested with 60 community members to assess clarity and comprehension. Pilot study participants indicated that the questionnaire phrasing was clear, contextually relevant, and did not require significant modification. Reliability was evaluated by measuring internal consistency using pilot study data. The 35‐item questionnaire demonstrated excellent internal consistency, with a Cronbach's alpha coefficient of 0.912 (95% CI: [0.906–0.919]). Each correct response received 1 point, yielding a total stroke knowledge score ranging from 0 to 35. Stroke knowledge was dichotomized (good or poor) at a 50% threshold.
2.6. Statistical Analysis
Data analysis was conducted using SPSS version 27.0. Descriptive statistics summarized sociodemographic characteristics, clinical history, and questionnaire responses as frequencies, percentages, means, and standard deviations. The components of the total score were also dichotomized. Inferential statistics, specifically the Chi‐square test, were used to compare knowledge status across groups defined by sociodemographic and clinical history variables. A binary logistic regression model, with stroke knowledge status as the dependent dichotomous variable, assessed factors associated with good stroke knowledge while adjusting for confounders. All sociodemographic and health‐related variables collected in the study were simultaneously entered into the multivariable logistic regression model, irrespective of their significance in bivariate analyses. This strategy was implemented to control for potential confounding and to estimate the independent association between each variable and stroke knowledge. The Events Per Variable ratio was 75.6, exceeding the commonly recommended minimum of 10–20 events per variable, thereby minimizing concerns about overfitting and permitting the inclusion of 12 relevant variables. A history of hypertension was incorporated into the multivariable model due to its status as a major stroke risk factor and its potential influence on exposure to stroke‐related education and healthcare counseling. Multicollinearity among independent variables was evaluated using variance inflation factors (VIFs) and tolerance statistics. No evidence of problematic multicollinearity was observed, as all VIF values were below 5 and all tolerance values exceeded 0.20. Thematic analysis was applied to responses to an open‐ended question to identify suggestions for improving community awareness of stroke. Statistical significance was defined as p < 0.05.
3. Results
3.1. Sociodemographic Characteristics of Palestinian Participants
A total of 1539 participants completed the survey. Among them, 933 (60.6%) were female, 873 (56.7%) were single, and slightly more than half were between 18 and 29 years of age. Of the participants, 1209 (78.6%) had completed higher education. The majority resided in either rural (743, 48.3%) or urban (759, 49.3%) areas. Additionally, 918 (59.6%) reported a low monthly income. The most prevalent comorbidities were dyslipidemia (18.5%) and hypertension (18.2%). Furthermore, 403 (26.2%) indicated that a family member had experienced a stroke. Detailed demographic and academic characteristics of the Palestinian participants are presented in Table 1.
Table 1.
Sociodemographic and clinical characteristics of participants (n = 1539).
| Variable | Mean (±SD) |
|---|---|
| Age (years) | 32.8 (± 14.5) |
| Variable | Frequency (%) |
| Sex | |
| Male | 606 (39.4) |
| Female | 933 (60.6) |
| Age group | |
| 18–29 | 896 (58.2) |
| 30–49 | 378 (24.6) |
| ≥ 50 | 265 (17.2) |
| Residence area | |
| Urban | 759 (49.3) |
| Rural | 743 (48.3) |
| Refugee camps | 37 (2.4) |
| Marital status | |
| Single | 873 (56.7) |
| Married | 606 (39.4) |
| Divorced | 28 (1.8) |
| Widowed | 32 (2.1) |
| Educational level | |
| Primary education | 50 (3.2) |
| Secondary education | 280 (18.2) |
| Higher education | 1209 (78.6) |
| Employment status | |
| Unemployed | 966 (62.8) |
| Employed | 573 (37.2) |
| Income level | |
| Low | 918 (59.6) |
| Medium | 449 (29.2) |
| High | 172 (11.2) |
| Smoking | |
| Non‐smoker | 1151 (74.8) |
| Ex‐smoker | 52 (3.4) |
| Current smoker | 336 (21.8) |
| Having a relative with stroke | |
| Yes | 403 (26.2) |
| No | 925 (60.1) |
| I do not know | 211 (13.7) |
| Past medical history | |
| Dyslipidemia | 284 (18.5) |
| Hypertension | 280 (18.2) |
| Angina | 162 (10.5) |
| Diabetes mellitus | 131 (8.5) |
| Arrhythmia | 118 (7.7) |
| Myocardial infarction | 46 (3) |
| Stroke | 37 (2.4) |
| Transient ischemic attack (TIA) | 24 (1.6) |
| Total | 1539 |
3.2. Knowledge of Palestinian Participants About Stroke
Participants demonstrated a generally satisfactory level of knowledge about stroke, with a mean score of 18.35 ± 8.97 out of 35, representing 54.1% of the total possible score. A substantial proportion of participants possessed good knowledge of general stroke‐related information (n = 1253, 81.4%) and protective lifestyle modifications (n = 1106, 71.9%). However, knowledge of stroke risk factors, early symptoms, and potential complications was insufficient, with scores below 50% across all domains. These results are summarized in Table 2 and Figure 1.
