TITLE PAGE KNOWLEDGE OF ASSOCIATED RISK FACTORS OF

TITLE PAGE
KNOWLEDGE OF ASSOCIATED RISK FACTORS OF
STROKE AMONG ADULTS IN NNEWI URBAN
BY
NWANKWO, CLEMENTINA UKAMAKA
Reg. No: 2004186001 P
A THESIS SUBMITTED TO THE DEPARTMENT OF HUMAN KINETICS
AND HEALTH EDUCATION, FACULTY OF EDUCATION, NNAMDI
AZIKIWE UNIVERSITY, AWKA. IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE (M.Sc.)
DEGREE IN HEALTH EDUCATION.
OCTOBER, 2010
i
APPROVAL PAGE
This is to certify that this thesis has been read and approved in the Department of
Human Kinetics and Health Education, Faculty of Education, Nnamdi Azikiwe
University, Awka.
………………………
Supervisor
………………………
Date
Prof. A.I. Ogbalu
…………………….
Head of Department
………………………
External Examiner
………………………
Dean of Faculty
………………………
Date
…………………….
Date
……………………..
Date
ii
CERTIFICATION PAGE
This is to certify that I am responsible for the work submitted in this Thesis, that
the original work is mine except as is specified in the acknowledgement and
references. Neither the Thesis nor the original work contained therein has been
submitted to this university or any other institution for the award of the M.Sc
degree in Health Education.
……………………………..
Nwankwo, Clementina U.
…………………………….
Date
iii
DEDICATION PAGE
This work is dedicated to my late father in-law, mother and nephew who were
victims of stroke. May their gentle souls rest in peace. Amen
iv
ACKNOWLEDGEMENTS
The researcher remains ever grateful to the Almighty God for His infinite
mercy and goodness to her and her entire family throughout the period of this
course.
She is indebted to her supervisor Prof. A.I. Ogbalu for his wonderful and
critical supervision of this work. He really left no stone unturned in ensuring that
this work is well done. May God bless him and his family. She wishes to express
her profound gratitude to Dr E.C Agbanusi - Head, Department of Human Kinetics
and Health Education. The researcher will not forget to extend her gratitude to all
her lecturers in the Department of Human Kinetics and Health Education in
particular and the Education Faculty in general for providing her with the
knowledge on which this thesis is based. Her special thanks also go to Prof. A.S.
Omenyi - Dean, Faculty of Education for her tireless effort to move the faculty
forward.
She is also grateful to her husband, children and entire family for their
understanding and support throughout the period of this program. She wishes to
thank Dr. C.A. Nwankwo for his wonderful statistical work and also Miss
Ogechukwu for typing the manuscript.
May the good Lord bless them all abundantly in Jesus Name, Amen.
Nwankwo, C.U.
v
ABSTRACT
The study is on knowledge of associated risk factors of stroke among adults in
Nnewi urban. Stroke has profound and devastating effects on human beings. It has
been observed that there is a great number of mortality and morbidity as a result of
stroke in Nnewi urban. New cases of stroke are being recorded each day and
previous records (2004-2008) from Nnamdi Azikiwe Teaching Hospital can attest
to this. Ensuring quality life and longevity is a challenge because adequate
knowledge of stroke-related factors is very vital. Thus, the rationale for the study
was to determine the knowledge of associated risk factors of stroke possessed by
adults in Nnewi urban. Five research questions and three hypotheses guided the
study. Adopting a survey research design, a sample frame of 8,610 adults was
drawn by the use of purposive sampling technique. Data were collected from the
subjects using structured questionnaire. The face and content validity of the
instrument was ascertained by six experts and also the researcher’s supervisor,
while the reliability of the instrument was established through split-half method
and data were analyzed using Pearson Product Moment Correlation Coefficient
and a coefficient alpha of 0.94 was obtained. The instrument was administered to
the subjects face to face. Descriptive statistical measures, t-test and ANOVA were
used to analyze data. The findings showed that the commonest risk factors of
stroke include stress, use of contraceptives like oral pills; and hypertension. Only
2920 (34%) of the adults have good knowledge of the associated risk factors of
stroke. The female adults are more knowledgeable than the male adults. Adults of
different age groups differ significantly in their knowledge of associated risk
factors of stroke, and that adults differ significantly in their knowledge of the
associated risk factors of stroke based on their educational levels. The researcher
therefore concluded that since adults in Nnewi urban generally possessed low
knowledge of associated risk factors of stroke, health education is highly needed at
Nnewi urban. Hence, the following recommendations were made; first, there is
need for state and local government to sponsor a well packaged health education
programme through the mass media to enlighten the populace on the associated
risk factors of stroke. Secondly, state and local government should organize
seminars or workshops for health facility staff on proper screening and early
detection of people at risk. Thirdly, people should adopt healthy life styles.
vi
TABLE OF CONTENTS
Contents
page
Title Page
i
Approval Page
ii
Certification Page
iii
Dedication
iv
Acknowledgements
v
Abstract
vi
Table of Contents
vii
List of Tables
x
Appendices
xii
CHAPTER ONE
1
INTRODUCTION
1
Background of the Study
1
Statement of the Problem
4
Purpose of the Study
6
Significance of the Study
7
Scope of the Study
8
Research Questions
8
Hypotheses
9
vii
CHAPTER TWO
10
REVIEW OF RELATED LITERATURE
10
Conceptual Framework
10
Concept of Stroke
11
Concept of Adulthood
50
Concept of Knowledge
51
Theoretical Framework
53
Disease Theory
53
Stroke Theory
56
Human Growth and Developmental Theories
58
Knowledge Theories
59
Review of Previous Researches (Empirical studies)
61
Summary of Literature Review
69
CHAPTER THREE
METHOD
72
Research Design
72
Area of the Study
73
Population of the Study
73
viii
Sample and Sampling Techniques
74
Instrument for Data Collection
74
Validation of the Instrument
74
Reliability of the Instrument
75
Method of Data Collection
75
Method of Data Analysis
76
CHAPTER FOUR
78
PRESENTATION AND ANALYSIS OF DATA
78
Summary of Findings
83
CHAPTER FIVE
85
DISCUSSION OF RESULTS, CONCLUSION AND
RECOMMENDATIONS
85
Discussion of Results
85
Conclusion
90
Implications of the Study
91
Recommendations
91
Limitations of the Study
93
Suggestions for Further Researches
94
REFERENCES
95
ix
LIST OF TABLES
Tables
Contents
Page
1
Frequency and Percentages
78
of Respondents on their knowledge
of Associated Risk Factors of Stroke .
2
Range of Scores, Frequency and
79
Percentages on the knowledge of
Associated Risk Factors of Stroke.
3
Mean Scores of Male and Female
80
Adults on the Knowledge of
Associated Risk Factors of Stroke.
4.
Mean Score of the Adults of Various
80
Age Groups on their Knowledge of
Associated Risk Factors of Stroke.
x
5.
Mean Scores of Adults on the
81
Knowledge of Associated Risk Factors
of Stroke Based on Educational Level.
6.
t-test on the Mean Scores of Male and
82
Female Adults on their Knowledge
of Associated Risk Factors of Stroke
7.
ANOVA on the Mean Scores of the
82
Adults from Various Age Groups
on their Knowledge of Associated
Risk Factors of Stroke
8.
ANOVA on the Mean Scores of
83
the Adults’ Knowledge of the
Associated Risk Factors of Stroke
Based on Educational Level.
xi
APPENDICES
Appendix A: Questionnaire on Associated Risk
page
104
Factors of Stroke
Appendix B: Previous Records from Nnamdi Azikiwe
University Teaching Hospital, Nnewi.
Appendix C: Area of Study (4 main towns & 29 villages)
110
111
xii
1
CHAPTER ONE
INTRODUCTION
Background of the Study
Stroke is defined as the interruption of blood to the brain; that is due to
blockage of a blood vessel in the brain or rupture of a blood vessel, causing
bleeding in the brain or into the space surrounding the brain. The most
common type of stroke is ischaemic, caused by a blood clot blocking an artery
or blood vessel. The brain cells in the immediate area die and those in the
surrounding areas are affected by the reduced blood flow and once brain cells
die, their functions die with them (Better Health, 2010). According to Heart
Communities.com (2010), strokes or brain attacks are a major cause of death
and permanent disability.
Wikipedia (2010) stated that stroke known medically as a
cerebrovascular accident (CVA) , is the rapidly developing loss of brain
function(s) due to disturbance in the blood supply to the brain and can be due
to ischaemia (lack of blood) caused by blockage (thrombosis, arterial
embolism) or a haemorrage (leakage of blood). As a result, the affected area is
unable to function, leading to inability to move one or more limbs on one side
of the body, inability to understand or formulate speech, or an inability to see
one side of the visual field. A stroke is a medical emergency and can cause
permanent neurological damage, complications and even death. It is the
leading cause of adult disability in the United States and Europe and is the
number two cause of death world wide.
2
According to Park (2002), the term “stroke” (syn: apoplexy) is applied
to acute or severe manifestation of cerebrovascular disease. It causes both
physical and mental crippling. World Health Organisation (WHO) defined it as
“rapidly developed clinical signs of focal (or global) disturbance of cerebral
function, lasting more than 24 hours or leading to death, with no apparent
cause other than vascular origin. It is a world-wide health problem.
Stroke has many risk factors which are those attributes that increase
one’s vulnerability to a disease condition. American Heart Association (2010)
stated that risk factors of stroke include age, heredity, race, sex, prior stroke,
heart attack, transient ischaemic attack, sickle cell disease, alcohol, high blood
pressure, diabetes mellitus and many others. Variables like gender, age and
educational level influence the knowledge of risk factors of stroke and
occurrence of stroke. The majority of people who suffer from stroke are 65
years or older and men are at higher risk than women (Better Health, 2010).
Persons over 65 years are affected more because of the adverse effects of
ageing process like atherosclerosis (Berman, Snyder, Kozier & Erb, 2008).
Education increases one’s knowledge and knowledge is the remembering or
recalling of a material that has been learned previously (Samuel & Kiloh,
2006). Knowledge as used in this study refers to the understanding and recall
of facts involving associated risk factors of stroke. Akinsola (2002) stated that
there is a health model called Knowledge, Attitude and Practice (KAP) which
is based on the principle that if you increase people’s knowledge about their
health practices (e.g. proper hygiene, avoidance of drug abuse, healthy life
3
styles) their attitude will be changed or modified, and once their attitude is
more positive, their health behavior will also improve.
Adelowo (2008) stated that a man aged 45, who was hypertensive and
diabetic died of stroke in his office and his co-workers believed that he had
suffered from a “Jazz” attack. This shows that they have no knowledge of risk
factors of stroke and even the dead man was not aware of the risk factors of
stroke. The researcher experienced this problem in Nnewi through her relatives
and a family friend who were victims of stroke and unfortunately lost their
lives out of it. They include, the researcher’s father-in law (a known diabetic
and hypertensive patient aged 61); her mother aged 95 who had congestive
cardiac failure, and a family friend aged 70 who was hypertensive.
The researcher is of the opinion that these victims would not have died if they
had adequate knowledge of associated risk factors of stroke. The researcher
while caring for her mother at Nnamdi Azikiwe Teaching Hospital, Nnewi for
four weeks witnessed increased admission of stroke patients and also high
death rate of patients with stroke compared with patients suffering from other
conditions.
Moreover, the researcher having lived in Nnewi for 13 years, now
observed that some inhabitants of Nnewi urban indulge in some unhealthy life
styles like smoking, abuse of drugs and excessive alcohol consumption which
are believed to be the commonest hazardous lifestyles that can predispose one
to diseases like stroke. The people of Nnewi are mainly business men and
women, some of them depend on junk foods and fast foods for breakfasts and
4
lunch. They only stay at their homes at night to eat normal diet if possible.
Excessive intake of calories from junk and fast foods more than the body can
burn may lead to overweight, which in turn may lead to other diseases of life
styles like obesity, diabetes, atherosclerosis and all these are factors associated
with stroke.
Again, Nnewi urban being one of the biggest commercial areas in
Anambra State, is a busy area with traffic congestion, noise everywhere
subjecting the inhabitants to stress, physical trauma, lack of exercise and over
concentration on acquiring wealth with little or no concern for their health,
invariably predisposing them to stroke. Knowledge of risk factors of stroke is
very important for its prevention and from their life style; it appears the people
have no such knowledge. Hence the researcher asked, do adults in Nnewi
urban possess knowledge of associated risk factors of stroke? From literature
no study has been conducted to ascertain the knowledge of risk factors of
stroke possessed by the adults in Nnewi urban. This study will fill this gap.
Statement of the Problem
Stroke imposes challenges on the health, social and economic
development of any family where it exists. It has been observed that the
mortality and morbidity as a result of stroke in Nnewi urban are on increase.
New cases of stroke are spiking up each day. Stroke whether partial or
complete often leads to morbidity and mortality. Previous records (2004-2008)
from Nnamdi Azikiwe Teaching Hospital Nnewi showed that this disease
5
(stroke) is affecting many people comprising various ages and gender groups.
Within the five years period (2004 – 2008), a total number of 298 adults were
affected by stroke and many lives were lost by it while some were disabled;
and some of these patients were from Nnewi urban. Therefore, the researcher is
worried about its increase in number in Nnewi urban. From literature,
knowledge of associated risk factors of stroke is necessary for its prevention.
