Stroke Knowledge in Spanish-speaking populations

Abstract

Background

Spanish is the second most spoken language in the world. Spanish-speaking populations (SSP) have heterogeneous cultural backgrounds, racial and ethnical origins, economic status, and access to health care systems. There are no published reviews about stroke knowledge in SSP. We reviewed the existing literature addressing stroke knowledge among SSP and propose future directions for research.

Summary

We identified 18 suitable studies by searching PubMed, Lilacs, Scopus, Embase, Cochrane and Scielo databases, and looking at reference lists of eligible articles. We also included 2 conference abstracts. Data related to stroke knowledge from studies of Spanish-speakers was analyzed.

Key messages

Little is known about stroke knowledge in SSP, especially in Latin America. Information is poor even among subjects at risk, stroke patients, stroke survivors, and health care providers. “Ictus”, the word used for stroke in Spanish, is largely unrecognized among subjects at risk. Furthermore, access to medical care and presence of neurologists are suboptimal in many regions.

There are several potential issues to solve regarding stroke knowledge and stroke care in SSP. Programs to educate the general population and non-neurologists medical providers in stroke and telemedicine may be suitable options to improve the present situation.

Introduction

Stroke is the second leading cause of mortality and the third leading cause of disability-adjusted life years.[1,2] Intravenous tissue plasminogen activator (IV rt-PA) is highly effective at reducing disability and improving outcomes. [3,4] Even though IV rt-PA utilization rates are increasing, [5,6] the overall utilization rates are far from optimal. The principal cause of non-use of IV rt-PA is delayed arrival time to the hospital.[7] These delays are mainly associated with recognition of stroke symptoms and activation of Emergency Medical Systems (EMS).[8-12]

Stroke awareness is poor in the general population [13-15] and post stroke patients [16] worldwide, though little is known about populations outside of North America and Europe, especially among Spanish-speakers. This is of concern given that Spanish is the second most frequent spoken language in the world, [17,18] and Spanish-speakers from developing countries represent an important source of immigrants to non Spanish-speaking countries.

In the United States of America (USA) for example, Hispanics are the largest and fastest growing minority [19,20] and appear to have a particularly high unawareness of stroke knowledge, along with lower chances to receive IV rt-PA treatment.[21,22] Spanish-speaking Hispanics (SSH) have been found to have higher prevalence of cardiovascular risk factors, greater barriers to care, and reduced quality and health outcomes than English-speaking Hispanics (EEH).[20,23] EEH women in one study were significantly less likely to correctly identify stroke symptoms than non-Hispanic whites.[24] Lower stroke knowledge among EEH and SSH suggests a cultural barrier in stroke awareness, which extends beyond language.[25] One potential barrier to stroke knowledge is the terminology used to describe the disease. “Ictus” is the Spanish word to name stroke. However “ictus” is not widely recognized as stroke equivalent among Spanish-speakers. [26-31]

It is important to know the current status of stroke knowledge among Spanish-speakers in different countries. As cerebrovascular disease is highly prevalent in Spanish-speaking countries and is a major public health problem, this information will be vital for the current health authorities to start tailored education programs for the general population. The purpose of this review is to summarize the literature regarding stroke knowledge among Spanish-Speaking Populations (SSPs) and propose future directions for research.

Search strategy

Studies were identified by searching PubMed, Lilacs, Scopus, Embase, Cochrane and Scielo databases (Appendix 1). No limits were applied. Additional data was found scanning reference lists of eligible articles. Search filters were constructed for 1) stroke knowledge and 2) Spanish-speaking population (Appendix 2).

Selection criteria

The inclusion criteria were: 1) studies about stroke knowledge: word to call stroke, damaged organ, risk factors (RF), etiology, warning signs (WS), treatment and intention to call EMS, 2) articles in English and Spanish. In case additional data was required we contacted authors.

Stroke knowledge in Spanish speakers

We found 18 articles addressing stroke knowledge among Spanish-speakers. Only three were related to Latin American populations: Colombia and Mexico. Of the remainder, 11 originated from Spain, and 4 from SSH living in USA. We included two conference abstracts from Argentina. [32,33]

The small amount of published data in Latin America is of concern and it is not clear what the reasons behind it may be. The absence of IV rt-PA availability in many Latin American regions may be a reason for underreporting. As rapid arrival in those countries is unlikely to lead to acute stroke treatment there is less of an impetus to understand delays to hospital arrival. Economic, cultural and access to health resources make extrapolation of data from the USA and Spain to Latin America suboptimal.