Table 2.
Knowledge of stroke among the Palestinian community (n = 1539).
| Variable | Mean (±SD) |
|---|---|
| Total stroke knowledge score (out of 35) | 18.35 (± 8.97) |
| Variable | Frequency (%) |
| Total stroke knowledge status | |
| Good (≥ 50%) | 832 (54.1) |
| Poor (< 50%) | 707 (45.9) |
| General knowledge | |
| Good (≥ 50%) | 1253 (81.4) |
| Poor (< 50%) | 286 (18.6) |
| Knowledge of risk factors | |
| Good (≥ 50%) | 621 (40.4) |
| Poor (< 50%) | 918 (59.6) |
| Knowledge of early symptoms | |
| Good (≥ 50%) | 718 (46.7) |
| Poor (< 50%) | 821 (53.3) |
| Knowledge of consequences | |
| Good (≥ 50%) | 734 (47.7) |
| Poor (< 50%) | 805 (52.3) |
| Knowledge of protective lifestyle modifications | |
| Good (≥ 50%) | 1106 (71.9) |
| Poor (< 50%) | 433 (28.1) |
| Total | 1539 |
Figure 1.
Participants' knowledge of stroke. A horizontal stacked bar chart demonstrating participants' level of knowledge of stroke. A good level of knowledge was set at ≥ 50%.
Most participants (56.7%) correctly identified the brain as the primary organ affected by stroke, whereas 47.6% recognized that stroke prevention can be achieved through lifestyle changes. Hypertension (70.6%), stress (60%), smoking (55.9%), and high cholesterol (53.9%) were the most frequently reported risk factors. Awareness of warning signs was moderate, with the most common being sudden difficulty walking or loss of balance (56.1%), difficulty speaking or confusion (55.9%), and numbness or weakness on one side of the body (55.7%). A majority (73.4%) acknowledged the importance of timely recognition, and 62% emphasized contacting emergency services. The most expected consequence was movement and functional problems (66.1%). Knowledge of lifestyle modifications to reduce risk ranged from 62.2% to 68.7%. Participants’ responses to the questionnaire items are summarized in Supporting Information S1: Table S1.
3.3. Participant's Source of Information
The internet and social media were identified as the primary sources of information about stroke (51.7%), followed by family and relatives (33.3%), and healthcare professionals (15.1%) (Table 3). The survey further revealed a notable scarcity of educational workshops on stroke in Palestine, as 1372 participants (89.1%) reported not having attended any stroke awareness workshops. Additionally, participants evaluated the general level of stroke awareness in Palestinian society as low (46.8%) and attributed this limited awareness primarily to insufficient public education (61%).
Table 3.
