Knowledge, attitude, and practice of stroke and thrombolysis among students preparing for undergraduate medical entrance examination in Kathmandu, Nepal

Abstract Background Stroke is a major disabling disease, especially for low and middle‐income countries like Nepal. The aim of our study is to assess knowledge, attitude, and practice (KAP) among the students preparing for undergraduate medical entrance examination regarding risk factors, warning signs and symptoms, and management of stroke. Methods A cross‐sectional, single staged study using self‐structured questionnaire intended to assess KAP about stroke and thrombolysis was conducted. Results A total of 378 students participated in our study (53% male; mean age = 18.12 ± 0.97). Majority of the participants (88.4%) had heard about stroke. The more common risk factors identified by them were hypertension (86.2%), oily food (48%), alcohol (37.8%), and smoking (32.8%). Limb weakness, slurring of speech and facial weakness as symptoms and signs of stroke were indicated by 43.4%, 30.2%, and 18.8% of the participants, respectively. Only 23.8% of the participants had heard about thrombolysis and 10% of all could rightly mention the window period of thrombolysis. Male participants had better knowledge about smoking [86 (43.0) vs 38 (21.3); P < .001] and oily food [108 (54.0) vs 73 (41.0); P = .012] being risk factors and facial weakness [50 (37.6) vs 21 (11.8); P = .001] being symptom of stroke compared with females. Similarly, male participants had heard more about thrombolysis than females [68 (34.0) vs 22 (12.4); P < .001]. Conclusion Knowledge regarding risk factors and signs and symptoms of stroke was adequate among the students preparing for undergraduate medical entrance examination. However, knowledge about thrombolysis was poor. Male participants had better knowledge about risk factors, warning signs and symptoms of stroke, and thrombolysis compared with female.

choice for acute ischemic stroke, it needs to be administered within 4.5 hours of onset of symptom or last known consciousness; this is referred to as the "time window" for thrombolysis. 5 Thrombolysis, as a definitive management, has revolutionized the outcome in patients of stroke which, when done in time, greatly reduces disability associated with stroke. 6,7 Thrombolysis in Nepal has recently been started in the capital city (Kathmandu) at four tertiary care centers (as of time of writing) and so far only a handful of cases have undergone thrombolysis. 8,9 This could largely be explained by lack of knowledge regarding identification of stroke and thrombolysis among the population. Students preparing for undergraduate medical entrance examination are the prime focus of our study, as this could be an important group who could effectively inform their families and others about stroke and effective timing for thrombolysis. This study is an attempt to evaluate KAP among students preparing for undergraduate medical entrance examination regarding stroke and thrombolysis.

| Study design and population
This was a cross-sectional study that was performed in a single stage at an institute in Kathmandu, Nepal from June 18, 2018 to August 17, 2018. It is a premier coaching institute for the preparation of undergraduate medical entrance examination, where students from all the 77 districts of Nepal attend for their higher education. A prior informed permission was gained from the institute for conducting the study. Students who were ≥16 years of age, preparing for undergraduate medical entrance examination and provided consent to participate were included in the study. A total of 378 students who met the inclusion criteria were selected by non-probability method for the study. Written informed consent was obtained from all the participants.

| Sample size determination
The sample size was calculated based on high-risk population for stroke and these were patients with hypertension. So, prevalence of hypertension was used to calculate the sample size.

| Data analysis
Data were subsequently analyzed using SPSS software version 21.
Results of the descriptive analysis are presented as frequency, percentage and mean ± SD. Two-tailed Chi square test was used to analyze association between gender and KAP related to stroke and thrombolysis. A P-value <.05 was considered to be statistically significant.

| RESULTS
A total of 378 students participated in our study. The majority of the participants (49.7%) thought that the best means to make people aware of stroke was community and schoolbased programs (Table 3).

| DISCUSSION
The students participated in our study belong to a particular institute in an urban setting, who have adequate general information on stroke.
Only about one-tenth of them had not heard about stroke previously.
However, we discovered that less than a quarter of them had seen patient who was previously diagnosed as stroke, which can be attributed to their limited information about symptoms of stroke. Less than half of the students could correctly identify the organ affected in stroke, which was significantly higher than shown by the study of Alreshidi et al. 15 Facial deviation, which is an important sign was recognized by only 18.8% of the study population and this finding is in accordance to study performed by Alreshidi et al. 15 Approximately, 60% of the students opted to take patients to hospital after witnessing a suspected case of stroke, which is not satisfactory when considered in the background of urban setting and The students had the least information about the centers providing thrombolysis service as only 4% of them could rightly respond all the four centers where thrombolysis is being routinely performed. Knowledge of appropriate centers that can provide thrombolysis and their locations has been found to significantly affect pre-hospital delay after the relatives of the victim are able to identify stroke. 19,20 A good number of students (56.9%) were of the opinion that patients with stroke can improve with appropriate physiotherapy.
Community and school-based programs and health education provided by doctors and medical personnel were considered to be the most effective methods to make people aware of stroke.

| CONCLUSION
Study on KAP is essential to increase the awareness of risk factors, warning signs and symptoms, thrombolysis and secondary prevention in patients with stroke. Dissemination of information among the general population on stroke and the golden hour of thrombolysis is vital to reduce stroke-related morbidity and mortality in developing nations like Nepal. Having found that, through ensuring sufficient knowledge of stroke among students preparing for undergraduate medical entrance examination, it is possible to promote the level of KAP among general population toward stroke and thrombolysis as these students could effectively aware their family members and surroundings about stroke and thrombolysis. We recommend further largescale studies should be carried among Nepalese people about stroke and thrombolysis to reduce delay of patients reaching the hospital after they get stroke or seen someone with stroke.