Awareness and Community Response To Stroke Signs and Symptoms Following the National ‘Act Fast’ Campaign in An Ethnically Diverse Population

Evaluation of public education stroke campaigns and behavioral studies to assess emergency response at stroke onset are scarce. We aimed to assess patient’s and bystanders’ foreknowledge of stroke signs and symptoms and their response at stroke onset. We also enquired if ‘Act FAST’ stroke campaign in Qatar contributed to their foreknowledge. The study We The was the


Abstract Background
Evaluation of public education stroke campaigns and behavioral studies to assess emergency response at stroke onset are scarce. We aimed to assess patient's and bystanders' foreknowledge of stroke signs and symptoms and their response at stroke onset. We also enquired if 'Act FAST' stroke campaign in Qatar contributed to their foreknowledge.

Methods
In Qatar, the rst national stroke awareness campaign, 'Act FAST', was launched in May 2015. The study population included a convenience sample of stroke patients admitted to the stroke service in Qatar's largest tertiary care hospital from November 2015-February 2016. We interviewed patients with acute onset stroke admitted to the stroke unit using a validated questionnaire. If the patient had disabling stroke, we interviewed relatives/bystanders present at stroke onset. The primary outcome was the correct response of calling Emergency Medical Services (EMS), recognizing the possibility of stroke.

Conclusions
The foreknowledge of stroke signs and symptoms and the Act FAST campaign was low in the community. However, seeking help by activating EMS at stroke onset was generally high in the study population irrespective of the awareness to the campaign.
According to the WHO (World Health Organization) Global Burden of Disease data and the leading cause of deaths report, 6.1 million deaths were recorded due to stroke in 2019 (4, 6-8). The incidence of stroke is increasing in developing countries along with the prevalence of hypertension and diabetes. Qatar's population and age at stroke presentation in Qatar are younger than those in European and North American countries (9,10). The indigenous population has undergone signi cant changes such as urbanization, increasing tobacco consumption, dietary changes, and sedentary lifestyle, contributing to an increased prevalence of vascular diseases (11)(12)(13)(14). The incidence of stroke in Qatar is relatively high compared to European and North American countries (10,12,15). The management of acute stroke is time-dependent so early recognition of the symptoms and rapid transfer to the hospital may reduce subsequent disability and mortality (16, 17).
Mass media campaigns are conducted globally focusing on improving community awareness about stroke signs and symptoms. The 'Act FAST' (Face drooping, Arm weakness, Speech problem, time is ticking) stroke campaign is one of the major internationally established stroke awareness programs.
Studies conducted to assess its effectiveness and outcomes have reported variable success rates (18-24). In the UK (United Kingdom), the campaign was found to be effective in creating an impact on stroke awareness and recognition, and in reducing pre-hospital delays in stroke patients (21,25). Studies from Australia also demonstrated an increase in emergency calls and ambulance dispatches for stroke post campaign; however, they were not able to provide evidence of whether the calls were true stroke and transient ischemic attacks, or other stroke mimics (20,22,23).
The cultural and linguistic diversity of Qatar's population presents particular challenges in the development of public health campaigns. The rst 'Act FAST' national stroke awareness campaign was launched in May 2015 in Qatar (26). The campaign ran on television, newspaper, social media and billboard advertisements in multiple languages targeting the general population. There is no published study assessing the effectiveness and impact of this campaign in a diverse population like Qatar to inform future development.
The aim of this study was to assess the foreknowledge of patients and bystanders, of stroke signs and symptoms and their response at the stroke onset. A secondary objective was to determine if the 'Act FAST' stroke campaign in Qatar contributed to their foreknowledge.

Methods:
This was a prospective study conducted in the only tertiary care hospital in Qatar. The study was

Setting and study population
Qatar is one of the six Middle Eastern GCC (Gulf Cooperation Council) countries located on the Arabian Peninsula's northeastern coast. Qatar has an ethnically diverse population of approximately 2.7 million, with about 88% being short-term immigrants from a wide range of countries (27)(28)(29). The local Qatari population constitutes only around 12%% of the total, while South-East Asians (approx. 60%), Non-Qatari Arabs (approx. 13%), people from the Far-East (approx. 10%) and minority groups from various other countries (approx. 5%) form the major part of this society (27)(28)(29)(30). Despite Arabic being the o cial language of Qatar and English being widely spoken, more than 65% of the non-Qatari population does not speak Arabic or English. In addition, the majority of this population were manual workers with limited education (31).
All stroke patients admitted to the stroke unit at Hamad General Hospital (HGH) between November 2015 till February 2016 were screened for participation utilizing the stroke team daily admissions log. Eligible participants (n = 165) were adults (≥ 18 years) with neuro-imaging con rmed stroke, as assessed by the neurology team. Patient relatives or witnesses/bystanders who were present at the onset of the event were interviewed if the patient had a disabling stroke which prevented self-reporting. Excluded participants were < 18 years old, clinically unstable and/or un t for interview without a witness/bystander, unable to understand verbal communication and/or diagnosis other than the stroke.