Consequences of not having knowledge of the risk factors of stroke
include adoption of unhealthy life styles like cigarette smoking, abuse of drugs,
excessive alcohol consumption which invariably results to high incidence rate
of stroke in the community, high mortality and morbidity rates in the country,
increased rate of disability , loss of loved ones, reduced family economic
status due to high cost of hospital bills for the stroke patient, permanent
neurological damage and increased rate of role conflicts in the families where
stroke exists. Also there may be loss of employment due to disability; physical
disabilities include muscle weakness, numbness, pressure sores, pneumonia,
incontinence, apraxia, difficulties in carrying out the daily activities, appetite
loss, speech loss, vision loss and pain. In severe cases, coma or death may
result. Emotional problems include anxiety, panic attack, flat effect, mania,
apathy and psychosis, depression, lethargy, irritability, sleep disturbance,
lowered self esteem and withdrawal. Emotional lability and cognitive defects
such as perceptual disorders, speech problems, dementia, hemispatial neglect
and seizures may develop.
Hence, the problem is; do adults in Nnewi urban possess knowledge
6
of associated risk factors of stroke? From the literature reviewed, no study has
been conducted in Nnewi urban on the knowledge of associated risk factors of
stroke and this is the gap the researcher wants to fill.
Purpose of the Study
The purpose of the study is to determine knowledge of associated
risk factors of stroke among adults in Nnewi urban; specifically this study
tends to:
1.
identify the associated risk factors of stroke known by adults in Nnewi
urban.
2.
ascertain the level of knowledge of associated risk factors of stroke
possessed by adults in Nnewi urban.
3
ascertain the knowledge of associated risk factors of stroke possessed
by adults in Nnewi urban based on gender.
4.
ascertain the knowledge of associated risk factors of stroke possessed by
adults in Nnewi urban based on age groups.
5
ascertain the knowledge of associated risk factors of stroke possessed by
adults in Nnewi urban based on educational level.
7
Significance of Study
The findings of the study will be of benefits to the Ministry of Health
especially Health Education Unit, health educators in the local government
area, nurses and other health workers in the community, researchers and people
in the villages. The ministry of health especially health education unit will be
provided with information from this study through publication of this work.
The information gathered will help the people organizing health education
programme to program seminars on associated risk factors of stroke with more
emphasis on those risk factors the adults possessed low knowledge of.
Health educators in the local government areas will also benefit from
the findings of this study through publication of the work to enable them plan
program for those with low knowledge in their various local government areas.
Nurses and other health workers like community health extension
workers (CHEW) will also benefit from the findings when published in
journals, magazines or newspapers.
Researchers will benefit from the findings of the work through
reading of journal, magazines, newspaper or internet containing the published
findings of the work. Report of the study will be useful to other curious
researchers who may want to find more information on some aspects of the
subjects not covered in the present work or who may at least wish to test the
replicability of the study in another environment.
People in the villages will also benefit from the findings through
listening to news in radio, television or health talk in the health facilities.
Presumably, this will increase their knowledge of associated risk factors of
stroke and contribute to a drop in the prevalence as well as morbidity and
mortality associated with stroke. Finally, the finding will add to the existing
literature on stroke.
8
Scope of the Study
The study focused on the knowledge of associated risk factors of
stroke by adults especially those risk factors that are preventable. It considered
such independent variables as age, sex and educational level. Structured
questionnaire was used to collect data for the study. It was also delimited to
Nnewi urban.
Research Questions
The following research questions were used by the researcher for
the study.
1.
Which associated risk factors of stroke are known by adults in Nnewi
urban?
2.
What level of knowledge of associated risk factors of stroke do adults in
Nnewi urban possess?
3.
What knowledge of associated risk factors of stroke do male and female
adults in Nnewi urban possess?
4.
What knowledge of associated risk factors of stroke do adults of
different age groups in Nnewi urban possess?
5.
What knowledge of associated risk factors of stroke do adults of
different educational levels in Nnewi urban possess?
9
Hypotheses
The following null hypotheses guided the study. These hypotheses were
tested at .05 level of significance.
1.
There is no significant difference in the mean scores of male and female
adults on their knowledge of the associated risk factors of stroke.
2.
There is no significant difference in the mean scores of adults in their
knowledge of associated risk factors of stroke due to their age groups.
3.
The adults in Nnewi urban do not differ significantly in their knowledge
of associated risk factors of stroke due to their educational levels.
10
CHAPTER TWO
REVIEW OF RELATED LITERATURE
This chapter discusses the related literature reviewed by the researcher.
Considering that, this research bordered on knowledge of associated risk
factors of stroke among adults in Nnewi urban; the literature review was
therefore treated under the following subheadings, viz:
 Conceptual Frame Work:
- Concept of stroke
- Risk factors associated with stroke
- Preventive measures for stroke
- Incidence of stroke
- Epidemiology of stroke in Nigeria
- Causes of stroke
- Clinical manifestations of stroke
- Concept of adulthood
- Concept of knowledge
 Theoretical Frame Work: Disease theory, stroke theory, human growth
and developmental theory and knowledge theory.
 Review of Previous Researches (Empirical studies)
 Summary of Related Literature.
11
Concept of Stroke.
Healthline.com (2010) defined stroke as an interruption of the blood
supply to any part of the brain and stroke is sometimes called a brain attack.
According to Heart Disease and Prevention (2010), stroke is a sudden death of
some brain cells due to a lack of oxygen when the blood flow to the brain is
impaired by blockage or rupture of an artery to the brain. A stroke is also
called a cerebrovascular accident (CVA). It is a medical emergency and any
one suspected of having a stroke should be taken to a medical facility for
diagnosis and treatment.
Okoye (2006) simply defined stroke as a condition that principally
presents with sudden inability of the affected person to move his or her hands
and/or legs; and is a common phenomenon that means different things to
different people. According to him, most Africans believe that stroke is a
product of evil spell from an enemy, though the sudden onset of signs and
symptoms of stroke somewhat support their negative instinct. Basavanthappa
(2007) stated that stroke refers to any pathological process involving the blood
vessels of the brain resulting to neurologic deficits. Proper functioning of the
brain depends on an adequate blood supply to deliver oxygen and glucose for
neuronal activity and to remove the end product of metabolism; therefore when
there is inadequate supply of blood to brain, stroke results.
Furthermore, Boon, Colledge, Walker and Hunter (2006), indicated that
stroke include episodes of focal brain dysfunction due to focal ischemia or
12
hemorrhage as well as subarachnoid hemorrhage. They added that it is the
third most common cause of death in the developed world after cancer and
ischaemic heart disease; and is the most common cause of severe physical
disability. Smeltzer and Bare (2000), opined that a stroke or what is now
being termed ‘brain attack” is a sudden loss of brain function resulting from
disruption of the blood supply to a part of the brain. Mcmurdo (2000),
stated that a stroke occurs when the blood supply to the brain is disturbed in
some way. As a result, brain cells are starved of oxygen causing some cells
to die and leaving others damaged. According to Walsh (2002), strokes are
among the most common of all neurological disorders and the greater
number may be classified as ischemic or hemorrhagic. Either may cause a
cerebrovascular infarction which is commonly known as a stroke.
More so, Minarik (1995), opined that complete lack of blood flow to
specific areas of the brain causes tissue infarction, resulting in stroke.
Senelick, Rossi and Dougherty (1994), stated that a stroke is an acute
neurological injury whereby the blood supply to a part of the brain is
interrupted and can also be said to be a syndrome of sudden loss of
neuronal function due to disturbance in cerebral perfusion. This disturbance
in perfusion is commonly on the arterial side of the circulation, but can be
on the venous side. The part of the brain with disturbed perfusion can no
longer receive adequate oxygen carried by the blood; brain cells are
therefore damaged or die, impairing function from that part of the brain. It
is a medical emergency and can cause permanent neurological damage or
13
even death if not promptly diagnosed and treated. It is the third leading
cause of death and adult disability.
According to Ferguson (1984), strokes represent episodes of brain injury
and necrosis resulting from a ruptured blood vessel (cerebral haemorrhage )
or vascular clot (cerebral thrombosis). Harrison (1984) declared that a
stroke is an abrupt loss of function of part of the nervous system due to a
vascular lesion and brain cells die if their blood supply is lost for 4 minutes
or longer. The dead (infarcted) areas of brain may become Scar tissue or a
cyst. Eldra and Davis (1983) opined that when atherosclerosis occurs in
cerebral arteries, the blood supply to the brain may be diminished; and
should an artery serving the brain be occluded by the plaque itself or by a
thrombus or embolism (an embolism is a thrombus that has moved from its
point of origin), a portion of the brain may be completely deprived of
oxygen and nutrients; and such conditions are commonly referred to as
strokes.
In the same vein, Price and Wilson (1982) posited that stroke is in
general terms, a disturbance in cerebral circulation and is a focal
neurological disorder and may be secondary to a pathologic process within
a cerebral blood vessel such as thrombosis, embolus, rupture of vessel wall,
basic vascular disease such as atherosclerosis, arthritis, trauma, aneurysms
and developmental malformations. Green (1976) described stroke as a
condition in which small blood vessels in the brain such as the branches of
the lenticulostriate artery, which supply the fibre tracks running through the
14
internal capsule from the motor cortex to the midbrain, may burst if the
blood pressure becomes too high. The haemorrhage which follows is
commonly called a “stroke”. Alternatively a cerebral thrombosis may occur.
In either case the interruption of the corticospinal tracts will lead to
weakness or paralysis on the opposite side of the body (hemiplegia).
Risk Factors Associated With Stroke:
Better Health (2010) and Wikipedia (2010) stated that risk factors of
stroke include high blood pressure, cigarette smoking, high cholesterol,
alcohol, diabetes mellitus, diet and exercise. Others are age, gender and
family history; and these are beyond one’s control. However, one can
substantially reduce one’s overall risk by making healthy changes to one’s
diet and life style. According to American Heart Association (2010), some
stroke risk factors are hereditary. Others are a function of natural processes
while still others result from a person’s life style. One can not change risk
factors related to natural processes or heredity, but those resulting from life
style or environment can be modified with the help of a health care
professional. Risk factors that cannot be changed include age, gender,
heredity (family history) and race, prior stroke, transient ischaemic attack or
heart attack.
National Stroke Association (2010) indicated two types of stroke risk
factors namely controllable and uncontrollable risk factors. Controllable
risk factors generally fall into two categories: life style risk factors and
15
medical risk factors. Life style risk factors can often be changed, while
medical risk factors can usually be treated. Examples of controllable risk
factors are high blood pressure, atherosclerosis, tobacco use, physical
inactivity, atrial fibrillation among others. Uncontrollable risk factors
include age, gender, race, family history, previous stroke, fibro muscular
dysplasia and patent foramen ovale (hole in the heart). Laura (2010)
identified ten simple and modifiable risk factors of stroke to include among
others, abdominal obesity, poor diet, more than 30 drinks per month or
binge drinking, ratio of blood fats known as apolipoprotein B (apo B) to
apolipoprotein AI(apo AI) and psychosocial stress / depression.
Centers for Disease Control and Prevention (2010) stated that anyone
can have a stroke, but certain behaviours and medical conditions can
increase one’s chances. Fortunately, anyone can take steps to lower their
risks whether conditions, behaviour or heredity. Michos, Albert and
Luekper (2010) discovered vitamin – D deficiency linked with fatal stroke
in whites but not in blacks. In whites, vitamin-D deficiency was associated
with a two-fold increase in fatal stroke after adjustment from other risk
factors.
Okoye (2006) stated that stroke is not on its own a disease entity rather
an end stage of certain chronic diseases and other circulatory/metabolic
derangements. There are risk factors that can lead to or increase the chances
of one developing stroke; and that some of the risk factors can be
eliminated while some can only be minimized. Department of Health and
16
Human Services Centers for Disease Control and Prevention (2007) stated
that some conditions as well as some lifestyle factors can put people at a
higher risk for stroke. Persons who have had a stroke need to control the
risk factors in order to lower their risk of having another stroke, and all
persons can take steps to lower their risk for stroke.
According to American Heart Association (2009), stroke risk factors are
traits and lifestyle habits that increase the risk of the disease.
They further opined that some stroke risk factors are hereditary, others are a
function of natural processes and still others result from a person’s lifestyle.
That one can not change factors related to heredity or natural processes, but
those resulting from lifestyle or environment can be modified with the help
of a healthcare professional through proper health education.
The most important treatable conditions linked to stroke are:High blood pressure (Hypertension), cigarette smoking, heart disease,
diabetes mellitus and transient ischemic attacks (National institute of
Neurological Disorders and Stroke, 2009; Okoye 2006 and Department of
Health and Human Services Centers for Disease Control and Prevention,
2007). According to American Heart Association (2009), risk factors of
stroke that can be changed, treated or controlled include high blood
pressure, cigarette smoking, oral contraceptives, diabetes mellitus, carotid
or other artery disease, atrial fibrillation, other heart disease, sickle cell
disease, high blood cholesterol, poor diet and physical inactivity and
obesity. Risk factors for stroke that cannot be changed are age, heredity
17
(family history) and race; sex (gender) and prior stroke, transient ischemic
attack or heart attack where as less well – documented risk factors of stroke
are geographic location, socioeconomic factors, alcohol abuse and drug
abuse. According to Okoye (2006), controllable risk factors include among
others family history of stroke, high cholesterol (fat), lack of physical
activity, over weight or obesity, Christianity without knowledge, age and
previous history of stroke or transient ischemic attack.
