Background: the recognition of stroke symptoms by the public and activation of the emergency medical services (EMS) are the most important factors in instigating pre-hospital stroke care. Studies have suggested that poor recognition of the warning signs of stroke is the main cause of delay in accessing the EMS. Methods: an integrative review of published studies about stroke knowledge and awareness was performed by searching online bibliographic databases, using keywords, from 1966 to 2008. Studies were included in the review if they focussed on risk factors, signs and symptoms, action and information. Each study was reviewed by two researchers (SJ and MJ). Results: we identified 169 studies of which 39 were included in the review. The ability to name one risk factor for stroke varied between studies, ranging from 18% to 94% when asked open-ended questions and from 42% to 97% when asked closed questions. The ability to name one symptom ranged from 25% to 72% when asked open-ended questions and from 95% to 100% when asked closed questions. When asked what action people would take if they thought they were having a stroke, between 53% and 98% replied that they would call the EMS. People generally obtained information about stroke from family and friends. Older members of the population, ethnic minority groups and those with lower levels of education had consistently poor levels of stroke knowledge. Conclusions: generally, levels of knowledge about recognising and preventing stroke were poor. Nevertheless, most participants stated they would contact the EMS at the onset of stroke symptoms.

Background: The burden of stroke is increasing in India; stroke is now the fourth leading cause of death and the fifth leading cause of disability. Previous research suggests that the incidence of stroke in India ranges between 105 and 152/100,000 people per year. However, there is a paucity of available data and a lack of uniform methods across published studies. Aim: To identify high-quality prospective studies reporting the epidemiology of stroke in India. Summary of review: A search strategy was modified from the Cochrane Stroke Strategy and adapted for a range of bibliographic databases from January 1997 to August 2020. From 7717 identified records, nine studies were selected for inclusion; three population-based registries, a further three population-based registries also using community-based ascertainment and three community-based door-to-door surveys. Studies represented the four cities of Mumbai, Trivandrum, Ludhiana, Kolkata, the state of Punjab, and 12 villages of Baruipur in the state of West Bengal. The total population denominator was 22,479,509 and 11,654 (mean 1294 SD 1710) people were identified with incident stroke. Crude incidence of stroke ranged from 108 to 172/100,000 people per year, crude prevalence from 26 to 757/100,000 people per year, and one-month case fatality rates from 18% to 42%. Conclusions: Further high-quality evidence is needed across India to guide stroke policy and inform the development and organization of stroke services. Future researchers should consider the World Health Organization STEPwise approach to Surveillance framework, including longitudinal data collection, the inclusion of census population data, and a combination of hospital-registry and comprehensive community ascertainment strategies to ensure complete stroke identification.

Background: The burden of stroke (a leading cause of disability and mortality) in Africa appears to be increasing, but a systematic review of the best available data to support or refute this observation is lacking. Aim: To determine the incidence and 1-month case-fatality rates from high-quality studies of stroke epidemiology among Africans. Summary of review: We searched and retrieved eligible articles on stroke epidemiology among indigenous Africans in bibliographic databases (MEDLINE, ScienceDirect, Google Scholar, and Cochrane library) using predefined search terms from the earliest records through January 2022. Methodological assessment of eligible studies was conducted using the Newcastle–Ottawa scale. Pooling of incidence and case-fatality rates was performed via generalized linear models (Poisson-Normal random-effects model). Of the 922 articles retrieved, 14 studies were eligible for inclusion. The total number of stroke cases was 2568, with a population denominator (total sample size included in population-based registries or those who agreed to participate in door-to-door community studies) of 3,384,102. The pooled crude incidence rate of stroke per 100,000 persons in Africa was 106.49 (95% confidence interval (CI) = 58.59–193.55), I² = 99.6%. The point estimate of the crude incidence rate was higher among males, 111.33 (95% CI = 56.31–220.12), I² = 99.2%, than females, 91.14 (95% CI = 47.09–176.37), I² = 98.9%. One-month case-fatality rate was 24.45 (95% CI = 16.84–35.50), I² = 96.8%, with lower estimates among males, 22.68 (95% CI = 18.62–27.63), I² = 12.9%, than females, 27.57 (95% CI = 21.47–35.40), I² = 51.6%. Conclusion: The burden of stroke in Africa remains very high. However, little is known about the dynamics of stroke epidemiology among Africans due to the dearth of high-quality evidence. Further continent-wide rigorous epidemiological studies and surveillance programs using the World Health Organization STEPwise approach to Surveillance (WHO STEPS) framework are needed.

Background Around 25% of patients who had a stroke do not present with typical ‘face, arm, speech’ symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives). Method We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool. Results Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%–28%), nausea/vomiting (n=94; 8%–38%), dizziness (n=86; 23%–27%), changes in mental status (n=51; 8%–25%) and visual disturbance/impairment (n=43; 13%–28%). Conclusion Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.