Risk factors and knowledge about stroke prevention among females aged 40-80 years – preliminary report

INTRODUCTION

Diseases of the central nervous system are one of the most serious challenges of modern medicine. The World Stroke Organisation reports that one in six people will suffer a stroke in their lifetime [1]. Currently, this disease is the leading cause of disability and the third most common cause of death in the world. In 2020, cerebral circulation pathologies became the main cause of health loss, right next to coronary artery disease [1-5]. In Poland, the number of deaths caused by stroke is one of the highest in Europe and has remained at the same level for several years. The overall mortality rate due to stroke is about 18% (haemorrhagic strokes are about 40%, while ischaemic strokes are about 14%). In highly developed countries, this percentage is decreasing, but despite this, stroke is a huge social problem [2-10]. Up to the age of 75 years, the risk of stroke is higher in men than in women. However, the longer life span of women com-pared to men ultimately leads to a higher incidence of this condition in women. As statistics show, twice as many women die from stroke as from breast cancer [3, 11-13]. Stroke is a major health problem that significantly reduces patients’ quality of life. Appropriate and effective prevention is an especially important element that should reduce the economic and social consequences of stroke. Primary prevention implemented at an early stage and properly supervised secondary prevention will result in a reduced incidence of stroke. Both pharmacological treatment and non-pharmacological measures can significantly reduce the risk of the first ischaemic stroke, as well as protect the patient from the occurrence of a subsequent incident [4, 14, 15]. Medical staff should educate patients about the occurrence of stroke. This knowledge is especially needed for patients at risk. Early recognition of the symptoms indicative of stroke will help provide faster professional help and minimise the risk of permanent disability or death. Stroke is a disease in which time is extremely valuable. Patient education should begin with an explanation of what “stroke” is, followed by a presentation of risk factors and a discussion of primary and secondary prevention [2-10]. A healthy lifestyle is an essential element in health education. In a patient at risk of stroke or after a stroke, lifestyle should be appropriate in terms of physical activity. It is also important to remember to rest, prevent stressful situations, stop smoking, and avoid other stimulants [16-20].
The main objective of the study was to identify the risk factors for stroke among female neurological ward patients aged 40-80 years and their knowledge of primary and secondary prevention of stroke.

MATERIAL AND METHODS

The study was conducted between December 2021 and March 2022, among 72 female patients hospitalised in a neurological ward in one of the district hospitals in the Małopolska Voivodeship, after obtaining a written consent from the Management of the Hospital. Patients participating in the study were informed about the purpose of the study, the anonymity, and about their voluntary participation. A diagnostic survey method was used to conduct the research. The research tool was a questionnaire of our own authorship. The survey included 33 questions – single-choice, multiple-choice, and open-ended. The first part included questions that allowed us to characterise the study group (age, place of residence, level of education, marital status). The second part related to the studied subject (patients’ knowledge about stroke, risk factors, and preventive methods). In addition, questions about the weight and height of the respondents were included, based on which the body mass index (BMI) was calculated.
The respondents were aged 40-50 years (19%), 51-60 years (21%), 61-70 years (27%) and 71-80 years (33%), resided in rural areas (76%) and cities (24%), had primary education (15%), vocational education (22%), secondary education (36%), and higher education (27%). In the study group, the surveyed women were single (10%), married (55%), widowed (32%), and divorced (3%) (Table 1).
The data were analysed using the STATISTICA programme. Univariate analysis of variance, Student’s t-test for independent samples, and the chi-square (χ²) test were used in the statistical analysis. A significance level of p < 0.05 was assumed in all tests performed.