However, the researcher wished to dwell on the risk factors of stroke
that can be changed, treated, minimized or controlled. Examples
hypertension, stress, diabetes mellitus, sickle cell disease/anaemia, cigarette
smoking. obesity, excessive alcohol consumption ,excess lipids and
cholesterol, polycythemia, advanced age, oral contraceptives, trauma,
menopause, atrial fibrillation, occupation, lack of exercise, poor nutrition,
genetic and congenital conditions, blood clotting and viscosity, heart
disease and carotid or other artery disease, and so on.
Hypertension: The major risk factor of stroke is hypertension (Snider,
1982;
Huntington, 1987; Waugh & Grant, 2006; Walsh, 2002, Guyton & Hall,
1996; Park, 2002, Edwards, Bouchier, Haslett & Chilvers. 1995, Mcmurdo,
2000, Senelick, Rossi & Dougherty, 1994, Okoye, 2006, American Heart
Association, 2009, Department of Health and Human Services Centers for
Disease Control and Prevention, 2007, & National Institute of Neurological
Disorders and Stroke, 2009). American Heart Association (2009) declared
18
that hypertension is the leading cause of stroke and the most important
controllable risk factor for stroke. Department of Health and Human
Services Centers for Disease Control and Prevention (2007), stated that
hypertension is a condition where the pressure of the blood in the arteries is
too high. Huntington (1989) stated that with increased resistance in the
form of high blood pressure, there may be rupture of a blood vessel in the
brain (cerebral haemorrhage) which causes stroke. According to Snider
(1982), the predominant villain behind strokes is high blood pressure which
raises the risk of stroke in two ways. It speeds up hardening of the arteries,
blocking the blood flow to the brain, and secondly increases pressure on
already damaged blood vessels in the brain causing them to rupture.
Stress: This is one of the risk factors of stroke (Snider, 1982; Engler &
Engler, 1995). According to Snider (1982), stress predisposes one to stroke
since daily living habits can affect hypertension. Anxiety, frustration and
anger aggravate hypertension which in turn causes stroke. People in certain
occupations who are always under the pressure of deadlines are four times
as likely to develop high blood pressure as are individuals in less stressful
jobs. Engler and Engler (1995) opined that stress is often mentioned as a
cause of high blood pressure which results to stroke. It elevates serum
lipids, increases blood coagulation, elevates blood pressure and can cause
myocardial ischemia. All these cause stroke.
Diabetes Mellitus: Watson and Royle (1987), Walsh, (2002); Park, (2002),
Smeltzer and Bare (2000), Edwards, Bouchier, Haslett and Chilvers,
19
(1995), Mcmurdo, (2000), Hornick, Lumley and Pierce, (1998), Senelick,
Rossi and Dougherty, (1994), Okoye (2006), Department of Health and
Human Services Centers for Disease Control and Prevention (2007),
American Heart Association, (2009) and National Institute of Neurological
Disorders and Stroke, (2009), indicated that diabetes mellitus increases
one’s vulnerability to stroke. According to Department of Health and
Human Services Centers for Disease Control and Prevention (2007),
diabetes increases a person’s risk for stroke and with diabetes, the body
does not make enough insulin, cannot use its own insulin as it should, or
both. This causes sugars to be unavailable to the body tissues and to build
up in the blood. People with diabetes have 2 to 4 times the risk of stroke
compared to people without diabetes and having diabetes can worsen the
outcome of stroke. Okoye (2006) opined that diabetes doubles the risk of
stroke by weakening of the blood vessels as well as the heart. Its effects on
the heart increases the chances of blood clot formation and possible
blockage of the brain arteries; resulting to stroke. Ichoku (2006) added that
diabetes is due to insufficient or absence of insulin secretion by pancreas q
or due to resistance of tissues to available insulin.
More so, Watson and Royle (1987), stated that diabetes mellitus is a
heterogeneous group of disorders of carbohydrate, fat and protein
metabolism characterized by chronic hyperglycemia, degenerative vascular
changes and neuropathy. Vascular degeneration involves the development
of atherosclerosis (deposits of the fatty substance cholesterol) in the
20
arteries, narrowing their lumen. Atherosclerosis of the coronary arteries of
the diabetic frequently leads to angina pectoris and stroke. Kuku and Bright
(2007), added that diabetes mellitus is a major cause of cardiovascular
morbidity like stroke.
Sickle cell anemia: American Heart Association (2009), discovered that
sickle cell anemia or sickle cell disease is a genetic disorder in which the
“sickled” red blood cells are less able to carry oxygen to the body’s tissues
and organs. Also these sickled red blood cells tend to stick to blood vessel
walls, which can block arteries to the brain and cause a stroke. According to
Watson and Royle (1987), sickle cell anemia occurs because the individual
inherited a gene for the abnormal hemoglobin from each parent. A large
amount of hemoglobin S is present which is less soluble than normal
hemoglobin, hence the blood becomes thicker, heavier and sticky and will
not flow as readily through the capillaries resulting to circulatory stagnation
and thrombosis. Sickling and vascular occlusion that results in an infarcted
areas may occur in any tissue or organ such as brain leading to stroke.
Cigarette Smoking: This is a risk factor of stroke (Walsh, 2002, Park, 2002,
Smeltzer & Bare, 2000 Edwards, Bouchier, Haslett & Chilvers, 1995,
Mcmurdo, 2000; Hornick, Lumley & Pierce, 1998, Senelick Rossi &
Dougherty, 1994; Craven & Hirnle, 2000; Gensini, Comeglio & Colella,
1998, Okoye, 2006, National Institute of Neurological Disorders & Stroke,
2009, Department of Health and Human Services Centers for Disease
Control and Prevention (2007), & American Heart Association, 2009).
21
According to American Heart Association (2009), the nicotine and carbon
monoxide in cigarette smoke damage the cardiovascular system in many
ways. Department of Health and Human Services Centers for Disease
Control and Prevention (2007), stated that smoking almost doubles a
person’s risk for ischaemic stroke, independently of other risk factors.
Cigarette smoking increases the risk of stroke by promoting atherosclerosis
and increasing the levels of blood clotting factors, such as fibrinogen. Also,
nicotine raises blood pressure and carbon monoxide reduces the amount of
oxygen that blood can carry to the brain.
Furthermore, Okoye (2006) opined that cigarette smoking is one of the
man made death inducers and that cigarette smoking increases the risk of
stroke by two and half times. Nicotine which is the component of tobacco
causes vasoconstriction (narrowing of the arteries) thereby increasing the
chances of blockage of the vessels and stroke. It also increases weakening
and damage to the blood vessels. Cigarette smoking is a life-threatening
habit as constantly emphasized by World Health Organization. “Smokers
Are Liable to Die Young”. Craven and Hirnle (2000), stated that smoking is
the most important life style choice that affects respiration Smokers are far
more likely than non-smokers to acquire lung cancer, cardiovascular disease
like stroke etcetera.
Gensini, Comeglio and Colella (1998) opined that smoking has been
called the most important modifiable risk factor for cardiovascular diseases.
It increases the heart rate and blood pressure, constricts arterioles and may
22
cause irregular cardiac rhythm. It also enhances the process of
atherosclerosis and is the major cause of peripheral vascular disease. It
limits the blood’s oxygen – carrying capacity by displacing oxygen with
carbon – monoxide. These effects of cigarette smoking lead to stroke.
Obesity
or
over
weight:
American
Heart
Association
(2009),
Basavanthappa (2004), Park (2002), and Smeltzer and Bare (2000) indicated
that obesity is one of the risk factors of stroke. Basavathappa (2004)
discovered that obesity is an abnormal and dangerous condition in which
there is stored large surplus of fat within the body. Its accumulation beyond
the normal limit may be due to endocrine dysfunction, it is due to either
excessive intake of food or to a deficient utilization of the food than the
produced energy. Fat in food is the most common cause of over weight,
which at first may cause merely discomfort and later on menace in life. It
increases susceptibility to diabetes mellitus, disease of the arteries, liver and
gall bladder disease, cerebral hemorrhage (which causes stroke) and number
of other ailments. Akinrogunde (2007) posited that obesity is a risk factor
for stroke and that people who are obese have almost three times the risk of
stroke as people with normal weights.
Excessive Alcohol consumption: It increases one’s risk to stroke
(Basavanthappa, 2004, Bouchier, Haslett & Chilvers, 1995, Mcmurdo 2000,
Senelick, Rossi & Dougherty, 1994, American Heart Association, 2009, &
Department of Health and Human Services Centers for Disease Control and
Prevention (2007), According to American Heart Association (2009),
23
alcohol abuse can lead to multiple medical complications, including stroke.
Department of Health and Human Services Centers for Disease Control and
Prevention (2007) indicated that generally excessive alcohol use can lead to
an increase in blood pressure; which increases the risk for stroke.
Basavanthappa (2004), opined that alcohol acts as a sedative, and is a food
and a narcotic but its food value is very limited. In certain occasions, if used
in small doses it may help digestion or induce sleep, but it has a devitalizing
action upon the tissues, the symptom of which range from impairment of
functions to gross degenerative poisons. Excess of alcohol or its misuse acts
as a slow poison. Now it has become a social evil, it may cause gastro
intestinal disorders, fatty degeneration of heart and liver, atherosclerosis,
peripheral neuritis.
Excess lipids and cholesterol: These are risk factors for stroke as opined by
Walsh (2002), Park, (2002); Smeltzer and Bare, (2000), Edwards, Bouchier,
Haslett and Chilvers (1995), Senelick Rossi and Dougherty (1994);
Department of Health and Human Services Centers for Disease Control and
Prevention (2007),; and American Heart Association (2009). According to
Department of Health and Human Services Centers for Disease Control and
Prevention (2007), some strokes can be caused by a narrowing of the
arteries through the build up of plaque, a mixture of fatty substances,
including cholesterol and other lipids. This is called atherosclerosis. Plaque
and blood clots build up inside the artery walls, causing thickening,
hardening, and loss of elasticity; and these can lead to decreased blood flow
and to stroke if they occur in the arteries to the brain. Again, cholesterol is a
waxy substance produced by the liver. It is needed by the body, and the liver
makes enough cholesterol for the body’s needs. Excess cholesterol usually
24
from eating foods that contain high levels of cholesterol and saturated fats
contributes to atherosclerosis. There are two major kinds of cholesterol, one
that is good and one that is bad when there is two much of it. A higher level
of high density lipoprotein cholesterol or HDL is considered good.
However, higher levels of low – density lipoprotein or LDL can lead to
atherosclerosis and stroke (Department of Health and Human Services
Centers for Disease Control and Prevention, 2007).
Moreover, Craven and Hirnle (2000) indicated that excess fat intake has
been related to obesity, increased risk of coronary artery disease (especially
increased intake of saturated fats) and several forms of cancer. Excess lipids
result to atherosclerosis which causes stroke. George (2000) stated that
saturated fatty acids when used abundantly increases the cholesterol level in
the blood, and is thought to increase the mortality caused by cardiovascular
disease like complex lipid (a kind of fat) of the group of sterols. Its function
in the body is to provide raw material for the synthesizing of sexual
hormones, among others, of the biliary salts and cellular membranes.
Although it is an indispensable substance of life, when its level increases
within the blood, it tends to be deposited in the walls of the arteries,
weakening them and narrowing their passage way, which is know as
arteriosclerosis. Hence, a high level of cholesterol tends to increase the risk
of a myocardial attack, arterial thrombosis and a lack of blood supply to the
extremities. More so, cholesterol circulates throughout the blood connected
to substances known as lipoproteins. The low density lipoprotein type
(LDL) of cholesterol favours the development of arteriosclerosis and it is
25
called the “bad or harmful cholesterol”.
Polycythaemia: Watson and Royle (1987) and Edwards, Bouchier, Haslett
and Chilvers (1995) indicated that polycythaemia is a risk factor of stroke. It
is an excessive number of erythrocytes (red blood cells) and a corresponding
increase in the concentration of haemoglobin. It increases the total volume
and viscosity of the blood. The blood pressure is elevated and the work load
of the heart is increased. The rate of flow through the vessels is reduced and
with the increased number of thrombocytes and blood viscosity, predisposes
to the development of thrombi. Occlusion of a vessel may occur, causing a
cerebral vascular accident (stroke), coronary thrombosis, pulmonary
infarction or gangrene of a limb.
Advanced Age: It is a risk factor of stroke (Craven & Hirnle, 2000,
Santrock, 1999; Mcmurdo, 2000; Senelick, Rossi & Dougherty, 1994,
Okoye, 2006; & American Heart Association, 2009).
According to
American Heart Association (2009), the chance of having a stroke
approximately doubles for each decade of life after age 55. While stroke is
common among the elderly, a lot of people under 65 also have strokes.
Okoye (2006) declared that age is the most important natural factor in stroke
and its risk increases with age. Stroke occurs mostly after 65 years of age
though depends on the other risk factors.
More so, Craven and Hirnle (2000) posited that in adults, there is
gradual increase in systolic and diastolic blood pressure with ageing. In part,
this trend is due to increased systemic vascular resistance, reflecting arterial
narrowing and decreased vessel elasticity due to atherosclerotic vessel
26
disease. According to Santrock (1999), the heart and coronary arteries
change in middle adulthood. The heart of a 40 –year old pumps only 23
liters of blood per minute. The heart of a 20 – year old pumps 40 – liters
under comparable conditions. Just as the coronary arteries that supply blood
to the heart narrow during middle adulthood, the level of cholesterol in the
blood increases with age. At age 20, it is 180 milligrams, at 40, 220
milligrams, at age 60, it is 230 milligrams and begins to accumulate on the
artery walls which are also thickening. The next result is that arteries are
more likely to become clogged. This increases the pressure on the arterial
walls which in turn pushes the heart to work harder to pump blood, thus
making a stroke or heart attack more likely. Blood pressure too, usually rises
in the forties and fifties which in turn leads to stroke.