Source of information and participant's opinion on the general knowledge of stroke in the Palestinian Society (n = 1539).
| Variable | Frequency (%) |
|---|---|
| Main source of information | |
| Internet or social media | 795 (51.7) |
| Family and relatives | 513 (33.3) |
| Healthcare professional | 233 (15.1) |
| Television or radio | 178 (11.6) |
| Family members as healthcare professionals | 103 (6.7) |
| Newspaper or magazine | 90 (5.8) |
| Studying health sciences | 83 (5.4) |
| Had a previous stroke | 39 (2.5) |
| Have you ever attended a workshop about stroke awareness? | |
| Yes | 167 (10.9) |
| No | 1372 (89.1) |
| Have you ever discussed your risk of stroke with a healthcare provider? | |
| Yes | 335 (21.8) |
| No | 1204 (78.2) |
| Is there a significance to public education in recognizing strokes? | |
| Yes, early recognition can save lives and reduce damage | 1375 (89.3) |
| No, people do not need to know how to recognize strokes | 164 (10.7) |
| Participants’ rating of the Palestinian community's knowledge about stroke | |
| Not at all aware | 200 (13.0) |
| Slightly aware | 721 (46.8) |
| Moderately aware | 548 (35.6) |
| Very aware | 49 (3.2) |
| Extremely aware | 21 (1.4) |
| Participants perceived barriers to stroke awareness in the community | |
| Lack of education about stroke | 939 (61.0) |
| Misinformation or myths about stroke | 759 (49.3) |
| Limited access to healthcare services | 712 (46.3) |
| Cultural beliefs | 477 (31.0) |
3.4. Factors Associated With Good Stroke Knowledge Among the Palestinian Community
The bivariate analysis identified several factors significantly associated with good stroke knowledge, including female sex (p = 0.01), higher age group (p < 0.001), higher educational level (p < 0.001), and higher monthly income (p < 0.001). Behavioral and experiential factors also showed significant associations, including non‐smoking status (p = 0.002), having a relative with a stroke (p < 0.001), attending awareness workshops (p = 0.001), and discussing stroke risk with a healthcare provider (p < 0.001). Supporting Information S1: Table S2 summarizes the results of bivariate analysis.
In the multivariate logistic regression model, the strongest independent factor associated with good knowledge was discussing stroke risk with a healthcare provider (adjusted odds ratio [aOR] = 3.20; 95% CI: 2.34–4.37; p < 0.001). Other significant independent predictors included higher education (aOR = 2.67; 95% CI: 1.37–5.20; p = 0.004), high monthly income (aOR = 2.83; 95% CI: 1.79–4.47; p < 0.001), and having a relative with a stroke (aOR = 2.15; 95% CI: 1.64–2.83; p < 0.001). Conversely, being married (aOR = 0.67; 95% CI: 0.46–0.97; p = 0.036), employed (aOR = 0.64; 95% CI: 0.47–0.87; p = 0.004), or a current smoker (aOR = 0.70; 95% CI: 0.52–0.95; p = 0.02) was associated with lower odds of having good stroke knowledge. Table 4 summarizes the results of the multivariate logistic regression analysis, which are visualized in Figure 2.
Table 4.
Factors associated with good knowledge of stroke among the Palestinian community (n = 1539).
| Variable | Crude OR (95% CI) | p value | Adjusted OR (95% CI) | p value | SE | Tolerance | VIF |
|---|---|---|---|---|---|---|---|
| Sex | 0.72 | 1.39 | |||||
| Male | 1.00 | — | 1.00 | — | — | ||
| Female | 1.31 (1.07, 1.61) | 0.01* | 1.30 (0.99, 1.69) | 0.055 | 0.136 | ||
| Age group | 0.45 | 2.2 | |||||
| 18–29 | 1.00 | — | 1.00 | — | — | ||