Data collection
A validated questionnaire was the primary data collection tool and was modi ed to our local setting and population (appendix 1) (32). The questionnaire focused on the knowledge and awareness of 'Act FAST' stroke campaign in Qatar, stroke signs and symptoms and patient response at stroke onset to assess campaign penetration and perception of general population to acute stroke. The participants were approached within 48 hours of admission to the stroke unit and were screened for eligibility. Verbal consent was obtained from all eligible participants and a structured interview conducted in English or Arabic language by trained research team members. If the participant did not speak conversational English or Arabic a trained organizational approved translator was utilized. The response of each participant was recorded verbatim during the interview.

Variables and data points
The study questionnaire contained closed ended questions with pre-de ned options and open-ended questions recording verbatim statements describing the FAST campaign, signs and symptoms of stroke and participants behavior at stroke onset. The closed ended questions included: awareness of stroke campaigns, awareness of the Act FAST stroke campaign in Qatar, knowledge of the signs and symptoms of stroke as depicted in the stroke campaign, the most common effective mediums used for the awareness campaigns, severity of different symptoms at stroke onset, behavioral response at symptom onset (with and without stroke recognition) and a conclusive analysis of how effective the awareness campaign was and how much it effected patients behavioral response at the onset of stroke symptoms (Appendix 1).
The participant's understanding of the Act FAST campaign acronym was de ned as satisfactory if the participants were able to identify three or more components of the 'FAST' acronym. Similarly, the participants' knowledge and awareness of stroke signs and symptoms was de ned as satisfactory if the participant was able to describe two or more signs and symptoms included in the Act FAS' campaign. The effect of the campaign on evoking an appropriate behavioral response at the onset of symptoms was de ned as the immediate activation of the emergency medical services (EMS).

Outcome measures
The primary endpoint of the study was the knowledge and awareness of the stroke awareness and Act FAST campaign in Qatar. Secondary endpoints were association of demographics and patient characteristics with stroke knowledge and awareness and EMS activation at stroke onset.

Statistical analysis
The descriptive analysis was reported as mean and standard deviation (SD) for all parametric continuous variables. All categorical variables were reported as numbers and percentages (n, %). We compared the proportion of all categorical data for sex, nationality, level of education, occupation, symptoms at stroke onset and behavioral response using Pearsons Chi-square test or Fisher exact test as appropriate. We also made comparisons using student's t test (means), with a p value of < 0.05 considered as statistically signi cant. All statistical analysis was conducted using STATA (quad-core 15MP, StataCorp, College Station, TX).
Among those interviewed, 33 (20.1%) participants knew about the signs and symptoms of stroke. 27 (16.5%) participants were aware of the 'Act FAST' stroke awareness campaign and 7 (4.8%) were able to recall the campaign acronyms and the message conveyed by the campaign. The behavioral responses of the study participants who were aware of the Act FAST campaign at the onset of stroke signs and symptoms were; 13 (48.2%) participants called relatives/friends, 13 (48.2%) of the participants immediately activated EMS, and 3 (11.1%) drove to the hospital. Unilateral limb weakness (n = 19, 17.4%) was the most commonly reported motor symptom among participants who were aware of the Act FAST campaign, followed by numbness, di culty in talking, dizziness, drooping of face, headache, loss of balance, and blurred vision (Table 1).
Twenty-one (14.5%) of the (n = 144) male participants were aware of the Act FAST stroke awareness campaign as compared to 6 (28.5%) of the 21 female participants reported to know about the campaign before having stroke symptoms. The majority of the participants from campaign aware group had a graduation level (16 out of 27, 59.3%) education; whereas, 36.2% (n = 50) of the participants from campaign unaware group had a graduate level education. A signi cant proportion of the participants who were aware of the campaign were witnesses/bystanders 10 (37.1%).
The participants from the campaign aware group compared to the campaign unaware group who responded by activating EMS were 13 (48.2%) and 42 (30.4%) respectively. Seeking help by only calling friends or relatives was reported by 8 (29.6%) from aware group compared to 41 (29.7%). The participants from the campaign aware group compared to the campaign unaware group who did not seek any help and waited to see if the symptoms resolved were 3 (11.1%) and 26 (18.8%) respectively.