The terminology used to name stroke in Spanish was an interesting finding, with different terms used among patients. All studies exploring this topic were done in Spain. (Table 2) Two studies found that 3.9% and 10% of individuals could not name a single term for stroke. [26,29] No patients knew the term “ictus” in 2 studies [26,28] and it was largely unrecognized in additional reports.[27,29,30]. In several studies “embolia” (embolism) appears to be the term most frequently recognized.[26,27,31] The term “ataque isquémico transitorio” (transient ischemic attack) is largely unrecognized.[26] This is of particular concern given that many strokes after TIA may be prevented by early recognition and treatment.[34,35]

Table 2.

Knowledge of words to name stroke.

Author	Population(n)	Ictus(%)	Embolia(%)	Trombosis(%)	Feridura*(%)	Ataque cerebral(%)	Infarto cerebral(%)	Accidente cerebrovascular(%)	Derrame cerebral(%)
Palomeras	347	0	31,5			0	0	0	0
Segura	3000	4.5	95,5
Montaner	1000	0	67,5	17,9	2,6	5,9	5,7	0,4	0
Oró	153	27,5	87,9	71,9	82,4	0	76,5	0	83
Pérez-Lázaro	356	40	60
Montaner	100	1	98,9	87,9	11	93,4	74,4	47,8	-

^*Word from Catalan

We found significant differences in studies regarding stroke knowledge according to whether they were performed in general population or in patients with stroke. We find this difference important since the first one provides information about “theoretical knowledge” and the latter one about the “practical knowledge”; what patients really did.

Stroke knowledge in general population

Table 1 shows the great heterogeneity across published studies making comparison between populations difficult.

Table 1.

Studies about stroke knowledge in Spanish-speaking population without stroke

Author/Country	Population (n)	Selection	Survey design (close/open ended)	Educational level (≤ Elementary school) (%)	Knowledge of ≥ stroke RF	Knowledge of ≥stroke WS	Would call EMS (%)	Would go to hospital (%)
Segura/Spain	3000	Random	Close	-	59,6	32,6	45,5
Montaner/Spain	1000	Health care centers	Close	61	-	<50	50	43
Oró/Spain	153	Health care centers	Close	69,9	-	-	9	21
Lundelin/Spain	11827	ENRICA study	Close	30	-	-	81	4,9
Díaz-Cabezas/Colombia	213	Primary health centers	Open	71	45	35	11,7
Pérez-Lázaro/Spain	356	Neurological consults	Close	51	49	55	60	39
Montaner/Spain	100	Health center	Close	-	96	95	46	50
Góngora-Rivera/Mexico	330	Building complex	Open	12,5	66	36,7	90
Bruera/Argentina	1650	Random	Open	11,2	-	-	20	-
DuBard/USA	527	SSH from BFRSS	Close	-	58	-	85	-
Goldstein/USA	76	Health program	Open	-	19	43	45
Ellis/USA	60	English classes	Close	-	-	-	71,7	-

Educational level

Most studies found that >50% of individuals had complete elementary school or lower. [26,27,29,31,36] SSH in USA had low literacy rates in several studies. In the Behavioral Risk Factor Surveillance System Survey study (BRFSS),51% of SSH had less than high school education compared with 14% of EEH.[23] An additional study showed that most SSH were functioning at the beginning level after testing literacy using the Basic English Skills test. This was notable as sudden trouble walking, dizziness or loss of balance were significant less recognized as stroke symptoms among lower literacy groups. [37]

Brain affected in stroke

Hispanics in Central Harlem were less likely to recognize brain as the damaged organ in stroke. Unfortunately data about language were not provided for this population. [38]

In Spain, between 78 and 86% of individuals responded the brain, the remainder responded it was arms or legs. [26,30,31]

Knowledge of risk factors (RF) and warning signs (WS) of stroke (Table 3)

Table 3.

Most frequently recognized RF and WS of stroke.