| 30–49 | 1.66 (1.30, 2.12) | < 0.001* | 2.08 (1.39, 3.14) | < 0.001* | 0.208 | ||
| ≥ 50 | 1.27 (0.96, 1.67) | 0.095 | 1.35 (0.86, 2.14) | 0.193 | 0.232 | ||
| Residence area | 0.97 | 1.03 | |||||
| Urban | 1.00 | — | 1.00 | — | — | ||
| Rural | 1.03 (0.84, 1.26) | 0.771 | 1.14 (0.91, 1.43) | 0.242 | 0.114 | ||
| Refugee camps | 1.43 (0.72, 2.82) | 0.304 | 1.80 (0.87, 3.74) | 0.113 | 0.372 | ||
| Marital status | 0.48 | 2.09 | |||||
| Single | 1.00 | — | 1.00 | — | — | ||
| Married | 1.22 (0.99, 1.51) | 0.058 | 0.67 (0.46, 0.97) | 0.036* | 0.194 | ||
| Divorced | 1.44 (0.67, 3.11) | 0.354 | 0.70 (0.28, 1.73) | 0.435 | 0.462 | ||
| Widowed | 1.36 (0.66, 2.79) | 0.400 | 0.98 (0.40, 2.40) | 0.967 | 0.457 | ||
| Educational level | 0.91 | 1.10 | |||||
| Primary education | 1.00 | — | 1.00 | — | — | ||
| Secondary education | 0.85 (0.46, 1.57) | 0.596 | 1.09 (0.54, 2.19) | 0.802 | 0.355 | ||
| Higher education | 2.14 (1.20, 3.81) | 0.01* | 2.67 (1.37, 5.20) | 0.004* | 0.341 | ||
| Employment status: | 0.63 | 1.59 | |||||
| Unemployed | 1.00 | — | 1.00 | — | — | ||
| Employed | 1.11 (0.90, 1.37) | 0.329 | 0.64 (0.47, 0.87) | 0.004* | 0.156 | ||
| Monthly income level | 0.69 | 1.44 | |||||
| Low | 1.00 | — | 1.00 | — | — | ||
| Intermediate | 1.40 (1.11, 1.76) | 0.004* | 1.58 (1.16, 2.16) | 0.004* | 0.158 | ||
| High | 2.37 (1.67, 3.36) | < 0.001* | 2.83 (1.79, 4.47) | < 0.001* | 0.234 | ||
| Smoking history | 0.75 | 1.33 | |||||
| Non‐smoker | 1.00 | — | 1.00 | — | — | ||
| Ex‐smoker | 1.15 (0.65, 2.02) | 0.637 | 1.04 (0.54, 2.01) | 0.90 | 0.334 | ||
| Current smoker | 0.65 (0.51, 0.83) | < 0.001* | 0.7 (0.52, 0.95) | 0.02* | 0.154 | ||
| Being diagnosed with hypertension | 0.85 | 1.17 | |||||
| Yes | 1.21 (0.93, 1.57) | 0.159 | 1.06 (0.78, 1.44) | 0.718 | 0.158 | ||
| No | 1.00 | — | 1.00 | — | — | ||
| Having a relative with stroke | 0.97 | 1.03 | |||||
| Yes | 2.33 (1.82, 2.98) | < 0.001* | 2.15 (1.64, 2.83) | < 0.001* | 0.139 | ||
| No | 1.00 | — | 1.00 | — | — | ||
| Attended a workshop about stroke awareness | 0.83 | 1.21 | |||||
| Yes | 1.74 (1.24, 2.43) | 0.001* | 0.96 (0.64, 1.44) | 0.805 | 0.205 | ||
| No | 1.00 | — | 1.00 | — | — | ||
| Discussed your risk of stroke with a healthcare provider | 0.84 | 1.19 | |||||
| Yes | 3.39 (2.58, 4.47) | < 0.001* | 3.20 (2.34, 4.37) | < 0.001* | 0.159 | ||
| No | 1.00 | — | 1.00 | — | — |
Note: Model summary: N = 1539; events = 832 (54.1%); EPV = 75.6; AUC = 0.712 (95% CI: [0.687, 0.738]; p < 0.001); Hosmer–Lemeshow χ 2 = 9.049 (p = 0.338); Nagelkerke R 2 = 0.184.
Abbreviations: CI, confidence interval; OR, odds ratio; SE, standard error.
Statistically significant (p < 0.05).
Figure 2.
Factors associated with good knowledge of stroke. A forest plot showing the adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) for factors associated with good knowledge of stroke among the Palestinian community.
3.5. Attitudes and Recommendations for Enhancing Community Stroke Awareness
Supporting Information S1: Table S3 summarizes respondents’ recommendations for improving community education on stroke awareness in Palestinian society. The most frequently cited strategies were media and digital outreach through social media, community workshops and lectures at universities and schools, public visual awareness campaigns using posters and banners, and health and policy interventions, including early screening for risk factors.