In the same vein, Snider (1982) stated that in the age group of 45 to 74,
hypertensive persons have more than 7 times the incidence of stroke.
Senelick, Rossi and Dougherty (1994) opined that 95 per cent of strokes
occur in people aged 45 and older, and two – thirds of strokes occur in those
over the age of 65.
Menopause: This can also predispose one to stroke because a woman’s
blood pressure rises sharply at menopause and usually remains above that of
a man throughout life’s later years. High blood pressure in turn leads to
stroke. (Santrock, 1999; & Senelick, Rossi & Dougherty, 1994).
Oral Contraceptives: Snider (1982) opined that stroke is higher among
birth control pill users, who may develop either clot or high blood pressure
27
.Of every 100,000 women using the pill in the United Kingdom, ten in a
year will be admitted to a hospital because of a stroke. American Heart
Association (2009); Park, (2002); Smeltzer and Bare (2000); and Edwards,
Bouchier, Haslett and Chilvers (1995) are also of the opinion that use of oral
contraceptives are associated with stroke.
Trauma: Trauma is a risk factor of stroke (Huntington, 1987, & Edwards,
Bouchier, Haslett & Chilvers, 1995). Trauma is considered in connection
with cerebral haemorrhage, because the essential danger of the condition is
laceration of the surface of the brain with accompanying haemorrhage. The
fracture may involve the upper part of the skull, or vault, or the base of the
skull. The later is by far the more serious, and is apt to prove fatal, if not
properly treated (Huntington, 1987)
Atrial Fibrillation: Mcmurdo (2000) stated that irregular heart beat (atrial
fibrillation) which is fairly common in old age, increases the risk of stroke
by causing blood clots to form on the heart. According to Department of
Health and Human Services Centers for Disease Control and Prevention
(2007), atrial fibrillation is irregular beating of the upper chambers or atria
of the heart, and when the atria quivers instead of beating in a regular
pattern, blood is not fully pumped out of them and may pool and clot. The
clots can then leave the heart and travel to the brain, causing a stroke. About
15 per cent of stroke patients have had atrial fibrillation before they
experience a stroke. American Heart Association (2009) described stroke as
heart rhythm disorder that raises the risk for stroke. The heart’s upper
28
chamber quivers instead of beating effectively, which can let the blood pool
and clot. If a clot breaks off, enters the bloodstream and lodges in an artery
leading to the brain, a stroke results.
Genetic and Congenital Conditions: American Heart Association (2009)
discovered that stroke risk is greater if a parent, grand parent, sister or
brother has had a stroke. African Americans have a much higher risk of
death from a stroke than Caucasians do; and this is partly because blacks
have higher risks of high blood pressure, diabetes and obesity.
According to Department of Health and Human Services Centers for
Disease Control and Prevention (2007), stroke can run in families and genes
play a role in stroke risk factors such as high blood pressure, heart disease,
diabetes and vascular conditions. It is also possible that an increased risk for
stroke within a family is due to factors such as a common sedentary life
style or poor eating habits, rather than hereditary factors.
Furthermore, Okoye (2006) opined that as hypertension and diabetes run
in families so does stroke. Senelick, Rossi and Dougherty (1994) posited
that family members may have a genetic tendency for stroke or share a life
style that contributes to stroke. Brother and sisters of people who have had a
stroke are nearly twice as likely as the average individual to experience a
stroke themselves; hence stroke risk is high for siblings of stroke patients.
Park (2002), stated that what man is and to what disease he may fall victim
depends on a combination of two sets of factors in his genetic factors and
the environmental factors to which he is exposed. Genetic factors are
29
biologic determinants indicated that the physical and mental traits of every
human being are to some extent determined by the nature of his genes at the
moment of conception. A number of diseases are known to be of genetic
origin (e.g. diabetes, sickle cell disease, chromosomal anomalies etc), and
these are risk factors of stroke.
Occupation as a risk factor: Job strain - a study by Tsutsumi, kayaba
Hirokawa and Ishikawa (2003) on job strain and risk of stroke among
Japanese workers. It was discovered that job strain predisposes workers to
stroke. Driving – according to the study by Tuchsen, Hannerz, Roepstorff
and Krause (2002) on stroke among male professional drivers in Denmark
1994 – 2001), it was discovered that professional driving is associated with
an increased risk of stroke morbidity. This may be due to the dangers they
may encounter on their ways which may trigger off hypertension in some
drivers; trauma from accidents and/or gunshot, keeping awake at night
during night travelling which disturbs the equilibrium of the central nervous
system; smoking of cigarette, excessive alcohol consumption, cocaine,
amphetamines, which is common among drivers. All these predispose them
to stroke.
Lack of Exercise: American Heart Association (2009) stated that being
inactive can increase one’s risk of high blood pressure, high blood
cholesterol, diabetes, heart disease and stroke. Okoye (2006) also opined
that lack of physical activity significantly increases the risk of stroke, partly
by increasing the three greatest risk factors for stroke, namely hypertension,
heart disease and diabetes. That the more physically active an individual, the
greater the reduction in this risk; moderately active people had a 20% lower
risk than inactive people and highly active people has 34% reduction of risk.
30
Furthermore, Bortkiewicz and Rydzynski (2003), stated that lack of
exercise or physical inactivity among others is a risk factor of stroke
because exercise promotes proper circulation of blood to all organs thereby
preventing hypoxia which results to ischaemia and cerebral ischaemia
causes stroke. According to Okafor (2002), physical activity in form of
exercise has some effects upon the body such as proper metabolism which
favours better oxygen absorption and utilization by maintaining a balance
between the oxygen required by the tissues and the oxygen made available
to them; regular exercise aids resistance to overweight through adequate
expenditure of energy, exercise also helps to activate other muscle groups
which are supplementary to the activities of the heart because the heart
cannot be expected to carry the entire load of circulation alone. Exercise
also aids lymphatic circulation as well as the flow of blood in the vein
thereby preventing thrombus formation which leads to stroke. Exercise
allows more exchange of oxygen and carbon dioxide between the lung
spaces and the blood stream, thereby preventing hypoxia or anoxia which
can lead to stroke.
Okafor (2006) stated that lack of physical activity (sedentary life style)
can result to heart disease, diabetes and stroke. According to Nweke (2009),
exercise is defined as any physical exertion or activity that results in
contraction of skeletal muscles and increase in blood circulation for the sake
of bodily health. He further stated that exercise is good generally and it is
something that man cannot refrain from. Benefits of regular exercise
31
include; it helps to prevent and control illnesses like heart disease, stroke,
high blood pressure, diabetes, obesity and colon cancer; it helps to control
weight by using up excess calories that otherwise would be stored as fat; it
stimulates various brain chemicals such as endorphins which help one feel
happier, more released and alert mentally; it builds strong muscles around
the joints, reduces joint pains and keeps the joints flexible; it increases the
general body circulation, breathing, digestion and metabolism; and
psychologically, it helps to improve one’s mood and the way one feels about
oneself. Regular exercise is a critical part of staying healthy. People who are
active live longer and younger (Nweke, 2009).
Poor Nutrition: American Heart Association (2009) declared that poor diet
is a risk factor for stroke. Diets high in saturated fat, trans fat and cholesterol
can raise blood cholesterol levels; and diets high in sodium (salt) can
contribute to increased blood pressure. Diets with excess calories can
contribute to obesity, while a diet containing five or more servings of fruits
and vegetables per day may reduce the risk of stroke. Okafor (2006) added
that poor nutrition can result to heart disease, stroke, atherosclerosis,
diabetes, obesity and hypertension.
High Salt Intake: Okoye (2006) stated that high salt intake is a risk factor
of stroke because it increases blood pressure. Chemically, salt is made of
sodium and chloride. Sodium is of a higher concentration than water thus
can easily draw water from the surroundings to dilute itself. This same
phenomenon takes place inside the blood vessels, if the salt concentration of
32
blood is high, water from the surrounding cells moves into the blood vessels
to dilute the salt through a process called osmosis. Hence the volume of the
blood increases which invariably increases the force (pressure) of the blood
that flow out of the heart into the blood vessels, thus hypertension which
results to stroke.
Substance (Drug) Abuse: This is a risk factor for stroke (Fauci, Braunwald,
Isselbacher, Wilson, Martin, kasper, Hauser & Longo, 1998; Okafor, 2006;
& American Heart Association, 2009). According to American Heart
Association (2009), drug abuse/ addiction is often a chronic relapsing
disorder associated with a number of societal and health related problems.
Drugs that are abused including cocaine, amphetamines and heroin, have
been associated with an increased risk of stroke. Strokes caused by drug
abuse are often seen in a younger population.
Oral infection: Kwasnica (2008) opined that oral infection is a risk factor of
stroke. In his study on the causal relationship of oral infection as a risk
factor
for
stroke,
discovered
that
people
diagnosed
with
acute
cerebrovascular ischaemia were found more likely to have an oral infection
compared to those in the control group. This explains that cerebrovascular
ischaemia is a cause of stroke where as oral infection is a risk factor
associated with stroke.
Previous Stroke: Senelick, Rossi and Dougherty (1994), posited that having
had a stroke in the past greatly increases one’s risk of future strokes. Okoye
(2006) stated that about 14 per cent of people who have stroke have a second
33
stroke within one year, and this is why it is necessary to know what it takes to
prevent reoccurrence.
American Heart Association (2009) indicated that the risk of stroke for
someone who has already had one is many times that of a person who has
not. Transient ischaemic attacks (TIAS) are “warning strokes” that produce
stroke – like symptoms but no lasting damage. TIAS are strong predictors of
stroke and a person who has had one or more TIAS is almost 10 times more
likely to have a stroke than someone of the same age and sex who has not.
Carotid or other Artery Disease: American Heart Association (2009)
declared that the carotid arteries in the neck supply blood to the brain and
when a carotid artery is narrowed by fatty deposits from atherosclerosis
(plaque buildups in artery walls), it becomes blocked by a blood clot.
Carotid artery disease or carotid artery stenosis leads to stroke. Peripheral
artery disease which is the narrowing of blood vessels carrying blood to leg
and arm muscles can lead to carotid artery disease which in turn results
stroke.
Furthermore, Department of Health and Human Services Centers for
Disease Control and Prevention (2007) discovered that heart disorders such
as coronary artery disease can also increase a person’s risk for stroke.
Coronary artery disease occurs when the arteries that supply blood to the
heart muscle become hardened and narrowed due to the build up of plaque.
Plaque and blood clots can build up inside the artery walls, causing
34
thickening, hardening and loss of elasticity; and they can result in decreased
or blocked blood flow and lead to a heart attack. Also, heart problems such
as valve defects, irregular heart beat, and enlargement of one of the heart’s
chambers can result in blood clots that may break loose and cause a stroke.
Christianity without Knowledge: Okoye (2006) discovered that this is
one of the greatest sicknesses in Africa today; that many people are making
mockery of faith and redemption because of gross ignorance and illiteracy in
Africa. He stated that lack of knowledge is the root of health calamity in
Africa. Every misfortune must have a witchcraft origin and to be sure of
healing, the suspected orchestrator must “fall and die”. He added that
Christianity without knowledge could be said to be AIDS in making, AIDS
in this context refers to as A = Acquired, I = Ignorance induced, D =
Devastating and S = Stroke. (Acquired Ignorance – induced Devastating
Stroke).
Preventive Measures for Stroke:
The management of stroke in Nigeria is suboptimal as there are significant
deficiencies in the provision of diagnostic, treatment, rehabilitation and
support services. The focus in Nigeria must be on preventive strategies and
ways to harness local resources in the acute treatment of stroke patients.
Health education of the community with emphasis on control of the
predisposing factors would reduce the burden of stroke in the country. Risk
management should begin in childhood, with emphasis on exercise, nutrition
weight and blood sugar control, avoidance of tobacco and excessive alcohol,
35
as well as effective treatment of hypertension and hyperlipidaemia
(Ogungbo, Ogun, Ushewokunze, Mendelow, Rodgers & Walker, 2005).
More so, Better Health (2010) opined that many strokes are avoidable
and are caused by unhealthy diet and life style choices. Okoye (2006) stated
that the truth is that stroke is completely a preventable disease; and such can
be achieved if the predisposing factors are controlled; for example
hypertension, obesity, diabetes mellitus and so on. Senelick, Rossi and
Dougherty (1994) opined that prevention is an important public health
concern and involves identification of patients with treatable risk factors for
stroke, treatment of risk factors in patients who have already had strokes
(secondary prevention) because they are at high risk of subsequent events
compared with those who have never had a stroke; medication or drug
therapy example aspirin is recommended for the primary and secondary
prevention of stroke. Patients who have stroke due to abnormalities of the
heart such as atrial fibrillation, anti coagulation with medications like
warfarin, are often necessary for stroke prevention.
According to Ogungbo et al (2005), carotid endarterectomy is a safe
preventive procedure for stroke resulting from severe narrowing or stenosis
of the carotid artery in the neck. It is also a safe and effective way of
reducing the risk of stroke in patients with transient ischaemic attacks
(TIAS). Routine use of aspirin in acute ischaemic stroke, intravenous
thrombolysis by using recombinant tissue plasominogen activator in
selected patients within 3 hours of stroke onset, control of blood pressure
36
within certain limits, antipyretic therapy, maintenance of blood glucose,
early feeding and fluid replacement are among the secondary prevention for
stroke. They also observed that public awareness programs are important for
prevention of stroke.
