The analysis based on the FAST-RIGHT study shows that 34.7% of the study participants in the 40-74 age group, and 36.6% in the 75-99 age group did not call EMS first,  even though they had considered abnormal symptoms as “stroke onset.” Similar to our results, 18.9% in Spain,  28% in Sweden , 33.6% in America , and 35.5% in a small study in China  avoided calling an ambulance despite recognizing stroke onset. In clinical practice in China, this rate showed a significant increase to 82.1% . Although several studies have reported a weak association between recognition of stroke and calling EMS, there still was a gap between knowledge and action [10-12, 23]. The main “alternative response” to stroke was “Call and wait for family, then go to hospital,” which may result in inability to receive thrombolysis [4, 5]. We propose that both the rate of intent to use EMS and receiving thrombolysis would increase remarkably if targeted interventions were carried out to change the “Wait for family” behavior to an immediate call for ambulance assistance .
In low- and middle- income countries including China, people aged 75 years and older had stroke incidence, prevalence, and mortality rates that were 18.8, 11.3, and 35.6 times more than those seen in people younger than 75 years, respectively . Similarly, in our study, the stroke prevalence in the 75-99 age group (5.6%) was nearly twice that in the 40-74 age group (3.2%). The markedly higher cardiovascular risk factors indicated a higher stroke recurrence rate. However, the intent to call EMS in 75-99 age group was slightly higher, inconsistent with their high stroke risk. Hence, there is still the concern that the two age groups are not identical, and the reasons influencing their behaviors may be different. In our study, the associated socio-demographic factors were examined in the 40-74 and 75-99 age groups, separately, and significant differences were found.
The population in the 40-74 age group with multiple sons and daughters, and those living with family or having relatives or friends who had experienced stroke onset tended to wait for their family. Therefore, it seems that family was a barrier to timely usage of EMS . We identified several reasons for this hesitation. Participants considered their family members more reliable and private transportation to be more efficient and convenient. Another concern was that they were unable to handle transactions due to lack of money and caregivers in the emergency department as the services provided are prepaid in Chinese hospitals . To change their understanding of stroke onset and dispel misgivings, the “Green Channel” of emergency network for stroke should be publicized among residents in addition to education regarding the critical importance of time and the benefits of EMS usage .
Living alone decreased the possibility of waiting for family, but did not naturally mean avoiding staying alone at home, in contrast to our hypothesis. Previous studies showed less than 7% patients activated EMS by themselves, and most ambulance calls were made by bystanders [24-26]. If we considered the high rate of living alone in 75-99 age group with high stroke risk, living alone was more detrimental than living with family to effective therapy at the time of stroke onset. Different from those living with family, ambulance call by themselves was the only avenue to activate EMS among individuals living alone. Direct education to improving the intent of using EMS among everyone living alone is reasonable.
Unexpectedly [13, 25, 27], those in the 75-99 age group with higher education levels were more likely to wait for the family than were those with low education levels, although the reasons for this finding are unclear. We speculate that they trusted their judgment too much but lacked the medical knowledge to inform it, and hence are of even greater concern. They probably considered the elapsed time as insignificant, underestimated the severity of stroke onset, and did not know the time required for the necessary diagnostic procedures before administration of recombinant tissue plasminogen activator [3, 14]. Different for the 40-74 age group, stroke history, number of children, sex and family history did not affect the “Wait for family” behaviors in the 75-99 age group. It seems that their behavior pattern was more fixed and not susceptible to other factors. Although multiple avenues to learn about stroke decreased the odds of waiting for the family, as shown by previous reports [28, 29], the reduction was markedly lower in the 75-99 age group. Moreover, they preferred a paper medium instead of the internet, although more than half of the individuals had a visual impairment . Therefore, the effect of stroke education may be limited in the 75-99 age group.
There are several limitations in our study. We used closed-ended questions to establish why residents did not call EMS after identifying stroke onset, while the underlying reasons were varied . Calling a taxi, visiting general practitioners, providing first aid, or 'something else' were the possible choices [3, 9]. Moreover, mobility difficulties were more common in the 75-99 age group, which probably influenced their options during stroke. However, this fact was not considered in our analysis. Finally, the factors associated with not calling EMS could be biased by the non-random sampling design and selection from the CNSSS .
In summary, the rate of not immediately calling EMS after recognizing stroke onset was slightly higher in the 75-99 age group than in the 40-74 age group. Although the majority of wait-and-see behaviors involved waiting for family members, the barriers of calling ambulance were different in both age groups. The behavior pattern in the 75-99 age group seemed more fixed and less susceptible to family factors. This study emphasizes the need to bridge the gap between recognition of stroke symptoms and appropriate action . Strategies should differ between both age groups, for instance, the stroke knowledge delivery may be more effective via newspaper in the 75-99 age group.