Author/Country	WS	RF
Segura/Spain	Weakness Speech disturbances Unconsciousness	Hypertension Tobacco Alcohol
Montaner/Spain	Weakness/ numbness	Hypertension Alcohol Tabacco
Oró/Spain	Speech disturbances	Hypertension
Lundelin/Spain	Speech disturbances Weakness	-
Montaner/Spain	Speech disturbances Numbness Weakness	Hypertension Alcohol Tobacco
Pérez-Lázaro/Spain	Weakness/ numbness Unconsciousness	Hypertension Dyslipemia Heart disease
Díaz-Cabezas/Colombia	Weakness Speech disturbances	Hypertension
Bruera/Argentina	Weakness/ numbness Confusion/ Speech disturbances	-
Góngora-Rivera/Mexico	Weakness Headache Dizziness	Hypertension
Gutierrez-Jimenez/Mexico	Headache Speech disturbances Unspecified pain	Hypertension Stress
DuBrad/USA	Weakness	-
Ellis/USA	Weakness/ numbness Visual disturbances	-

The most recognized RF across several populations was hypertension. [26,27,29-31,36,39,40] Tobacco and alcohol were the second most recognized RF in two studies [26,29,30] and stress in one. [40] Advanced age, diabetes, dyslipemia and heart disease on the other hand were poorly recognized.[29,31]

Weakness with or without sensory disturbances was the most recognized WS in eight studies [23,26,29,31,32,36,37,39] and speech disturbances in three. [27,30,41] Interestingly headache and unspecified pain were the first and third most frequently reported WS in Mexico and this remained unchanged after an educational campaign. [40]

Hispanics in Central Harlem were likely to misclassify chest pain as a symptom of stroke compared with other populations.[38] Around 30% of individuals did it in Spain and USA, [37,41] and approximately 5% in Mexico. [39,40] However in Mexico, chest pain was most frequently associated with stroke than weakness or altered sensitivity on one side of the body. [40] In Spain, 72% of respondents to a survey identified confounders as stroke symptoms. [31] Again SSH of the BRFSS were less likely to recognize stroke WS after adjustment for socio-demographic characteristics, healthcare access, and cardiovascular risk factors.[23] Remarkably, 11% of 76 uninsured SSH in North Carolina confounded the terms “risk factor” and “symptom” suggesting barriers to comprehension of standard health education materials. [42]

A combination of stroke RF and WS knowledge was used to define the “level of stroke knowledge” in seven studies. Whether “Good stroke knowledge” was present was difficult to determine due varying definitions. (Table 4)

Table 4.

Definitions of “level of stroke knowledge”.

Author/Country	Level	Definition	Achievement
Oró/Spain	Good	>3 WS/RF and <2 distractors	-
	Optimum	>4 RF/WS and ≤ 1 distractor	31/40
	Minimum	Motor and speaking	57
Segura/Spain	Suitable	Advanced age/hypertension and weakness-speech disturbances/vision loss	10,5
Lundelin/Spain	Adequate	4-6 WS	65,2
Montaner/Spain	Good (RFs)	Recognition of ≥5 and ≤1 error	37
	Good (WSs)	≥3 and ≤1 mistake	50
	Very good	Good knowledge of WS and RF	20
Díaz-Cabezas/Colombia	Bad	*No correct answers/ ** 1 correct option and ≥2 distractors	RF*50/**39
	Regular	*≥ 2 correct answers /**2 correct options and 2 distractors	WS*94/**60
	Good	*One/**≥3 correct options and one distractor	RF 50/**61 WS *6/**40
Pérez-Lázaro/Spain	Good	**Four RF no distractors **Three WS no distractors	30 56
	Very good	>*One WS , >*1 RF	29 26
Montaner/Spain	Good	≥3 WS ≤1mistake ≥3 RF ≤1mistake	42 46
	Very good	Good knowledge of RF and WS	22

^*Spontaneous answers

^**Answers after recognition from a list

Behavior in response to stroke symptoms

Several studies reported the proportion of patients who would go to an emergency department or would call the EMS without differentiating between both decisions. (Table 2)

No significant differences in intention to call EMS were found comparing literacy groups among SSH in USA.[37]

Different actions in front of a hypothetical stroke or TIA situation were assessed in five studies. In Spain, 31% and 60.6% of patients would go to the hospital/call EMS or call personal doctor the same day respectively if a stroke was suspected. These percentages changed to 13.7% and 56.9% if symptoms were transient. [27] In additional studies, > 95% of individuals would call EMS or go to the hospital in a stroke situation compared with 40, 53 and 75% of TIA situations. [26,30,31]Patients with “very good global stroke knowledge” were more likely to assign importance to TIA. [26] Lastly, in Colombia, only 11.7% of patients would present to the emergency room if stroke were suspected. [36] This percentage improved to 92% when options were given, however it decreased to 62% with transient symptoms. [36]

No studies took into account behavior in response to stroke symptoms to define “level of stroke knowledge”. Ultimately in may be more important to capture “good stroke knowledge for action” combining knowledge of WSs and intention to call EMS. This concept for potential responsiveness in a population can be tested and compared with actual action at the onset of stroke.