More so, “brain attack” is a term used to describe the acute presentation
of stroke which emphasizes the need for urgent action. Delays in
presentation are caused mostly by lack of awareness of stroke. All patients
within the age range and with a high stroke risk should know the symptoms
of stroke. The need to present early for evaluation, treatment and prevention
of further attacks must be discussed at various levels. Information about
stroke should be made widely available to the public. The local press,
celebrities and Television personalities should be educated on the risks of
stroke and the importance of wide public awareness. Stroke issues should be
introduced in schools, churches, mosques, plays on television, in the theatre
and brought to national attention. Health talks as well as the use of posters
and radio jingles would assist in re-education of relatives of stroke patients
and the community at large (Ogungbo et al, 2005).
Treating hypertension or the control of blood pressure is the key to
prevention of stroke (National Institute of Neurological Disorders & Stroke,
2009; Department of Health and Human Services Centers for Disease
Control and Prevention (2007), Senelick, Rossi & Dougherty, 1994, Price &
Wilson, 1982; Macleod, 1986; Park, 2002; Smeltzer & Bare, 2000; &
Harrison, 1984)
37
According to National Institute of Neurological Disorders and Stroke
(2009). High blood pressure can be treated and reduced by eating a balance
diet, maintaining a healthy weight and exercise; and also by use of available
drugs for reduction of blood pressure. Department of Health and Human
Services Centers for Disease Control and Prevention (2007) stated that
medicines to lower blood pressure can decrease the risk of stroke among
those with high blood pressure. According to Price and Wilson (1982),
control of blood pressure may involve reduction in salt intake. This can be
started early in life with low salt baby food since salt affects blood pressure
negatively. For the elderly, extreme care to maintain blood pressure during
surgical procedures is needed, avoid over sedation and prolonged bed rest.
Regular medical check-up is essential for any hypertensive patient.
More so, Ogungbo et al (2005) opined that hypertension is the single
most important cause of stroke and the one, which is eminently reducible by
treatment. Reduction in both systolic and diastolic pressure substantially
reduces stroke risk. That the recent British Hypertension Society guidelines
recommend a target blood pressure of 140/85 mmHg; and also deduced that
5mmHg reduction in diastolic pressure reduced stroke risk by 34%, and
each 10mmHg reduction of systolic pressure reduce stroke risk by 28%.
Hence it is the duty of every clinician or nurse to at least check the blood
pressure of all adults they are reviewing for any health problem.
Stress: Proper management of stress helps to prevent stroke. Snider (1982)
stated the following recommendations for stress – talk it out; escape for a
38
while; work off your anger; give in once in a while if you find your self
defiant, stubborn and getting into quarrels with others frequently; do
something for others; shun the superman urge; go easy with criticism; give
the other fellow a break; take time out for recreation; and tackle one thing at
a time. Okafor (2002) added that one should adopt a new way of looking at
life; have a positive out look on life; be reasonably organized; learn how to
say no; always let go of the past and always have adequate sleep.
Physical Inactivity: Okafor (2002) opined that regular physical activity has
been said to reduce stress level and provide more positive state of mind;
lower pulse rate and reduce blood pressure; and lowers blood cholesterol
and improves the ratio of high density lipoprotein to low density lipoprotein.
Examples of physical activities are walking, swimming, dancing, racket
games like tennis.
Price and Wilson (1982) recommended increased
activity (daily walking part of a fitness program).
According to Ogungbo et al (2005), physical inactivity causes about 15% of
diabetes and heart disease, hence the American Heart Association
recommends 30 – 60 minutes of exercise 3 – 4 times per week. American
Heart Association (2009), stated that one should go on a brisk walk, take the
stairs, and do whatever one can to make one’s life more active. Again one
should try to get a total of at least 30 minutes of activity on most or all days.
Diabetes Mellitus: A diabetic patient should be on regular medical check –
ups and adhere to dietary recommendations and drug therapy to prevent
complications like stroke (Watson & Royle, 1987, & Smeltzer & Bare,
39
2000). According to Ogungbo et al (2005), diabetes is a modifiable risk
factor for stroke. In view of the high prevalence of undiagnosed diabetes
among stroke patients and the increased morbidity and mortality associated
with diabetes mellitus, screening for diabetes is recommended especially in
those with ischaemic stroke. Diabetics should avoid refined simple sugars
(because they increase the blood sugar level readily) and excessive weight
gain. Care of feet and prompt treatment of infections should also be
emphasized. Kuku and Bright (2007) opined that education, diet, drug, food
care and exercise are pillars of the management of diabetes mellitus. They
added that life style modification and patient compliance are vital.
Avoidance of Excessive Physical and Job Strain helps to prevent stroke
(Harrison, 1984; & Tsutsumi, Kayaba, Hirokawa & Ishikawa, 2003). Life
style modification in relation to one’s occupation or change of occupation if
possible can help to reduce stroke occurrence (Tuchsen, Hannerz,
Roepstorff & Krause, 2002; & Ogungbo et al 2005)
Cigarette Smoking: National Institute of Neurological Disorders and Stroke
(2009) stated that a smoker can quit smoking; and that medical help is
available to help quit. Senelick, Rossi and Dougherty (1994) and Okafor
(2007), also indicated that smoking cessation reduces one’s risk to stroke.
Alcohol Consumption: American Heart Association (2009), declared that
for those who consume alcohol, a recommendation of no more than two
drinks per day for men and no more than one drink per day for non pregnant
woman best reflects the state of the science for alcohol and stroke risk. Price
and Wilson (1982); Park (2002); Senelick, Rossi and Dougherty (1994) and
Okafor (2002) stated that excessive alcohol consumption must be avoided.
In addition that drug abuse should be avoided as well. Okafor (2002) opined
40
that one should enjoy moderate quantities of drug and alcohol, and avoid use
of hard drugs.
Hypercholesterolemia: Senelick, Rossi and Dougherty (1994) opined that
blood cholesterol level should be controlled, by avoiding eating of fatty foods
and foods rich in saturated fats, examples eggs, beef, and fried food. Ogungbo
et al. (2005), stated that life style modification is a key matter, as high blood
pressure and high blood cholesterol are closely related to excessive
consumption of fatty, sugary and salty foods. Eating fruits and vegetables can
help prevent cardiovascular disease like stroke and health screening and early
treatment of hypercholesterolemia helps to reduce the stroke occurrence. A
lipoprotein profile can be done to measure several different kinds of
cholesterol (Department of Health and Human Services Centers for Disease
Control and Prevention (2007).
Nwagbo (2007) stated that Banana have
abundant vegetable fibre which lowers the cholesterol.
Obesity or Over Weight: Price and Wilson (1982) indicated that there is need
to decrease weight if overweight. Okafor (2002) stated that an overweight
person should reduce his/her food intake which is the safest and most effective
means of weight reduction. Any diet low in calories but adequate in proteins,
vitamins and minerals is a reducing diet. Physical exercise is also
recommended. Body mass index should be between 18.5 to 24.9 in healthy
individuals (Ogungbo et al. 2005). Nwagbo (2007), enumerated, the food that
one should increase their intake to avoid obesity viz, pineapple, sweet potato,
mushroom, sour sop, broccoli, cabbage, asparagus (green), lettuce, cucumber,
41
grape fruit, peach and pepper. While those to restrict or eliminate their intake
in obese cases include; saturated fat (e.g. whole milk, cheese, eggs, meats,
sausages etc); fried foods and refined baked goods.
Sickle Cell Disease: Watson and Royle (1987) opined that pre-marital blood
testing be done to prevent a person with SS genotype getting married to AS or
SS genotype person or two people with AS genotype getting married.
Senelick, Rossi and Dougherty (1994) stated that a sickler should be on regular
medical check-ups to prevent crisis.
Transient Ischaemic Attacks (TIAS): Park (2002) opined that for transient
ischaemic attack which may be one of the earliest manifestations of stroke,
their early detection and treatment is important for the prevention of stroke.
Facilities for the long-term follow – up of patient are essential. The education
and training of health personnel and of the public, form an integral part of the
prevention programme. Reliable knowledge of the extent of the problem
(stroke) in the community concerned is essential.
In the same vein, Ogungbo et al. (2005) stated that it is important to
recognize and diagnose a patient with transient ischaemic attack. The health
personnel and the public should know the simple clinical features of transient
ischaemic attack which include confusion, blurring of vision, speech
impairment, difficulty walking and weakness of an arm or a leg. These are
possible pointers to impending major stroke. American Heart Association
(2009) also opined that recognizing and treating transient ischaemic attacks
can reduce risk of a major stroke; and that TIAS should be considered a
42
medical emergency and followed up immediately with a health care
professional. National Institute of Neurological Disorders and Stroke (2009),
stated that a patient with TIAS should seek for help and that TIAS are small
strokes that last only for a few minutes or hours. They should never be ignored
and can be treated with drugs or surgery.
Furthermore, Watson and Royle (1987) indicated that prevention of
reoccurrence of stroke as a secondary prevention is possible. They stated that
the patient who recovers from stroke may be required to continue taking an
anticoagulant and he and the family are advised of its purpose and the
importance of prompt reporting of signs of bleeding. A balanced diet with less
fat content may be recommended and a dietary plan reviewed with the patient
and family so that it will meet his weight and energy expenditure. If necessary
the patient is strongly advised against smoking, also female patients should not
take contraceptive pills.
Genetic Factor/Family History: Okoye (2006) opined that where there is
family history of stroke, one of the ways to find out and prevent such ugly
occurrence is to check one’s blood pressure and sugar levels routinely because
stroke runs in families. Department of Health and Human Services Centers for
Disease Control and Prevention (2007) stated that sedentary lifestyle and/or
poor eating habits must be changed to reduce risk of stroke.
Nutrition: American Heart Association (2009) opined that one should take
food less in fat especially saturated fat and cholesterol; low in sodium (salt)
content, less calories and more of fruits and vegetable. Price and Wilson
(1982) are also of the opinion that reduction in salt intake is very vital. No
extra raw salt should be added to the food once it is served (Okoye, 2006)
43
Heart Disease: National Institute of Neurological Disorders and Stroke (2009)
indicated that heart disease can be managed and reduce risk of stroke. That
doctor can treat heart diseases and may prescribe medication to help prevent
the formation of clots, such as aspirin therapy. Department of Health and
Human Services Centers for Disease Control and Prevention (2007), stated
also that persons with heart disease may be given medicines such as aspirin to
help prevent clots from forming.
Advanced Age: Okoye (2002) opined that the way we live, however has an
effect on the speed and nature of our ageing, despite the determination by our
genes; that if we adopt a life-style that promotes our well-being, we can slow
down the process considerably; and that we can not wait until we are 30, 50 or
70 to become concerned about ageing. Examples of the life styles that promote
our well-being are proper stress management, adequate diet, avoiding harmful
substances; and physical activity.
Incidence of Stroke:
Heart Communities. Com (2010) declared that stroke is the third leading
cause of death and the leading cause of disability in the United States. The
incidence rate is higher in African Americans than in Caucasians and it occurs
at equal rate in men and women, but women are more likely to die. Ischaemic
stroke occurs more frequently in people over 65 years and haemorrhagic stroke
is more common in younger people. Health Grades Inc (2010) stated that
stroke is the third leading cause of death in United States after heart disease
44
and cancer. It is a major cause of disability among adults and a major factor in
late – life dementia. The incidence of stroke is on the rise. Estimated 15
million people worldwide survive minor strokes each year. Internet Stroke
Center (2010) opined that stroke can – and – do – occur at any age and nearly
one quarter of strokes occur in people under the age of 65.
According to Kissela, Alwell, Khoury, Moomaw, Woo, Adeoye,
Flaherty, Khatri, Ferioli, Broderick and Kleindorfer, (2010) stated that the
average age of stroke patients in 2005 was nearly three years younger than the
average age of stroke patients in 1993 – 1994. Moreover, the percentage of
people 20 to 45 having a stroke was up to 7.3 per cent in 2005 from 4.5 per
cent in 1993 – 1994. Stroke has traditionally been considered a disease of old
age, but in 1993 – 1994, the average age of stroke patients was 71.3 years old.
The average age dropped to 70.9 in 1999 and was down to 68.4 by 2005. Also
discovered was that there is racial differences in incidence of stroke. For
blacks, the incidence of stroke among those over age 85 dropped significantly
by 2005. For whites, the incidence decreased significantly starting at age 65 by
2005. In both races, the incidence rates for stroke in 20 to 45 year olds
increased.
American Heart Association (2009) stated that stroke is more common
in men than in women; and that in most age groups, more man than women
will have a stroke in a given year. Though more than half of total stroke deaths
occur in women and at all ages, more women than men die of stroke. Okoye
(2006) opined that stroke incidence is more common in men than women but at
45
old age more women than men have stroke and at all ages, more women than
men die of stroke. According to Basavanthappa (2008) ,Walsh(2002) ,and
Watson and Royle (1987); the highest incidence of stroke occur in those over
60 years of age. Park (2002) and Macleod (1986), declared that over 80 per
cent of all stroke deaths occur in persons over 65 years in developed countries.
Furthermore, Parry (1984) observed that stroke is common in Africa.