4. Discussion
The concept of health literacy is no longer merely about “storing information” or having it; it has evolved into a core tool (functional empowerment) that enables individuals to make critical decisions in critical moments. This includes situations arising from it, such as the golden rule “Time is brain,” in which the patient's awareness of early symptoms and prompt seeking of medical attention to prevent permanent disability [17]. We evaluated the knowledge of the Palestinian public regarding stroke, and found that Palestinian community members may have, on average, a good level of knowledge regarding stroke. Moreover, the perceived level of awareness regarding stroke was generally low. Gaps in the Palestinian public knowledge regarding stroke were also identified, which can be targeted in future community‐based educational interventions.
On average, participants demonstrated a good level of knowledge about stroke, meeting the 50% threshold. Studies from Ireland, Malaysia, and Jordan have shown similar findings [10, 18, 19]. On the other hand, the Palestinian community demonstrated a relatively higher level of knowledge than was reported in previous studies from Saudi Arabia and Lebanon [16, 20]. The study also revealed that only 56.7% identified the brain as the primary organ affected by a stroke. Although more than half of the participants correctly identified the organ, this percentage was significantly lower than that reported in Jordan and Australia [10, 21]. While this finding might be satisfactory, less than half of the population demonstrated poor knowledge, reflecting the need to improve public awareness of stroke.
Identifying and managing risk factors is essential for reducing stroke‐related mortality and morbidity. Therefore, public awareness of stroke risk factors and timely consultation with primary healthcare providers are crucial. While stroke risk factors are prevalent among the Palestinian population, we found that the knowledge about these factors among the community is poor. The majority of the participants correctly identified hypertension, stress, and smoking as risk factors for stroke; however, many participants did not identify other risk factors, such as diabetes, obesity, physical inactivity, and atrial fibrillation. A local study showed that diabetes and atrial fibrillation are associated with stroke, and that smoking increases stroke severity and the risk of premature death. This discrepancy between public awareness and the actual prevalence of risk factors necessitates urgent public awareness interventions that focus on lesser‐known factors [6]. Compared with other studies in neighboring countries, hypertension and stress were identified as less common risk factors among participants in studies from Lebanon, Sudan, and Saudi Arabia [16, 20, 22], whereas in Jordan and Iraq their prevalence was higher [10, 23]. In countries such as Australia and South Korea [21, 24], awareness of these factors was lower. Overall, these findings underscore the need to raise public awareness of stroke risk factors to better align them with the burden of risk factors.
The high rate of hypertension being identified as a stroke risk factor in Palestinian families can be explained by the widespread prevalence of the disease. Monitoring hypertension at Palestinian primary healthcare centers may encourage patients to discuss the link between stress and stroke risk with their healthcare providers. Furthermore, the association of psychological stress with stroke can be explained by a South Korean study that confirms stress is perceived as a health‐affecting factor even from an individual's own perspective, regardless of whether they suffer from non‐communicable diseases [25]. Although the American Heart Association (AHA) classifies diabetes as a serious modifiable risk factor, only 38% of our study participants describe it as one [26]. This result is consistent with many international and Arabic studies; for example, a study in Brazil, Jordan, Iraq, Oman, and Sudan [15, 22, 23, 27, 28]. Since many participants already recognize stress and high blood pressure as major contributing factors, but do not recognize the rest of the stroke risk factors, Palestinian physicians are encouraged to counsel patients and their families on these stroke risk factors and their management.
Timely recognition of stroke symptoms is crucial for improving survival rates. Therefore, public education regarding stroke symptoms remains essential. The present study identified a low level of knowledge among the Palestinian population concerning early stroke symptoms. Although most respondents recognized motor and functional symptoms, fewer identified symptoms such as visual impairment, memory loss, and headache. This result indicates a gap in community perception, with an overemphasis on visible physical symptoms. Sensory symptoms are often overlooked by patients and their families, likely due to a lack of association with stroke, which may contribute to delays in seeking medical intervention. Approximately two‐thirds (62%) of participants indicated they would call emergency services immediately upon recognizing stroke symptoms, reflecting a high level of awareness regarding the appropriate response. However, more than one‐third (38%) reported alternative actions, including waiting and observing, indecision, private transportation to the hospital, or providing first assistance without proper training. These findings suggest that challenges in Palestine extend beyond inadequate knowledge of symptoms and risk factors to include insufficient awareness of the appropriate actions following the identification of stroke signs and symptoms. Public education initiatives may benefit from incorporating the FAST (Face‐Arm‐Speech‐Time) framework, a validated tool that facilitates rapid recognition of stroke symptoms and encourages prompt activation of emergency medical services. Previous studies have shown that FAST‐based awareness campaigns improve symptom recognition and reduce delays in seeking medical care [29, 30]. The 2026 guidelines for the early management of acute ischemic stroke by the AHA and American Stroke Association (ASA) continue to recommend educational programs for both the general public and healthcare personnel to increase knowledge of stroke warning signs and symptoms and to reduce prehospital delays [31]. These programs include interventions targeted at the general public to enhance stroke preparedness.