Treatment

No participants knew about the existence of IV rt-PA in a Colombian study. [36] Among 1645 Argentinian people, 40% knew that there was a specific treatment for stroke, and only 24% knew that it was time-sensitive. [32] Interestingly, 86% of 76 SSH in USA responded that stroke could be treated despite their poor stroke knowledge. However this study did not explore IV rt-PA or therapeutic window time knowledge. [42] Whether or not knowing about IV rt-PA availability would have a public health impact is unknown because it is not available to treat stroke in many regions of South America.[43,44] In Argentina, for example IV rt-PA was administered only, to 1.2% of patients in private hospitals.[44] It is not known to what degree this is influenced by availability of neurologists.

Information source for gaining stroke knowledge

Physicians and relatives are the most frequently cited information sources. Mass media seem to be important too. (Table 5) In Colombia 10.2% of patients had not received any information regarding stroke. [36] This percentage was much higher in Mexico, where 83% had not received any information. Among the latter, those who had received information made fewer mistakes in their answers about stroke knowledge. [39]

Table 5.

Information sources for gaining stroke knowledge.

Author/Country	Physicians (%)	Nurses/health care system (%)	Relatives (%)	Internet (%)	Television/Newspapers/radio/books (%)	School/institutes (%)
Oro/Spain	43,8	7,8	32,7	11.1	24,2	3,9
Diez/Spain	64	-	33	16	13	-
Montaner/Spain	-	-	50	-	-	-
Díaz-Cabezas/Colombia	23	12,2	31,2	-	23	-
Góngora-Rivera/Mexico	10	-	-	-	7,3	-

Educational interventions

Educational campaigns in Latin America are limited. One educational campaign conducted by previously trained medical students through conferences and printed material was done for 6 months among randomly selected habitants of a multifamily housing unit in Mexico. After it, recognition of obesity, lipid disorders, and drug use as RF and hemiparesis as WS improved. [40]

In Argentina recognition of RF and WS, behavior against stroke and treatment knowledge improved after a multimodal campaign conducted by previously trained medical students among randomly selected people. However 60% of individuals thought that stroke is an infrequent illness before and after educational intervention. [32]

Stroke knowledge in patients evaluated after stroke

Six studies evaluated stroke knowledge from “what patients did when they had a stroke”.

Knowledge regarding cause of symptoms

Awareness of having a stroke and emergency perception of stroke symptoms were associated with shorter arrival times. [28,33,45]

Between 27% and 43% of stroke patients correct interpreted their symptoms as consistent with stroke in different studies. [25,33,45-47]

Stroke severity, motor symptoms, speech disturbances and prior stroke/TIA have been related with correct symptom interpretation. [45-47] The latter association was not found in Argentina and Spain. [33,46] For example, in Spain, 76.2% of patients with recurrent stroke did not recognize new events after the first one. [46] Interestingly educational level was not related with correct stroke symptoms recognition in the same studies. [33,46]

Behavior in response to stroke symptoms

In Madrid, Spain, 56% of surveyed went directly to the emergency department despite only 27% recognized their symptoms as stroke. The remaining stayed at home or attended to primary care physician. [46] In Meresme (county with rural areas), Spain, 31.8% of individuals went immediately to the hospital or called an ambulance. Others waited for symptoms to improve (21.9%) or called their primary care doctor or pharmacy (21.2%). [28]

In other study from Spain, 60% of individuals arrived before 3 hours of symptom onset. However, ambulance delay was argued by 15% of 247 patients who arrived to hospital after the first hour. [47] Additional data from the same country suggest that not contacting a primary care physician as first action in acute stroke have been related with arrival in first 3 hours. [45] Mexican Americans in USA were less likely to use the EMS compared with non-Hispanics whites. However no association with language and time to presentation or mode of arrival was found. [25] This may suggest a cultural or economic rather than a language barrier to EMS activation.