Examples in Dakar and Senegal, it accounts for 20 per cent of neurological
admissions. The incidence related to age and sex, is generally the same as in
industrialized countries, but in several African countries the mean ages for
subarachnoid hemorrhage, cerebral hemorrhage and cerebral infarction have
been found to be low at 35, 40 and 42 years respectively. Senelick, Rossi and
Dougherty (1994) indicated that the incidence of stroke increases exponentially
from 30 years of age; and aetiology varies by age. Boon, Colledge, Walker and
Hunter (2006) added that incidence of stroke rises steeply with age and in
many developing countries incidence is rising because of the adoption of less
healthy life styles.
Epidemiology of Stroke in Nigeria
Okoye (2006) observed that the rate of stroke in African, precisely,
Nigeria is currently alarming, that despite the poor statistical record, there is no
day a stroke patient is not admitted in the emergency unit where he works.
Regrettably, majority of the stroke cases present when the worst had already
occurred. He further opined that despite these awful but factual reports, the
46
good news is that there is a lot people can do to prevent both stroke and its
occurrence. Hence one now has the opportunity to make stroke a history
through the power of applied knowledge. By knowledge shall the just one be
delivered, said Okoye (2006).
Moreover, Ogungbo et al (2005), stated that the actual incidence and
prevalence of stroke have not been established in Nigerian. The frequencies in
hospital populations varied from 0.9% to 4.0% and stroke accounted for 0.5%
to 45% of neurological admissions. At the Lagos University Teaching
Hospital, stroke was the second commonest cause of neurological admission
and constituted 3.7% of all medical emergencies. At the Ogun State University
Teaching Hospital, Ibadan, and (OSUTH), Sagamu, it accounted for 8.7% of
medical admissions and was the third commonest cause of medical admissions.
At the university College Hospital, Ibadan, and OSUTH, Sagamu, stroke
accounted for 4.6% and 17% of medical deaths respectively compare to 7.7%
of all deaths at LUTH emergency. This therefore appears to be a huge problem
in African Nigerians. The population of Nigeria exceeds 126 million people
and if one assumes an average stroke incidence of 116 per 100,000 of the
population in Nigeria, then 147,000 people suffer a stroke in Nigeria yearly
(Ogungbo et al; 2005).
Causes of Stroke:
Stroke has several causes which may include atherosclerosis, intracranial
heamorrhage, cerebral thrombosis, cerebral embolism, cerebral ischaemia,
cerebral tumour, subdural haematoma, vascular lesions, vascular disorders,
inflammation, non-syphilitic aortitis and so on.
47
Atherosclerosis: Heart Disease and Prevention (2010), Walsh (2002) and
Watson and Royle (1987) stated that atherosclerosis causes stroke and it is a
narrowing or obstruction of arteries which reduces the blood supply to the
myocardium of the heart and brain cells and result to ischemic disease. The
resultant deficiency of oxygen and nutrients to the brain cells lead to their
death. Again fatty substance like cholesterol deposited within the artery walls
cause atherosclerosis of those arteries.
Intracranial haemorrhage: Wikipedia (2010), Watson (2002), Watson and
Royle (1987); and Smeltzer and Bare (2000), stated that intracranial
heamorrhage is a bleeding within the cranium which may result to formation of
a haematoma and may follow a head injury. The bleeding may be extradural,
subdural, subarachnoid or intracerebral. Intracranial haemorrhage may result
from a contrecoup injury, a gun-shot or stabbing wound or cerebral
atherosclerosis.
Cerebral thrombosis: Wikipedia (2010), Mcmurdo (2000) and Hamilton
(1987) posited that cerebral thrombosis occurs when a blood clot (thrombus)
forms in an artery (blood vessel) supplying
blood to the brain. The clot
interrupts the blood supply and brain cells are starved of oxygen.
Cerebral embolism: This is a blood clot that forms somewhere in the body
before traveling through the blood vessels and lodging in the brain. This causes
the brain cells to become starved of oxygen (Wikipedia, 2010; Mcmurdo,
2000, Walsh, 2002; &Watson & Royle, 1987).
Cerebral ischaemia: Senelick, Rossi and Dougherty (1994) and Guyton and
Hall (1996), observed that cerebral ischaemia causes ischaemic stroke which
48
occurs in approximately 85-90 per cent of strokes. Here a blood vessel
becomes occluded and the blood supply to part of the brain is totally or
partially blocked.
Cerebral tumor: Walsh (2002) and Smeltzer and Bare (2000) opined that
cerebral or brain tumour is a localized intracranial lesion that occupies space
within the skull and usually grows as a spherical mass but can grow diffusely,
infiltrating tissue. Tumours may be benign or malignant.
Vascular lesions: Macleod (1986) stated that stroke may be due to lesions of
veins and capillaries as well as lesions of arteries. Arterial lesions are divided
into ischaemic cerebral lesions and hemorrhagic lesions.
Vascular disorders: Heart Disease and Prevention (2010), Edward, Bouchier,
Haslett and Chilvers (1995) stated that the causes of stroke under vascular
disorders causing infarction and those causing hemorrhage, examples
atherosclerosis, arteriolar sclerosis, embolism, arteritis, dissection, vasospasm,
aneurysms, arteriovenous malformation, and head trauma.
Inflammation: Smeltzer and Bare (2000), Long and Phipps (1995) and Watson
and Royle (1987) observed that inflammation can cause stroke. That
inflammation is a local tissue reaction to injury or irritation but designed to
remove or destroy the injurious agent, keep the injury localized and repair the
damage. It results from physical, chemical, biological or immunological
agents. Inflammation can also occur in cell injury events, such as stroke and
myocardial infarctions.
Non-syphilitic aortitis: Parry (1984) stated that non-syphilitic aortitis (disease
49
of the aorta not resulting from syphilis) leads to aneurysms accounted for a few
cases of stroke in Nigeria.
Clinical Manifestations of Stroke
Heart Disease and Prevention (2010) declared that symptoms of a stroke
depend on the area of the brain affected. The most common symptom is
weakness or paralysis of one side of the body with partial or complete loss of
voluntary movement or sensation in a leg or arm. There can be speech
problems and weak face muscles, causing drooling. Numbness or tingling is
common. A stroke involving the base of the brain can affect balance, vision,
swallowing, breathing and even unconsciousness. National Institute of
Neurological Disorders and Stroke (2009) observed that symptoms of stroke
include sudden numbness or weakness of face, arm or leg; sudden confusion or
trouble speaking or understanding speech, sudden trouble seeing in one or both
eyes, sudden trouble walking, dizziness or loss of balance or co-ordination; and
sudden severe headache with no known cause.
The most common signs of stroke are weakness, paralysis or numbness
of the arm and leg, speech may be difficult, swallowing may be affected,
blurred vision (Mcmurdo, 2000, Ferguson, 1984, & Hosley, Jones & MolleMathews, 1997). Hornick, Lumley and Pierce (1998), indicated that features of
stroke may include hemi sensory loss, amaurosis fugax, higher cortical
dysfunction (e.g. dysphasia), conjugate gaze to side of lesion, nystagmus, gait
and stance problem, and vertigo. According to Macleod (1986) and Watson
50
and Royle (1987), features of stroke include headache, loss of consciousness,
drowsiness, epileptic fits, brief confusion, vomiting and incontinence.
More so, Harrison (1984) opined that symptoms of stroke vary, but may
include a transient weakness of a limb to coma with hemiplegia, dysphasia or
aphasia, blindness, forgetfulness, emotional labile, giddiness, dysarthria,
ataxia, slow pulse rate, breathing is stertorous or cheyne stoke and neck
stiffness. Long and Phipps (1985) added that manifestations of stroke include
photophobia, nausea, respiratory distress and shock. Basavanthappa (2007)
indicated that clinical manifestations of stroke include neuromotor activity
dysfunction, elimination problem, intellectual dysfunction, spatial- perceptual
alterations, personality and affect disorders and communication impairment.
Concept of Adulthood:
The adult stage starts where teenage ends, although some individual may
continue to exhibit adolescent characteristics well into adulthood. According to
Berman, Snyder, kozier and Erb (2008), adulthood starts from age of 20. For
the purpose of this research work, ages 24 and above are to be considered. The
issues of adulthood development then includes marriage, parenthood, career,
retirement and widowhood, and certain changes occur in adulthood (Peterson,
1991). According to Craven and Hirnle (2000), as people mature throughout
adulthood, changes in the cardiovascular system may lead to decreased activity
tolerance and decrease endurance. Along with natural “wear and tear”, diet,
51
stress, smoking, and several other life style factors may contribute to the
processes of calcification, fatty degeneration and diminished elasticity of the
blood vessels. These processes are likely to account for increase in blood
pressure as adults grow older.
More over, Berman, Snyder, Kozier and Erb (2008) classified adults into
young adults (20 to 40 years), middle-aged adults (40-65 years); and older
adults are (65 years and above). That these adults are faced with many
challenges and health risks such as injuries, suicide, substance abuse,
hypertension,
sexually
transmitted
infections,
certain
malignancies,
alcoholism, and so on. Some of these factors predispose them to stroke.
Taylor, Lillins and Lemone (2001) after classifying older adults into the
young old (ages 60 to 74), the middle-old (age 75 to 84) and the old-old (ages
85 and above), added that adaptation is necessary with advancing age because
of physical or cognitive limitations, retirement, loss of a spouse or family
member or changing income to prevent the adult from having stress and
hypertension which in turn leads to stroke.
Concept of knowledge:
Knowledge is defined by Oxford English Dictionary variously as
expertise and skills acquired by a person through experience or education; the
theoretical or practical understanding of a subject, what is know in a particular
field or in total, facts and information, or awareness or familiarity gained by
experience of a fact or situation. Knowledge acquisition involves complex
52
cognitive processes - perception, learning, communication, association and
reasoning. The term knowledge is also used to mean the confident
understanding of a subject with the ability to use it for a specific purpose if
appropriate (Mullins, 1999).
According to Prabhakara (2003), knowledge, attitude and practice
(KAP) is the basis of information, education and counseling (IEC), where a
person gets information by many modes which becomes his knowledge, then
gets motivated to have attitude and adopts to maintain a practice. In this study,
the researcher uses a definition of knowledge by Foskett (1982) which states
that it is acquaintance with facts, truths or principles, as from study or
investigation.
Haralambos, Holborn and Heald (2008) opined that knowledge is essential to
accomplish practical tasks in everyday life. Hence the researcher is more
concerned with the adults in Nnewi urban being acquainted with facts, truths or
principles from this study about associated risk factors of stroke.
Domains of knowledge: Craven and Hirnle (2000) opined that knowledge can
be acquired in three different domains- cognitive, affective and psychomotor
learning. Cognitive learning may involve learning facts, reaching conclusions,
making decisions or inferring. Affective refers to emotions or feelings and
affective learning changes beliefs, attitudes or values, whereas psychomotor
refers to the muscular movements that result from some sort of knowledge and
involves mastering a new task or skill. Flavell (1996) declared that human
beings have a unique ability to acquire knowledge, solve problems and plan for
53
the future, and perform these tasks by mental manipulation of information
gained. Hence the researcher is of the opinion that adults in Nnewi urban
should have knowledge of associated risk factors of stroke (cognitive), change
some of their beliefs, attitudes or values that predispose them to stroke
(affective), and finally, master those healthy lifestyle that reduce risk of stroke
(psychomotor).
Anso (2009) stated that people have become more educated, and have
more knowledge about health and illness. That through the news media such as
radio, television, newspaper and the internet they have become health wise.
Hence the researcher wants to confirm this statement in relation to the
knowledge of associated risk factors of stroke among adults in Nnewi urban.
Theories:
Disease theory: Wikipedia (2006), indicated that disease theory may include
ecological and biopsychosocial theories. Ecological theory rests on
evolutionary adaptive view of human beings in continuous interaction with
their environment. It is this theory that explains why maladaptation or poor
management of stress can lead to conditions like hypertension which
invariably results to stroke, whereas biopsychosocial theory expands on the
ecological theory viewing disease as interplay between environment, physical,
behavioral, psychological and social factors. Illness related behaviour whether
perceived or actual, frequently disrupt personal or family equilibrium and
coping abilities. This explains how behaviour like excessive alcohol
54
consumption and drug abuse can predispose one to stroke.
More so, Watson and Royle (1987), stated in their disease causation
theory, that the cause of some disease is unknown and research continues to
search for the aetiological factors in conditions like cancer, multiple sclerosis,
rheumatoid arthritis, leukemia and psychosis. In some diseases, predisposing
and perpetuating factors have been recognized even though the primary
causative factor has not been identified. Such information contributes to
preventive care. Recognized causes of disease include heredity, development
defects, biological agents, physical agents, chemicals, deficiencies and
excesses, emotions and tissue responses.
Heredity: Hereditary diseases may be transmitted from one generation to
another by a genetic or chromosomal disorder or both gametes. Example sickle
cell disease which results when a person with AS gene marries one with SS
gene or both persons having AS gene get married. This sickle cell disease
predisposes one to stroke.
Development defects: Some abnormal structural and functional defects are
present at birth due to a failure or abnormality in the embryonic or fetal stage.
Example hole in the heart which predisposes the person to diseases like stroke;
especially in the young.
Biological agents: Watson and Royle (1987) also stated that one of the
commonest causes of disease is the invasion of the body by bacteria, fungi,
viruses or parasites. They harm or destroy the tissues by their direct action on
the cells or by the toxins they produce, and the disease is referred to as an
55
infection. This theory indicates that oral infection can lead to stroke.
Physical agents: Tissue may suffer injury or destruction as a result of external
forces in the environment and these include pressure, blows, falls, lacerations
and entry of foreign bodies, such as bullets. This explains why trauma or gun
shot wound can predispose one to stroke.