We found that participants who reported a prior discussion with a healthcare provider about stroke risk factors had higher odds of demonstrating adequate knowledge of stroke. Despite this, healthcare providers were the third most commonly reported source of information about stroke among the Palestinian public. Other studies have also found that healthcare providers are usually not the primary or strongest source of information about stroke [32, 33, 34], suggesting that the public prefers other sources. The association between discussing stroke risk factors with healthcare providers and higher odds of adequate stroke knowledge underscores the importance of discussing healthcare issues with trained healthcare professionals. It also highlights the need to encourage healthcare providers in primary and secondary care to consult with patients and their families about stroke risk factors, symptoms, and management, particularly at the scene. The public, on their side, needs to be made aware of the importance of discussing stroke risk factors and symptoms with their healthcare providers rather than relying on other sources of information, such as the internet and social media. For instance, a study among primary‐care patients in Saudi Arabia found that patients who reported healthcare providers as their source of information on stroke had higher odds of better knowledge regarding stroke [35]. On the other hand, a Lebanese study concluded that the role of healthcare providers, particularly physicians and pharmacists, in raising public awareness of stroke “appears limited and unsatisfactory” [33]. However, we found that discussion with a healthcare provider about stroke risk factors was the strongest predictor of good knowledge regarding stroke among the Palestinian community. Overall, we suggest that healthcare providers’ role in raising the Palestinian public's awareness of stroke and the appropriate course of action upon identifying patients with stroke signs and symptoms is crucial. This is further supported by our data, in which participants with family members who had a stroke demonstrated higher knowledge regarding stroke, possibly due to their interaction with healthcare providers caring for their relatives in the hospital. Accordingly, we encourage Palestinian healthcare providers not only to participate in public educational interventions but also to lead them, thereby contributing to public awareness grounded in trusted, evidence‐based information sources.
Other factors associated with higher odds of good stroke knowledge among the Palestinian community included higher education, higher monthly income, non‐smoking, and, surprisingly, being unmarried and unemployed. Consistent with previous studies, higher educational attainment was associated with a good level of stroke knowledge [36, 37, 38]. This can be explained by the fact that more literate groups may be more exposed to health‐related educational programs or more likely to interact with professional healthcare providers, and thus, achieve a better understanding of stroke [36]. Moreover, other studies also found that higher socioeconomic status, as measured through monthly income, is associated with more favorable stroke knowledge among the public [10, 36, 39]. Additionally, current smokers demonstrated a lower level of knowledge regarding stroke, a finding that is consistent with previous studies [36, 40, 41]. This observed association may also reflect broader differences in health literacy and health‐seeking behaviors between smokers and non‐smokers rather than a direct effect of smoking itself. Individuals with greater health awareness are generally more likely to adopt healthy lifestyles, avoid smoking, and seek information regarding disease prevention. Contrary to findings from several previous studies [10, 36], marital status and employment were independently associated with lower odds of good stroke knowledge in our cohort. These associations may reflect unmeasured sociocultural factors, competing family and occupational responsibilities that limit engagement with health‐information sources, or characteristics specific to the study sample, including its relatively young and highly educated composition [38]. Given the inconsistency of these findings with the existing literature and the study's cross‐sectional design, they should be interpreted with caution and warrant further investigation in future research.