RESULTS

The average body weight of the respondents was 77.2 kg (SD = 13.8 kg), in the range of 46-105 kg. The average BMI value was 29.2 (SD = 5.7), in the range of 17.3-40. Only one patient was underweight, 16 patients had a normal body weight, 20 were overweight, obesity was diagnosed in 23 respondents, and 12 patients were obese in the second degree. Most of the respondents were non-smokers (62%). On average, there were 9.9 cigarettes per day per smoker. Only 5 patients who participated in the study admitted that they had quit smoking. Every fifth respondent declared being abstinent, 8% consumed alcohol several times a week, 15% several times a month, and occasionally 57%. Of other stimulants, only 14% of the respondents mentioned drinking coffee. White-collar work was performed by one in four women, physical work by one in three, while 44% were not professionally active.
Every third respondent declared a family history of stroke, and it mainly affected the mother (58%). Among the comorbidities, the respondents indicated diabetes (44%), hypertension (78%), myocardial diseases (19%), and vascular diseases (15%). According to the respondents, the diseases that increase the risk of stroke are arterial hypertension (94%), diabetes (81%), obesity (67%), and transient ischaemia (65%), followed by myocardial diseases (36%), migraine (24%), gout (14%), and vascular diseases (35%). Among the factors predisposing to stroke, the respondents indicated; age over 55 years (90%), age under 55 years (3%), masculine gender (29%), feminine gender (21%), Black race (29%), White race (22%), and positive familiar history (69%). Another risk factor for stroke in women may be the use of oral contraception, which is why the respondents were asked about its use. In the study group, 13% of the respondents used oral contraception. Of the respondents using oral contraception, 22% had been using it for less than 5 years, 22% for 5-10 years, while 56% had been using it for more than 10 years. Stress was often experienced by 32% of the respondents, and rarely by 36%. The respondents observed symptoms of stress mainly in the form of irritability (47%), headache (61%), nausea (22%), and trembling hands (40%). The majority (75%) of the respondents believed that diet has an impact on the incidence of stroke. They had 2-3 meals per day (18%), 4-5 meals (71%), and 6 or more meals per day (11%). One in four women surveyed declared that they take care of good eating habits, and 47% did not. Only 38% of the respondents ate regularly, while 62% did not eat regularly. The respondents indicated the following eating habits contributing to the reduction of the incidence of stroke: reducing salt in the diet (92%), eating cereals (51%), increasing the consumption of fruit and vegetables (58%), limiting meat consumption (56%), reducing fat consumption (65%), limiting coffee drinking to 2 cups per day (33%), limiting the consumption of saturated fatty acids (36%), and limiting alcohol consumption (54%). As primary prevention of stroke, the respondents indicated blood pressure control (86%), treatment of carbohydrate metabolism disorders (64%), reduction of overweight (78%), a balanced diet (50%), regular physical exercise (60%), avoidance of excessive stress (63%), quitting smoking (47%), and avoidance of excessive alcohol consumption (44%). As secondary prevention of stroke, the respondents indicated lifestyle changes and avoidance of stroke risk factors (78%), treatment with anticoagulants (63%), or surgical treatment of carotid artery stenosis (50%). More than half (54%) of those surveyed said that they followed the stroke prevention recommendations. Only 40% of the respondents were undertaking physical activity: 26% did it 0-2 times a week, 10% 3-4 times a week, and 4% 5-7 times a week. Among the respondents who undertook physical activity (n = 29), the forms of activity indicated by the respondents were: cleaning (10%), walking (59%), cycling (7%), fitness (3%), kitchen work (3%), swimming (7%), and running (10%). In the study group, as many as 89% of the respondents intend to change their lifestyle to one that is more favourable for health, while only 11% of respondents do not intend to change anything.
The study further examined the relationship between the respondents’ education and their knowledge of diseases that increase the risk of stroke. The χ² test of independence was used, in which no significant relationship was found between the variables studied (p = 0.9959). Similarly, when analysing the relationship between the respondents’ education and the factors that they believe predispose to stroke, no significant relationship was found (p = 0.9711).
The next step was to examine the relationship between BMI and the number of meals consumed by the respondents. A univariate analysis of variance was used. On the basis of the test, no significant relationship was found between BMI and the number of meals consumed (Table 2).
Next the relationship between BMI and regular food intake by the respondents was examined. Student’s t-test was used for independent samples, on the basis of which a significant relationship was found between BMI and eating regular meals (Table 3).
To examine the relationship between the respondents’ knowledge of primary and secondary prevention of stroke and their adherence to preventive recommendations, the χ² test of independence was used. Based on the test, no significant relationship was found between the respondents’ knowledge of primary stroke prevention and their adherence to preventive recommendations (p = 0.9947) (Table 4).
There was also no significant relationship between the respondents’ knowledge of secondary prevention of stroke and their adherence to preventive recommendations (p = 0.9056) (Table 5).