Chemical: When some chemicals are introduced into the body, they have an
injurious effect on tissue cells, by disrupting normal cellular chemical reactions
either by forming incompatible compounds or interfering with normal
enzymatic action within the cells. This explains how chemical in cigarette can
limit the blood’s oxygen-carrying capacity by displacing oxygen with carbonmonoxide. Again chemicals in oral contraceptives cause blood clotting and
vasoconstriction leading to hypertension and stroke.
Watson and Royle (1987) further stated that deficiencies and excesses of
essential materials supplied to normal tissue structure and activity may cause a
variety of diseases example excess of nutrients in the body can lead to obesity
which is a risk factor of stroke. Deficiency of oxygen in the cells can lead to
starvation and death of cells especially brain cells resulting to stroke. In the
same vein, that emotions- psychological reactions to stressful situations may
influence a person’s autonomic nervous system and alter its control of visceral
activities. This may increase or decrease the function of certain structure and
may have marked effects on total body functioning. This explains how stress
can lead to stroke. Tissue responses may cause illness because of the responses
or reaction of tissue to an injury or irritation. Examples inflammation and
56
allergic reaction (Watson & Royle, 1987). Hence inflammation is one of the
causes of stroke.
Stroke Theory: Several theories exist to explain the link between periodontal
disease (gum disease), heart disease and stroke. One theory is that oral bacteria
can affect the heart when they enter the blood streams, attaching to fatty
plaques in the coronary arteries and contributing to clot formation. Coronary
artery disease is characterized by a thickening of the walls of the coronary
arteries due to the build up of fatty proteins. Blood clots can obstruct normal
blood flows, restricting the amount of nutrients and oxygen required for the
heart to function properly. This may lead to heart attacks and can also lead to
stroke (kwasnica, 2008). He further stated that the inflammation caused by
periodontal disease increases plaque build up, which may contribute to
swelling of the arteries. This theory explains causes of stroke in relation to
thrombus (blood clot), inflammation as well as coronary artery disease.
According to Steve (2008): In his theory termed “May is stroke
awareness month – my theory to solving stroke”, he stated that May is stroke
awareness month and month to flaunt everything known about stroke to the
able-bodied. To him, stroke awareness is about honouring the millions that
have fallen to stroke and trying to prevent this disease from continuing its
deadly rampage. His theory is to try to get young people to understand what
stroke is about, that after all, stroke is greatly diet and life style driven. Eating
fatty foods and not exercising can cause high blood pressure and high blood
pressure is the greatest risk factor of stroke.
57
Steve (2008) in his another theory indicated that stroke do not just
happen to old people, as most people think you have to be over 80 to have a
stroke. Steve made a proof according to the Center for Disease Control (CDC)
that 33% of people having strokes are over 80 while 30% are between 18 and
64 years of age. Hence there is not much difference between the ages of
younger and older people having strokes.
In Steve’s other theory, which is to get results from kids by scaring them
straight, he thought that every kid, as part of the high school curriculum,
should have to take a field trip to their local hospital with a stroke ward. He
opined that seriously, this would also show them what happens to people that
have a stroke. That the children will be let to see the arms hanging limp, see
the physical horrors that every patient endures, the speech deficits, the loss of
cognitive skills and make them visit speech, physical and occupational therapy
sessions. This Steve’s theory explains the need for prevention of stroke
through health education and life style modification.
Vandevelde (2008), in his theory of stroke disclosed that strokes do not
just happen for no reason; and that any of the following life style factors
experienced over a period of years could eventually result in a stroke; example
working long hours under stressful conditions without adequate rest; physical
over work including excessive strenuous sport; emotional strain; irregular
eating habits; excessive consumptions of fats, diary products, greasy or fried
foods, sugar or alcohol. He also opined that the most effective way to prevent a
stroke is to modify the life style factors that lead to stroke. This theory explains
58
the associated risk factors of stroke.
Human Growth and Developmental Theories:
Berman, Snyder, Kozier and Erb (2008) grouped these theories into
psychosocial, growth and development; and moral and spiritual theories. For
the purpose of this study the researcher will look only at some of these
theories.
Havighurst (1900-1991), in his theory believed that growth and development
occurs during six age periods (infancy to later maturity). Each age period has
developmental task; achieving the developmental tasks helps the individual’s
transition to the next developmental period. At early adulthood, the individual
is concerned with task like selecting a mate, learning to live with a partner,
starting a family, rearing children, managing a home, getting started in an
occupation, taking on civic responsibility and finding a congenial social group.
Middle age involves tasks like achieving adult civic and social responsibility,
establishing and maintaining an economic standard of living, assisting teenage
children to become responsible and happy adult, developing adult leisure-time
activities, relating oneself to one’s spouse as a person, accepting and adjusting
to the physiologic changes of middle age; and adjusting to aging parents. Later
maturity is concerned with adjusting to the decreasing physical strength and
health; adjusting to retirement and reduce income; adjusting to death of a
spouse; establishing an explicit affiliation with one’s age group, meeting social
and
civic
obligations;
and
establishing
satisfactory
physical
living
59
arrangements. This theory explains the challenges facing an adult which if not
adequately managed can lead to stress, frustration and anxiety thereby
predisposing the adult to stroke.
Moreover, cognitive development theory by Piaget (1896-1980)
indicated that cognitive development refers to the manner in which people
learn to think, reason and use language, and it involves a person’s intelligence,
perceptual ability, and ability to process information. It represents a
progression of mental abilities from illogical to logical thinking, from simple
to complex problem solving, and from understanding concrete ideas to
understanding abstract concepts. This theory has five major phases - sensori
motor, preconceptual, intuitive, concrete operations and formal operations
phases. This theory explains the ability of adults in Nnewi urban to know the
associated risk factors of stroke.
Knowledge Theories:
Cannon (1998) observed that theories of knowledge have major schools
of thought and groupings of theories. They are Rationalism, Empiricism,
Epistemology and Idealism. Rationalism school of thought holds that true
knowledge is essentially independent of sensory experience. It is discovered by
dialectional philosophical reasoning, and not by sense perception. Examples –
logical and mathematic truths. This explains why people give reasons for the
life styles they adopt. For instance, a cigarette smoker may give reason that
man must die of one thing, not necessary cigarette smoking. Empiricism school
60
of thought holds that all knowledge is based upon sense experience and what is
know is changeable, of questionable universality, contingent and to some
extent uncertain. Knowledge about the world is discovered by empirical
research by observation, generalization and experimentation, not by reason
operating independently from sense perception. This theory adopts knowledge
acquisition through empirical studies and their findings.
More so, Locke’s Empiricism declared that knowledge derives from and
is based on sense experience, and that the mind is a “blank tablet” until sense
experience writes upon it. Sense experience is made up of sensory impressions
produced in our minds by things in the external impact upon the sense organs
of our bodies. This theory indicates the need for adults in Nnewi urban to seek
for knowledge or information on associated risk factors of stroke to prevent
occurrence since no body is born with knowledge or information at birth.
Finally Idealism school of thought by Kant agrees with
empiricism that all knowledge arises with perceptual experience, and he also
agrees with rationalism that we do have some knowledge specifically
knowledge of universal and cannot possible derived from perceptual
experience. Then Kant reconciled rationalism and empiricism, and stated that
knowledge and experience are not created by the mind. That their content
comes from raw sense impressions. This theory explains the need for adults in
Nnewi to acquire knowledge through rationalism and empiricism, and then
decide on the ideal life styles to maintain which prevent stroke occurrence.
61
However, based on the reviewed theories, it is obvious that stroke is
greatly diet and life style driven, and its occurrence can be prevented to some
extent. Again, if adults especially those within the ages of 24 and above are
knowledgeable enough concerning associated risk factors of stroke and
endeavour to put the information into practice, they will be less likely to have
stroke.
Review of Empirical Studies
Robinson and Merrill (2003) in their study conducted in United States
titled relation among stroke knowledge, lifestyle and stroke-related screening
results, stated that stroke is a leading cause of individual and public health
burden in the united state. That a better understanding of the relation among
stroke knowledge, lifestyle and stroke related screening results may be useful
for improving prevention efforts. Their paper assessed the relation among
demographics, lifestyle, stroke awareness and the presence of
stroke risk
factors determined by screening tests for a selected elderly population. They
used a population of 322 participants in the 1999 World Senior Games who
received one or more free screening tests and completed a stroke awareness
questionnaire. Results indicated that stroke education efforts should be targeted
at the very elderly, those who have less than a college education, and those
who do not have a history of chronic disease. It also may be effectively
directed toward those with higher cholesterol.
Nordhorn, Nolte, Rossnagel, Jungehulsing, Reich, Roll, Villringer and
62
Willich (2006), conducted a study in Germany titled knowledge about risk
factors for stroke. A population based survey with 28,090 participants. They
stated that increased knowledge of stroke risk factors in the general population
may lead to improved prevention of stroke, and their objective was to assess
knowledge of stroke risk factors and to determine factors associated with
knowledge. Results indicated that increased knowledge of stroke risk factors
was significantly associated with younger age, a higher educational level, not
living alone, a German nationality, and having received any information about
stroke during the last year.
According to a study by Sutterer, Carey, Silver and Nash (2005) in New
York titled risk factor knowledge, status and change in a community screening
project, their report described a community-based cardiovascular riskreduction program which targeted high-risk individuals. A total of 1,471
individuals participated and were screened for blood pressure, fasting serum
cholesterol, blood glucose level and appearance of the serum. These
individuals also completed a questionnaire regarding their knowledge of heart
diseases. Overall,
522 (35.5%) individuals had a cholesterol level of 240
+mg/dl, 261 (17.7%) had hypertension, 118(8%) had a glucose level of
120+mg/100ml blood, 266 (18.1%) smoked, and the serum was evaluated as
“turbid” or “lipemic” in 105 (7.1%). Therefore, of the 1,471 individuals
examined, 733(49.8%) could be considered “at risk” due to the presence of one
or more risk factors.
Furthermore, they discovered that 73% of respondents knew their blood
63
pressure, whereas only 15% and 12% respectively, knew their cholesterol and
glucose levels. Eighty per cent of the sample knew that smoking, hypertension
and cholesterol were risk factors, but only 50% of the sample identified
diabetes as an independent risk factor. Contrary to expectation, knowledge of
heart disease and diabetes was not related to either initial level or change in
cholesterol at 18-month retest. Overall, these results indicate that a community
screening program can identify high risk individuals at a relatively low cost,
and that knowledge of risk factors and disease is not related to initial risk status
or self-initiated change in risk status.
Clark, Annu and Lorig (2003) in their study conducted in United States
on the self management approach to stroke risk factor control, discovered that
self-management of stroke risk factors or more generally, chronic conditions,
entails enhanced patient education that is based on self-efficiency and involves
a patient provider partnership. According to them, several key of concepts
underly self-management which include, the patient is at the centre of chronic
disease control, the family is one of the most important influential factors in
patient’s success in this endeavour and the health care providers and health
systems must partner with the patients and family to achieve control of the
patient’s chronic conditions.
Clark, Annu and Lorig (2003), further stated some key features of the
self-management interventional approach are patient participation in goal
setting, use of personalized strategies to overcome anticipated barriers to
adherence, and follow-up including evaluation and problem solving. These
interventional approaches should be effectively tailored for diverse racial
/ethnic groups with varying social resources. Tailoring of these may involve
64
modifications that address such contextual factors as, medical care availability
or accessibility, level of health literacy, economic resources availability, social
organizations such as churches within the community, social networks within
the community, and family or community traditions.
Corbin, Poddar, Hennis, Gaskin, Rambarat, Wilks, Wolfe and Fraser
(2004), conducted a study on the incidence and case fatality rates of first-ever
stroke in a black Caribbean population of
352
adults
(142
males,
210
females) using community –based prospective design. The mean age of the
subjects was 72.5 years (range 24 to 104). The stroke types identified in their
study were cerebral infarction (81.8%), intra cerebral haemorrrhage (11.9%),
subarachnoid haemorrhage (20%), and unclassified strokes (4.3%). They
observed from findings that comparatively, stroke incidence among the black
population of Barbados was lower than among African-origin population in the
USA and UK.
According to the study conducted by Walker, Rolfe, Kelly, George and
James (2003), on mortality and recovery after stroke in the Gambia, the mean
age of the 106 patients (70 men and 36 women) was 58 years (range, 20 to 93
years). By one and six months, 29 (27%) and 47 (44%), respectively, had died,
with only 27 (25%) surviving to final follow-up (4 patients not traced). The
deaths occurred in hospital in 43 patients (57%), and cause of the deaths was
the initial stroke in 46(61%), further stroke in 5 (7%), infection in 9 (12%),
miscellaneous in 8(11%) (only 1 vascular), and unknown in 7 (9%).
According to study by Nourjah, Wagener, Eberhadt and Horowitz
65
(1999) conducted in United States on knowledge of risk factors and risk
behaviours related to coronary heart disease among blue and white collar males
it was indicated that the data regarding coronary heart disease from the 1990
Health Promotion and Disease Prevention Supplement of the National Health
Interview Survey are used to examine the relationship between risk factor
knowledge and health related behaviours among currently employed white
collar (N=5,349) and blue collar (N=4,158) men workers. It was also stated
that blue collar employees have less knowledge about coronary heart disease
risk factors, less favourable risk factors status, and poorer health practices than
their white collar workers. In the same vein that despite these findings within
each occupational group, the relationship of knowledge to either risk factors
status or health practices is similar. Knowledge is generally related to the
attempts to change behaviours.