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Discussion: In this study foreknowledge of stroke signs and symptoms, and awareness about the Act FAST campaign was lower than expected. Although the campaign ran through multiple communication mediums throughout Qatar, awareness of the Act FAST campaign was low (16.5%). Most participants (> 50%) belonged to the less educated craft and manual workers, who have limited communication skills in English and Arabic languages, and many lack access to commercial media running the Act FAST campaign (31).
Several studies have been conducted to assess the effect of mass media stroke campaigns on the behavioral response of the targeted population, aiming to improve patient outcomes (18-24). A similar campaign in the UK was found highly effective in creating impact on stroke awareness and recognition; however, it had little impact on the behavioral response to stroke symptoms (21). Our data suggest, even though the public awareness to the campaign was lower [27 out of 165 (16.5%)] compared to the UK study [68 out of 75 (90.6%)]; 55 (33.3%) of our study population activated EMS at stroke onset which is comparable to the participants activating EMS 28 (37.3%) in the UK. Our study suggests that apart from knowledge and awareness the behavioral response at stroke onset is multifactorial, and may vary from person to person.
Another study suggested that the UK 'Act FAST' campaign successfully reduced pre-hospital delays in stroke patients and also signi cantly increased the percentage of bystanders seeking medical attention after identifying signs and symptoms of stroke (25). Our data supports this evidence, considering 43.5% (10 out of 23) of the bystanders in the study group were aware of the stroke 'Act FAST campaign', and 7 of 10 (70%) bystanders from aware group sought medical attention by activating the emergency services.
Since media has become a signi cant source of providing information to the general population, the clarity and impact of mass media interventions in changing behavioral responses requires careful evaluation (33,34). Studies in Australia have concluded that the ambulance dispatches for stroke as well as the awareness of the general population for stroke warning signs signi cantly increased following their 'Act FAST' stroke awareness campaign. The studies also suggested the campaigns were more effective in increasing the ambulance dispatches when the knowledge of FAST symptoms was linked to calling an ambulance at symptom onset (22,23).
The Act FAST stroke campaign in Qatar focused on disseminating stroke awareness using pictorial representations of FAST components with strong emphasis on calling EMS immediately (Fig. 1). The education level of the target population and language of communication used for the campaign has a signi cant role in message penetration among the general population. Most participants in our study were non-native speakers of Arabic or English. However, the Qatar Act FAST campaign was mainly conducted in English and Arabic languages, which may be one of the reasons for lower success rates. We believe education level of the population, language of mass media communication, and the access to channels of advertisements were unmeasured factors which could explain the difference observed between our study results and the results reported from Australian and the UK campaigns. Further studies focused on factors mentioned above will inform public strategies focused to reduce pre-hospital delays and to improve outcomes for stroke patients using the 'Act FAST' campaign in Qatar.
Although, our study describes the perception, awareness and response evoked by the campaign among the target population including bystanders, there are some limitations to our study. Firstly, we were unable to record the language read and understood by the participants. Considering the majority of our population are expatriates, language barriers could play an important role in the understanding of this public health intervention. Secondly, we had a limited sample of participants, with the majority of the participants belonging to the South-Asian region. Thirdly, although the study interview was conducted within 48 hours of admission to the stroke unit and by survey trained stroke team members, the study relied on the recall of the participants. Fourthly, the study was executed after the second wave of the Act FAST stroke awareness campaign and perception of the campaign and the response based on recall of the campaign may have changed for participants interviewed later in the study. Finally, the type of stroke was not de ned for participants in our study and included all stroke patients admitted to the stroke unit. However, our study is one of the rst studies in Qatar to conduct detailed interview of stroke patients including bystanders after a national stroke awareness campaign.

Conclusions:
The awareness and knowledge of stroke presentations following the stroke 'Act FAST' campaign in patients with a con rmed stroke and their bystanders was low in the study population. However, seeking help by activating Emergency Medical Services at stroke onset was generally high in the study population. Availability of data and materials: The data that support the ndings of this study are available from Hamad Medical Corporation but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data is however available from the authors upon reasonable request and with permission of Hamad Medical Corporation.

List Of Abbreviations
Competing interests: The authors declare that they have no competing interests.
Funding: The research project was supported by the Health Service Research Investigator Initiated Grant (HSRIIG) cycle by the Medical Research Center at Hamad Medical Corporation, Doha, Qatar. There was no role of the study sponsor/funder, if any, in the study conception, study design, data collection, data analysis and interpretation of data, manuscript writing and the decision to publish the manuscript.
T.P.: Finska Läkaresällskapet (T.P.), Viipurin tuberkuloosisäätiö (T.P.), Maire Taposen säätiö (T.P.) Authors' contributions: Z.B. conceived the study proposal, compiled, and modi ed the data collection tool to local setting and population, data collection and data management, data cleaning and analysis, data interpretation, abstract and manuscript writing.
S.P. conceptualized the proposal with Z.B. and reviewed proposal, review and modi cation of the data collection tool, data analysis and interpretation, abstract and manuscript writing.
T.P., M.C. and P.C. reviewed the data, conducted review of the data analysis and interpretation of results, writing and review of the manuscript and provided overall supervision for the study.
N.A. supported in the designing of the data collection process, conducted review of the data and writing and review of the manuscript.
S.T. supported in the conceptualizing of the study proposal, data interpretation and review of the manuscript.
T.H. reviewed the data, conducted review of data analysis and interpretation of results, writing and review of the manuscript and provided overall supervision for the study.
A.S. conceptualized the stroke campaign and review of the manuscript.