DISCUSSION

The conducted study shows that the body weight of people who have suffered an ischaemic stroke significantly exceeds the norm considered correct. Most of the patients in the study group were overweight, obese, or obese to the second degree. In recent years, there has been a trend towards an increasing number of overweight and obese people in the population. This is particularly dangerous in the context of stroke incidence because the presence of obesity increases the risk of stroke [21]. People diagnosed as overweight are 22% more likely to have a stroke than people of normal weight, while patients with obesity are 64% more likely to have a stroke. A BMI that increases by 1 kg/m2 increases the risk of ischaemic stroke by 4% and haemorrhagic stroke by 6% [22].
In the study group, 33% of the patients responded that stroke had occurred in their families. A significant proportion of the family history of stroke involved the patients’ mother. In a study conducted by Szeliga et al. [23] in a group of 50 women, at the age of 39 to 81 years, after a stroke, the following results were obtained: 36% of the respondents stated that stroke had previously occurred in the immediate family. This justifies the conclusion that inheritance plays a vital role in the development of strokes. Among comorbidities, hypertension and diabetes were mentioned by most respondents. Ischaemic strokes occur as a result of impaired proper brain perfusion, due to either narrowing of the vessel or its obstruction. The main risk factors are hypertension, atherosclerosis, and embolism [24]. Arterial hypertension increases the risk of stroke by 3-4 times, hence the correlation between the high incidence of hypertension in patients and their incidence of ischaemic stroke [25]. High blood pressure increases the risk of patient deterioration or death. Increased blood pressure values are often observed within the first 24 hours of the onset of stroke symptoms. It is also the time of the highest mortality of the patient [26]. Diabetes and its complications are directly responsible for approximately 60-80% of deaths. Complications of diabetic macroangiopathy increase the risk of death by 2-4 times. This is of great concern, especially since the number of people with diabetes is increasing significantly. In a UKPDS study conducted in the United Kingdom by the British Prospective Diabetes Study Group [27], blood pressure control had an impact on reducing the risk of microvascular complications, stroke, and diabetes-related death. It should be remembered that treatment of all risk factors is important in reducing complications resulting in cardiovascular diseases [27]. Diabetes is a significant risk factor for stroke. There is also an increased risk of death from stroke in a patient with an additional burden of diabetes. This is because the aetiology of stroke in a diabetic is related to small vessel disease due to fibrinoid necrosis or as a result of large intracranial vessel disease, causing atherosclerotic closure of the vessel lumen or its thrombosis [28]. Patients from the study group classified hypertension and diabetes as the most common diseases increasing the risk of ischaemic stroke. As a predisposing factor for stroke, as many as 90% of the surveyed women indicated the age over 55 years, which was the most frequently chosen answer by the patients. In a study conducted at the Department of Rehabilitation of the Musculoskeletal System in Wrocław on a group of 70 people aged 25-88 years, after a stroke, the results showed that the higher the patient’s age, the greater the risk of stroke. Over 80% of the respondents were over 50 years of age. Analysis of the results of the study shows that older people, i.e. over 60 years of age, are more likely to suffer a stroke [29]. When it comes to factors predisposing to stroke, genetic factors were another frequently chosen answer by the patients. The above-mentioned study conducted at the Department of Musculoskeletal Rehabilitation in Wrocław showed that more than 30% of women and 25% of men had previously had a stroke in an immediate family member (parents, siblings). Most people did not indicate the occurrence of stroke in family members [29]. A study by Rosińczuk et al. [30] found that one in five patients surveyed had previously had a stroke in someone in their immediate family. When comparing the relationship between gender and predisposition to stroke, patients more often indicated male gender. In a study based on the analysis of medical records of 168 patients staying in the neurology department, more than 55% of them were female. This study confirmed that gender does not play a significant role in the occurrence of stroke. Men and women have a similar level of risk of stroke [31]. Zawadzka et al. [32] reached the same conclusions. Only 29% of the respondents indicated Black race as a predisposing factor for stroke. Studies show that Black and Hispanic people have a higher tendency of morbidity and mortality from stroke compared to White people [29].
In the study group, one in three women was a smoker. Studies show that smoking cigarettes is the most common risk factor for stroke. A strong interaction between smoking cigarettes and taking contraceptives has also been demonstrated by Kustra et al. [33], where this combination increased the risk of stroke sevenfold.
Not many (13%) of the surveyed patients admitted that they had used oral contraception. Our study shows that most of them had been using it for more than 10 years, which significantly increases the risk of stroke. Taking birth control pills is associated with the risk of cardiovascular diseases, including stroke [34].