4.1. Strengths and Limitations
This study contributes to shedding light on the level of awareness and knowledge about stroke within the Palestinian community. However, it is not without some methodological limitations that should be considered. The study employed a non‐randomized convenience sampling method, which will affect the representativeness of the sample within the Palestinian community, thus limiting the generalizability of the results. The relatively high educational attainment observed in the sample likely reflects the strong emphasis on education within Palestinian society. However, the overrepresentation of individuals with higher educational levels in the study may have contributed to elevated stroke knowledge scores and should be considered when interpreting the findings. Furthermore, data collection via self‐administered questionnaires may make responses susceptible to biases, such as a tendency to provide socially acceptable answers or to recall poorly. Moreover, although the questionnaire demonstrated excellent internal consistency, formal construct validation using exploratory or confirmatory factor analysis was not performed. Future studies may further evaluate the instrument's psychometric properties in Palestinian populations. Despite these challenges, the study's strength lies in its large sample size and the rigorous statistical analysis, which supports the reliability of the results and their ability to meet the study's objectives. It also underscores the important role of health education in promoting stroke awareness within the Palestinian community.
4.2. Recommendations
To raise stroke awareness, the study recommends planned, coordinated, and sustainable public health interventions. Programs should inform the population of all symptoms and risk factors so they can recognize them. They should be diverse, reach all demographics, and emphasize seeking immediate medical help for stroke symptoms. Social media and other traditional and digital media should also be used to convey clear, culturally relevant stroke awareness messaging. Public events, awareness workshops, and visual and print materials can help people understand stroke and recovery. Primary healthcare's ability to include stroke awareness messaging into formal care is crucial to public health education. Palestinian clinicians can also use the findings of this study to identify members of the public who can benefit from clear, evidence‐based consultation on stroke. The clinical value of our findings underscores the urgent need to promote widespread public awareness to change societal cultures that tend to adopt a “wait‐and‐see” approach or rely on home remedies when dealing with injuries. Raising broad awareness is crucial given the time‐sensitive nature of these conditions, where every minute of delay leads to the irreversible loss of millions of nerve cells [17], directly contributing to lower injury and mortality rates among the Palestinian population. This aligns with established research confirming that strategic investment in community awareness campaigns is essential to reducing transport times before reaching the hospital and preventing serious adverse outcomes associated with delayed treatment [21, 42]. Finally, future research should assess the long‐term impact of community awareness initiatives by examining their effects on community members’ health knowledge, attitudes, and preventive practices.
5. Conclusion
This study underscores the need for raising awareness about stroke in the Palestinian society. Participants demonstrated moderate knowledge with important gaps regarding risk factors, symptom recognition, and complications. Simply knowing what a stroke is not enough; comprehensive prevention is essential. People's awareness of these factors and symptoms can motivate them to seek early medical advice before their condition worsens. Therefore, the public educational interventions, preferably healthcare provider‐led, are warranted to raise public awareness of stroke prevention, identification, and proper management at the scene. Further research is recommended to assess the impact of such interventions on stroke‐related mortality and morbidity in Palestine.
Author Contributions
Mohammad Abuawad: study conception and design, statistical analysis, first draft writing and editing, editing the final manuscript. Heba Faqih: data collection, first draft writing and editing. Hayat Nayfeh: data collection, first draft writing and editing. Deema Issa: data collection, first draft writing and editing. Ahmad Rjoub: study conception and design, statistical analysis, first draft writing and editing, editing the final manuscript. Mustafa Ghanim: study conception and design, first draft writing and editing. Malik Alqub: study conception and design, first draft writing and editing. Majdi Dwikat: study conception and design, first draft writing and editing.
Funding
The authors have nothing to report.
Ethics Statement
Ethical approval to conduct this study was granted by the Institutional Review Board (IRB) at An‐Najah National University, Nablus, Palestine (Ref Number: BioMed. Dec. 2024/69). This study fully adhered to the principles outlined in the Declaration of Helsinki.
Consent
Participants were provided an informed consent form before completing the questionnaire, which outlined the study's objectives and guaranteed their confidentiality and anonymity. Participants were informed that their participation was voluntary.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author, Mohammad Abuawad, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Supporting information
Supporting File
Acknowledgments
The authors would like to thank An‐Najah National University (www.najah.edu) for the technical support provided to publish the present manuscript.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting File
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.