Only data from Argentina is available in Latin America. In one study, only 36% of individuals called EMS without improvement of arrival times. [33]

Patients’ beliefs

Two studies explored patients’ beliefs about stroke. In a Spanish population 60% thought that religion helped them to recover after a stroke. Up to half of patients could explain biological mechanisms of the illness and thought that an emotional stressor was the cause the stroke. [46] Mexican-Americans in USA reported distrust in the medical establishment and expressed concern that financial considerations impeded their seeking medical care. These beliefs may result in avoidance to call EMS. [25]

Stroke knowledge among providers

According to WHO data 50% of countries in America responding to a survey have less than 1 neurologist per 100.000 population. No data was available on Chile, Bolivia, Peru, Paraguay and other countries in Central America. (Table 5) [48]

Misdiagnosis of stroke is common in the emergency room and by primary care physicians. [49] The presence of a neurologist available in the ER could solve this difficulty. [50]

We found limited data regarding misdiagnosis of stroke in Spanish-speaking countries. However indirect findings suggest that misdiagnosis may interfere with initial stroke workup and hence thrombolysis in SSP. [6,33,45,51]

In Argentina 14 out of 41 (36%) patients who arrived in the first 6 hours of stroke symptoms had a diagnostic delay, losing an opportunity of potential treatment. The principal cause was misdiagnosis, with a non-neurologist being the initial provider 95% of the time. [33]

Also in Argentina, 596 physicians working in an emergency department were evaluated about pre-hospital stroke scales as an instrument to screen for stroke notifications. Only 32% knew about Cincinnati (CPSS) and Los Angeles Scales (LAPSS), and only 8.4% could tell all points of CPSS, 1.9% the LAPSS and 0.7% both. Nonetheless 89% of the surveyed physicians found the scales useful to evaluate stroke patients in the emergency room. Interestingly those who remembered the scales felt more secure to evaluate a patient with possible stroke. [51]

In Andalucía, Spain, 46.4% of emergency physicians failed the first stage exam of an educational program of stroke knowledge. Worst scores were found in knowledge of neurological impairment, dosages for antihypertensive drugs and IV rt-PA, physiological neuroprotection, early signs of stroke, and contraindications for thrombolysis. After training, knowledge improved and use of IV rt-PA increased 4.5% over 3 years. [6]

Conclusions

SSP are heterogeneous regarding cultural backgrounds, racial and ethnical origins, economic status and sophistication of health care systems. Studies examining stroke knowledge in Spanish-speaking countries are lacking, particularly in Latin America. In the few studies published stroke knowledge is poor among potential stroke sufferers, stroke survivors, and providers. These findings may occur due to inconsistency on the word used for stroke in Spanish, inconsistent utilization of IV rt-PA in several Latin American countries, and overall poor access to medical care and neurologists in specific. It is necessary to make greater efforts mainly in Latin American population to know more about stroke in general population but mainly in high risk population and particularly related to risk factors, warning signs and quick call to EMS associated with shorter arrival time to hospital.

Recognition and conduct when symptoms are transient is a topic of concern and little is known in Spanish-speakers. This point deserves special attention to further educational programs. New epidemiological studies from Latin American countries describing the current state of stroke knowledge are needed, particularly since data from USA and Spain may not be generalizable. Further understanding of the baseline knowledge and gaps in these countries can then allow for future studies examining educational campaigns which culturally tailored to each individual country and population for potential patients, families, the public and providers. These interventions will need to consider using a consistent term for stroke in Spanish (including in the medical literature), and include personal physicians and relatives since they are often the most reported information sources by patients. Partnerships between government agencies, non-profit organizations, medical institutions and mass media outlets akin to efforts in the USA will be necessary, particularly to make them specific to the cultures of each country and region. Lastly, education will likely need to be expanded in parallel early on in the instruction of medical students in Latin America to improve stroke knowledge among providers.

Unlike many regions in Europe, the lack of neurologists in some countries and their concentration in large metropolitan centers may be an important gap to solve in next years. Programs to train general practitioners in stroke and telemedicine presents one possible solution to improve access in under-served areas similar to successfully implemented program in the USA.

Table 6.

Neurologist per 100.000 population (WHO)

Neurologist per 100.000 population
>5	1,1-5	0,11-1	No data
USA	Spain	Mexico	Chile
	Canada	Venezuela	Bolivia
	Brazil	Ecuador	Peru
	Argentina		Paraguay
	Colombia
	Uruguay

Appendix 1

Lilacs:[27,29,36,39,41,45] Scielo:[36]

Scopus:[42]

Pubmed:[23,25-29,31,37,41,42,52]

Appendix 2

Search strategy:(“stroke awareness” OR “stroke literacy” OR “stroke knowledge” OR “stroke recognition” OR “stroke symptoms” OR “stroke preparedness” OR “stroke perception” OR “ictus knowledge”) AND (“hispanic” OR “latin” OR “spanish speaking” OR “spanish” OR “Spain” OR “latin america” OR “south america” OR “central america” OR “america” OR “hispanos” OR “latinos” OR “España” OR “español”)