When asked about the frequency of alcohol consumption, the majority of the respondents (57%) answered that they drink alcohol occasionally. Alcohol is extremely harmful to the body, and has a particular effect on the brain, contributing significantly to the poorer recovery of patients after a stroke treated in neurological wards. In a study conducted at the Stanisław Staszic Specialist Hospital in Piła, based on 2770 patients’ medical histories, it was concluded that less than 30% of hospitalised patients abused alcohol [35]. In the surveyed group, only 14% of the respondents admitted that they abuse other stimulants. All respondents answered that it was coffee. Potentially, caffeine increases blood pressure, which is directly related to the occurrence of stroke. In contrast, the Framingham Heart Study [36] found that a 250 ml cup of coffee reduced the risk of stroke by 8%. A meta-analysis of cohort studies by Ding et al. [36] including more than one million participants showed that moderate coffee consumption reduces the risk of stroke.
When asked about the frequency of experiencing stress, as many as 7% of the respondents answered that they always feel stressed. The highest percentage of patients, 36%, indicated that they rarely experience stress. In a study conducted at the Department of Rehabilitation of the Musculoskeletal System in Wrocław, most of the respondents admitted to experiencing stressful situations in their lives once to several times a day – 75% of women and 65% of men [29]. In patients participating in our study, headache, irritability, and trembling hands appeared as the most common symptoms of stress. Another risk factor for stroke was the use of an inappropriate diet, with as many as 75% of the respondents answering that diet has an impact on the incidence of stroke. A diet rich in salt causes the development of hypertension, which can result in the occurrence of a stroke. Paying attention to healthy eating habits reduces the risk of stroke [37]. The most important elements of stroke prevention in terms of diet are adherence to the recommendations of the Mediterranean diet or the DASH diet [7]. The majority of the respondents answered that they eat 4-5 meals a day, and only 25% admitted that they care about good eating habits. As many as 47% of the patients admitted that they do not care about their diet and adherence to dietary recommendations. In the study group, only 38% of the respondents had regular meals. Most of the surveyed women drank 1.5 to 2 litres of fluids during the day. It should be remembered that proper hydration of the body is a key element of a healthy lifestyle. Since the brain consists of 80% water, it is considered essential for the proper functioning of the nervous system [38]. Most of the surveyed women indicated that a habit that reduces the risk of stroke is to limit the consumption of salt and fat in diet. For the surveyed women, diseases predisposing to stroke were primarily hypertension. A study conducted on 150 patients aged 28-88 years [39], hospitalised due to stroke showed that hypertension was the most common risk factor, diagnosed in 78% of patients. Ischaemic heart disease appeared in the history of 68% of the patients [39]. The number of people with hypertension is growing at an astonishing rate. The incidence of hypertension is closely related to behavioural factors (diet, alcohol, smoking, etc.). Poland has a high percentage of hypertensive patients. The first study in Poland in this field was the Pol-MONICA study, which was coordinated by the WHO (World Health Organisation). At that time hypertension was examined in 2 local populations. Hypertension was detected in 41% and 44% of the patients from the populations concerned [40]. Currently, this problem is growing, with an increasing rate of people with high blood pressure, and an increasing risk of death [40]. Therefore, it is important to adhere to the rules of prevention. In the study group, the surveyed women considered the following to be primary prevention: blood pressure control, reduction of excess weight, treatment of carbohydrate metabolism disorders, and regular physical exercise. As far as secondary prevention is concerned, most responses indicated lifestyle changes, treatment of stroke risk factors, and treatment with anticoagulants. The majority, as many as 54% of the surveyed women, declared compliance with preventive recommendations. Studies conducted in recent years show that the control of adherence to stroke risk factors is still not satisfactory. Most often, patients do not follow basic preventive recommendations [41]. The study involved 98 people after stroke, treated at the Military Health Resort and Rehabilitation Hospital and the Health Resort Hospital No. 4 in Ciechocinek [42]. The Health Behaviour Inventory by Z. Juczyński was used in the study. The study shows that patients pay attention to health-promoting behaviours only after they have had a stroke. Preventive behaviour was the lowest rated health behaviour [42]. The presented results of the study show that 60% of the surveyed women do not undertake physical activity. Of the 40% of women who declare to undertake physical activity, most of them undertake activity 0-2 times a week. The most frequently chosen activity by the respondents was walking. In people who have had a stroke, physical activity should be appropriately adapted to the patient’s abilities to avoid