Proportions mentioning high blood pressure or smoking in response to open-ended questions on

the causes of stroke

0%

49%

51%

32%

32%

5%

19%

22%

39%

29%

97 urban and 91 ruralsubjects in N-E Bulgaria*

1880 respondents GreaterCincinnati Ohio, USA**

2173 respondents GreaterCincinnati Ohio, USA**

822 respondents inNewcastle, Australia**

2500 respondents Michigan,USA**

High blood pressure Smoking

 Krassimira Stoeva1, Klara Dokova1, Philip Kirov2, Nevijana Feschieva1, Stefka Petrova3 John Powles4

(1) Dept of Social Medicine, Medical University, Varna, Bulgaria, (2) Clinic of Neurology, Acute Stroke Unit, University Hospital , Varna, Bulgaria   (3) National Centre for Hygiene, Medical Ecology and Nutrition, Sofia (4) Dept of Public Health and Primary Care, University of Cambridge

More women than men were able to nominate an accepted

risk factor (45% compared to 33% for first mentions) and

more urban dwellers than rural dwellers (44% compared to

33% for first mentions). There was thus an overall gradient in

knowledge from urban females to rural males (23%

compared to 11% for ‘acceptable’ first mentions).

382 Public understanding of the causes of high stroke risk in north-east Bulgaria

Subjects eligible for inclusion in the study were residents of

the village of Grozdovo, and the Primorski district of the city

of Varna with stated ages of 45 to 74. They were quota

sampled from the lists of cooperating general practitioners

with the aim of achieving approximately equal numbers in

each 10 year age stratum for each sex location group. The

91 rural and 97 urban subjects who completed the winter

cycle of the parent study form the basis of this report.

Comparison with census data from 1992 showed that

persons with less schooling were under-represented in our

samples, especially in the rural areas.

During interviews conducted in January – March 2000

covering many aspects of lifestyle and family circumstances

respondents were asked: “Why do you think stroke is so

common in this region? ”. Interviewers were instructed not to

prompt responses and to record first and other reasons

offered in summary verbatim form. All answers were post-

coded – first into 33 categories, which were then combined

into 10 more inclusive groups.

Descriptive statistical analysis was performed using SPSS

version 11.0

Knowledge of those established causes of stroke likely to

be incurring the greatest population attributable risk – namely

high blood pressure and cigarette smoking – is very low in

these high risk populations.

The roles of overweight and obesity (widespread in these

populations) and heavy drinking (present in a proportion of

the adult male population) were also largely overlooked.

The gradient in knowledge between urban female and rural

male participants, corresponds (inversely) to the gradient in

stroke incidence.

Ignorance of the modifiable causes of stroke should be

investigated as a contributing cause to their current high

rates in Bulgaria. The addition of open ended (unprompted)

knowledge questions to risk factor surveys could help

document the extent of this phenomenon in large

representative populations.

A high percentage nominated stress and poverty as

causes of stroke. The study was performed in a transition

period which is imposing enormous economic burdens on the

population. The popular belief that poverty causes stroke is

consistent with considerable epidemiological evidence

identifying it as a (distal) cause2,3,4. However the relief of

poverty through the life cycle2 is a long term objective lying

mostly outside public health responsibilities.

Our findings point to the ineffectiveness of the efforts so far

made within Bulgaria to deal with the public health challenge

posed by stroke. This needs to be addressed immediately by

concerted national programmes of public education about the

established modifiable causes of stroke.

Wellcome Trust, London

1. Introduction

178 (94,6 %) of the respondents offered at least one reason for

the high risk of stroke and 57 people (30 %) gave more than 3

reasons.

Neither high blood pressure nor hypertension were mentioned

by any of the study participants.

Only 5,6% of the respondents suggested smoking (not as a

first answer) as a cause for stroke.

Salty food or low consumption of fresh fruits and vegetables

were not included among the first mentions.

Stress (101) and poverty (20) accounted for 68% of the first

mentions.

Dietary factors other than high salt and low fruit and vegetable

consumption accounted for 40% of other mentions.

  

2. Methods

4. Conclusions

Funding source

3. Results

References

[1] Powles J, Kirov P, Feschieva N, Stanoev M, Atanasova V. Stroke in urban and rural populations in north-east Bulgaria: incidence and case fatality findings from a 'hot pursuit' study. BMC-Public Health 2002;2(1):24.

[2] Davey Smith G,Hart C, Blane D et al. Adverse socioeconomic conditions in childhood and cause specific adult mortality: Prospecitve observation. BMJ 1998;316:1631-5.

[3] Jakovljevi D, Sarti C, Sivenius J, et al. Socioeconomic status and ischemic stroke: The FINMONICA Stroke Register. Stroke 2001;32:1492-8.

[4] Hart C, Hole D, Davey Smith G. The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: The Renfrew/Paisley Study. Am J Public Health 2000; 90 (11) : 1788-91.

* Question addressing population risk

** Question addressing individual risk

Responses to open ended question on why stroke was so common in Varna

region

101

20

0

0

26

19

0

10

2

70

59

13

4

130

16

10

17

3

stress

poverty

salt / salty preserves

insufficient fruit & veg/vitamins

other diet

pollution/environment

lifestyle incl smoking

other

biomedical (but withno mentions of bp)

First mentions Other mentions

Data from associated stroke incidence study

3. Results (cont)

Stroke incidence in North - Eastern Bulgaria is amongst the

highest yet reported for European populations1. The extent

to which Bulgarian publics are aware of scientific knowledge

about the main modifiable causes of stroke appears to be

undocumented.

We assessed public knowledge of stroke risk factors among

well defined urban and rural populations in North Eastern

Bulgaria as a part of “Varna Diet and Stroke Study" (a

preliminary investigation of risk factors for stroke combined

with a diet validation study).

Web address: http://www.phpc.cam.ac.uk/varna/stroke/index.html