overloading the body. Walks are therefore a particularly good form of activity because it is easy to adjust the pace and the distance to one that the patient will be able to cover [43]. Physical activity is also important in the prevention of primary hypertension, which is closely related to the occurrence of stroke. Through physical activity, hypertension can be prevented and thus the risk of stroke can be reduced. With regular physical activity, the risk of death decreases by more than 50% [44]. In the study group, 89% of the respondents intend to change their lifestyle to one that is more conducive to health. In industrialised countries, the incidence of stroke has decreased significantly since the 1960s. This is associated with an increasingly widespread primary and secondary prevention, as well as improved detection and treatment of hypertension and an emphasis on lifestyle changes. In Poland, epidemiological studies to date have not shown such trends [45]. The relationship between the education of the respondents and their assessment of the risk of stroke was examined. No significant relationship was found between education and the assessment of diseases that increase the risk of stroke. People with primary education most often chose hypertension as a disease that increases the risk of stroke. Patients with vocational, secondary, and higher education also most often indicated hypertension as a disease that increases the risk of stroke. In the case of the relationship between education and the assessment of which factors predispose to stroke, patients with primary, vocational, secondary, and higher education most often indicated the age over 55 years. When examining the relationship between the age of the respondents and the presence of comorbidities, it was noted that hypertension is the most common comorbidity in patients of all ages. This indicates how big a problem the occurrence of hypertension is in post-stroke patients. According to the WHO, hypertension affects as many as 40% of the population over 25 years of age [46]. Examining the relationship between BMI and the number of meals consumed, it was noted that most patients ate 4-5 meals during the day, and there was no significant relationship between their BMI and the number of meals consumed. People who ate regularly had a significantly lower BMI level. A study conducted in February 2015 in a health clinic in Lublin on a group of 148 respondents showed that the BMI level was influenced not by the number of meals consumed, but by maintaining adequate intervals between meals, regularity, and caloric demand [47]. Proper nutrition is not only limited to supplementing the essential nutrients, but also to eating regularly. The number of meals consumed should be appropriate to the demand, and the times should be regular [47]. Examining the relationship between the respondents’ knowledge of primary prevention and their adherence to preventive recommendations, it was noted that the largest number of women declaring compliance with preventive recommendations indicated regular physical exercise as an element of primary prevention of stroke. Women who indicated that they did not follow the preventive recommendations most often indicated blood pressure control as an element of primary stroke prevention. No significant relationship was found between the respondents’ knowledge of primary stroke prevention and their adherence to preventive recommendations. While examining the relationship between the respondents’ knowledge of secondary prevention of stroke and adherence to preventive recommendations, it was noted that women who declared following preventive recommendations most often chose lifestyle changes and treatment of stroke risk factors. Women who did not declare compliance with preventive recommendations also most often selected these responses. No significant relationship was found between the respondents’ knowledge of secondary prevention of stroke and their adherence to preventive recommendations. The relationship between the assessment of conditions predisposing to stroke and the diseases the surveyed women suffered from was also examined. Patients suffering from atherosclerosis most often indicated hypertension as a condition predisposing to stroke, while women suffering from cardiac arrhythmias, hypertension, coagulation disorders, and transient ischaemic attacks also most often indicated this condition. There was no significant relationship between comorbidity and the condition predisposing to stroke according to the respondents. The limitation of the study is the large age range of the subjects, which could have affected the results obtained. In the next stages of the research, the focus should be on comparing knowledge taking into account the age ranges of respondents.

CONCLUSIONS

The main risk factors for stroke in women are improper diet, being overweight, insufficient physical activity, stress, and coexisting diseases.
Most of the women in the study were aware of the risk factors for stroke and the principles of primary and secondary prevention of stroke, but they did not always follow the preventive recommendations.
Education of the patients on the principles of proper nutrition is advisable, as most of the women surveyed did not take care of good eating habits.
Most of the surveyed women declared that they would change their lifestyle to one that is more conducive to health.
It is advisable to increase physical activity among the respondents.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References