However, they stated that, for the different risk factors, the associations
vary. For example, knowledge of cigarette smoking as a risk factor of coronary
heart disease is negatively associated with reported ever smoking or current
smoking, but not with heavy smoking. Knowledge of overweight, high serum
cholesterol and high blood pressure as coronary heart disease risk factors is not
associated with risk factors status. These results suggest that while difference
in level of knowledge and risk profiles remains between blue collar and white
collar employees, the associations between knowledge and risk profiles are
similar. Hence programs located at worksites must provide education
opportunities about the risk factors. An objective of this type of health
66
education program is to improve workers’ knowledge about the health effect of
certain lifestyles (Nourjah, Wagener, Eberhadt & Horowitz,1999).
In Mochan, Modi and Modi (2003)’s Study on stroke in black South
African HIV- positive patients which was a prospective analysis, consisting of
35 hospital based black South African, heterosexual, HIV-infected patients. In
their results, the age range years 20 to 61 years (mean, 32.1 years ), 21 female
and 14 male patients, with a female to male ratio of 1.5:1 cerebral infarction
occurred in 33 patients (94%) and intracerebral haemorrhage in two patients
(6%). Underlying causes identified were coagulopathies, meningitis, cardio
embolism and hypertension.
More so, Sorokin, Ronen, Tamir, Geva and Eldar (1996), conducted a
prospective study on stroke in the young in Israel: Incidence and outcomes,
during one year. From their results, 253 first stroke victims were identified, of
whom 62.8 % were males. The majority of strokes (80.6%) were cerebral
infarctions, with 9.9% intra cerebral haemorrhages, 7.9% subarachnoid
haemorrhages, and 1.6% stroke of unspecified type. The case-fatality rate of all
types of stroke was 9.9% (mortality within the first four weeks after the event,
on average 6 days). The survival rate was 95% for cerebral infarctions, 64%
for intracerebral heamorrhages, and 80% for subarachnoid haemorrhages;
80.7% of all survivors remained with an impairment resulting in a disability.
According to Samuel and Kiloh (2006), in their study about gender
differentiation in the knowledge and attitude of in- school adolescents in
Jalingo Local Government Area of Taraba State in Nigeria toward HIV/AIDS,
67
it was stated that high knowledge of HIV/AIDS lead to positive attitude
towards prevention of such disease. Again that possession of higher knowledge
and positive attitude effectively helps in developing health education and
making health education grow. Possession of accurate knowledge concerning a
disease is a step that can cause health education to grow and become more
advanced or organized. This is because the people too can positively influence
others. They can disseminate accurate knowledge of the disease and influence
positive attitude. This can be translated in desirable health behaviour. Accurate
knowledge regarding a particular disease will reduce incidence of death from
the disease, increase the proportion of people who maintain health life style
and thereby reducing the disease occurrence.
According to Okoronkwo, Anarado and Ehiemere (2003), in their study
of knowledge and Practice of Breast Self Examination (BSE) among women in
Enugu urban; it was discovered that there was poor knowledge of BSE. And
there was even greater discrepancy between knowledge and practice of BSE
among the subjects. It implies that poor knowledge increases disease
occurrence, and than calls for need of more health education awareness
campaign.
Opara and Onuzulike (2006) in their study on cognition of health
consequences of tobacco smoking among in-school adolescents in Owerri
metropolis. The results showed that the level of cognition of the respondents
on health consequences of tobacco smoking was low. Also showed that female
students are more cognizant about health consequences of tobacco smoking
than male students.
A study by Belue, Okoror, Iwelunmor, Taylor, Degboe, Agyemang and
Ogedegbe (2009) titled an overview of cardiovascular risk factors burden in
Sub-Saharan African (SSA) countries are currently experiencing one of the
68
most rapid epidemiological transitions characterized by increasing urbanization
and changing lifestyle factors. Again that this has resulted in an increase in the
incidence of non-communicable diseases, especially cardiovascular disease.
Their results showed that the epidemic of cardiovascular disease in SSA is
driven by multiple factors working collectively. For instance, lifestyle factors
such as diet, exercise, smoking and obesity. Additionally, structural and system
level issues such as lack of infrastructure for health care, urbanization, poverty
and lack of government programs also drive this epidemic and hampers proper
prevention, surveillance and treatment efforts.
Ogun, Ojini, Ogungbo, Kolapo and Danesi (2005), discovered in their
study termed “stroke in South West Nigeria’, a 10- year review, that stroke is a
significant economic, social and medical problem world wide. That their
retrospective follow-up study aimed to review the pattern, types and case
fatality of stroke in Nigeria. From the result, a total of 708 patients were
reviewed. On clinical grounds, 49% of the patients had cerebral infarction and
45% had intracerebral haemorrhage, whereas 6% had subarachnoid
haemorrhage. Stroke constituted 1.8% of all deaths at the emergency unit and
the case fatality was 9% at 24 hours, 28% at seven days, 40% at 30 days, and
46% at six months.
In the study conducted by Ogun, Oluwole, Aogunseyinde, Ofatade, Ojini
and Aodusote (2000) on accuracy of the Siriraj stroke score in differentiating
cerebral haemorrhage and infarction in African Nigerians a retrospective study
1991-1999, carried out at University College Hospital (UCH) Ibadan. It was
69
discovered that 96 patients had complete clinical records and computerized
tomography (CT) scan features consistent with stroke. Of these, 52 had
cerebral haemorrhage. The Siriraj stroke score (SSS) had sensitivity and 58%
for cerebral haemorrhage and 58% for cerebral infarction with an accuracy of
54.2%. Increased knowledge of stroke risk factors in the general population
may lead to improved prevention of stroke (Nordhorn et al,2006).
Summary of Literature Review
The researcher has succeeded in reviewing the related literature for this
topic: knowledge of associated risk factors of stroke among adults in Nnewi
urban, using subheadings, conceptual frame work, theoretical frame work and
review of previous researches. Stroke is a sudden death of some brain cells due
to lack of oxygen when the blood flow to the brain is impaired by blockage or
rupture of an artery to the brain (Heart Disease & Prevention, 2010). The risk
factors of stroke include hypertension, obesity, diabetes mellitus, trauma
among others (Okoye, 2006; American Heart Association, 2009; Laura, 2010
& National Stroke Association, 2010). Prevention of stroke, Okoye (2006)
indicated that stroke is completely a preventable disease and such can be
achieved if the predisposing factors are controlled examples, hypertension,
obesity, diabetes mellitus and so on. Better Health (2010) added that many
strokes are avoidable and can be avoided by maintaining adequate diet and
healthy life style choices.
Strokes have their highest incidence in those over 60 years of age
70
(Walsh, 2002, & Basavanthappa, 2008). Heart Communities. Com (2010) have
it that stroke occurs at equal rate in men and women, but women are more
likely to die. In epidemiology of stroke in Nigeria, Okoye (2006) observed
that the rate of stroke in African, precisely, Nigeria is currently alarming
despite the poor statistical record. Ogungbo et al (2005) stated that the actual
incidence and prevalence of stroke have not been established in Nigeria.
Causes of stroke may include atherosclerosis, intracranial haemorrhage,
cerebral thrombosis or embolism (Heart Disease & Prevention, 2010;
Wikipedia, 2010; & Walsh, 2002). Clinical manifestations of stroke include
paralysis of one side of the body, speech problem, numbness, sudden
confusion among others (Heart Disease & Prevention, 2010; National Institute
of Neurological Disorders & Stroke, 2009; & Basavantappa, 2007).
Adult’s stage starts from 20 years and above (Berman, Snyder, kozier
& Erb, 2008). It also starts where teenage ends and certain changes occur in
adulthood (Peterson, 1991, & Craven & Hirnle, 2000).
Furthermore,
knowledge is defined as acquaintance with facts, truths or principles, as from
study or investigation (Foskett, 1982 & Oxford dictionary). Domains of
knowledge include cognitive, affective and psychomotor (Craven & Hirnle,
2000). Disease theory explains some issues like maladaptation or poor
management of stress which is the
risk factor of stroke. Ecological theory
rests on an evolutionary adaptive view of human beings in continuous
interaction with their environment. Human growth and developmental theories
by Havighurst and Piaget were reviewed as well as knowledge theories like
71
Rationalism, Empiricism and Idealism. Some previous research works
reviewed indicated that stroke education efforts be targeted to the very elderly,
those who have less than a college education and those who do not have a
history of chronic disease (Robinson & Merrill ,2003). Again increased
knowledge of stroke risk factors in the general population may lead to
improved prevention of stroke (Nordhorn et al, 2006). Of all the previous
research works reviewed, indeed none was conducted in South East of Nigeria
and Nnewi in particular on the knowledge of associated risk factors of stroke
among adults. Hence the need for this study to close the existing gap.
72
CHAPTER THREE
METHOD
In this chapter, the researcher wished to indicate the method used for
the research, and it includes:• Research Design
• Area of the Study
• Population of the Study
• Sample and Sampling Technique
• Instrument for Data Collection
• Validation of the Instrument
• Reliability of the Instrument
• Method of Data Collection
• Method of Data Analysis
Research Design
The researcher used survey design. A survey research is one in
which a group of people or items is studied by collecting and analyzing data
from only a few people or items considered to be representative of the entire
group (Akuezuilo & Agu, 2002). A survey obtains information regarding the
prevalence, distribution and interrelationships of variables within a
population (Floyd, 1988). It collects information on people's actions,
knowledge, intentions, opinions and attitudes (Polit, Beck & Hungler, 2001).
The purposes of survey research are to describe, explain, predict and explore
issues. Surveys allow the researcher to obtain data about practices, situations
or views at one point in time through questionnaires or interviews and also
allow the researcher to study more variables at one time (Igbokwe, 2009)
73
This research design has been used in similar studies by previous
researchers like Ogun, Ojini, Ogungbo, Kolapo and Danesi (2005) in studying
stroke in South West Nigeria; Ezeilo (1995) used this design in studying stress
in the Nigerian undergraduates; Opara and Onuzuluike (2006) also used
survey design in studying cognition of health consequences of tobacco
smoking among in-school adolescents in Owerri Metropolis; and survey was
also used by Fabunmi, Oworu and Odunaiya (2008) on study titled
prevalence of musculo-skeletal disorders among nurses in University
College Hospital, Ibadan. Mgbekam and Charles (2008) used survey for study
on knowledge and practice of problem-based learning: A case of Kasama
School of Nursing, Zambia.
Area of the Study
The study was carried out in Nnewi Urban. Nnewi is in the South East
of Nigeria in Anambra State and Nnewi North local Government Area. It
shares boundaries with Nnobi on the West, Ozubulu in the East, Amichi in
the North and Ichi in the South. Nnewi has one Federal Teaching Hospital
named Nnamdi Azikiwc University Teaching Hospital (NAUTH); many
health centers and private hospitals. It is a commercial area with the biggest
market called Nkwo Nnewi Market. They are well known for motor and
motorcycle spare parts, new and second hand motorcycles. The inhabitants
indulge in some unhealthy life styles like smoking, excessive alcohol
consumption, eating of junk foods and so on.
Population of the Study
The population used for the study involved all adults in Nnewi urban
(24 years & above) who are inhabitants of the four main towns in Nnewi.
Age range of 24 and above was chosen because the hospital records
indicated that stroke occurrence is very insignificant at ages below 24.
According to the 2006 population census, Nnewi has adult population of
74
177, 087 of which 90, 314 were males and 86, 773 females (National
Population Commission NPC, 2006).
Sample and Sampling Technique
The sample size for the study was 8,610 persons. This was based on
the fact that Nwana (1985) opined that where a population of study is
several thousands, a five per cent or less sample size will be adequate for
the study. Purposive sampling technique was employed in selecting 297
adults within 24 years and above in each of the 29 villages in Nnewi urban.
Using this type of sampling, the researcher selected her sample to satisfy
predetermined criteria that the subject must be an adult, within 24 years
and above; and an inhabitant of Nnewi urban. The area (Nnewi urban) is
made up of four towns namely Otolo, Uruagu, Umudim and Nnewichi.
Otolo has nine (9) villages, Uruagu has ten (10) villages, Umudim has six
(6) villages and Nnewichi has four (4) villages, making a total of 29
villages.
Instrument for Data Collection
The main instrument for data collection was structured questionnaire.
The structured questionnaire titled Associated Risk Factors of Stroke
Questionnaire was developed by the researcher following thorough review of
related literature. The structured questionnaire consisted of two sections. In
section A, the respondents were required to provide the demographic
information such as age group, gender and educational level. Section B of
the questionnaire was on knowledge of the associated risk factors of stroke.
Validation of Instrument
The questionnaire was given to experts for face and content validity.
Six experts were involved, four in Human Kinetics and Health Education
Department and two consultant physicians in Nnewi urban. It was also given
to the researcher's supervisor. They were given copies of the research
75
questions, hypotheses, purpose of the study and the draft of the
questionnaire for validation. The experts were required to ascertain the content
and face validity and best suitable statistical methods to be used. The two
consultant physicians in Nnewi urban added some risk factors that were
omitted by the researcher. With the useful inputs by the six experts, some
questions were dropped and some were restructured. Final corrections were
made before copies of the questionnaire were administered to the respondents.
Reliability of the Instrument
The reliability of the instrument was established through split half
method. A pilot test was carried out on fifty (50) adults in Onitsha urban
who did not form part of the study population. Fifty copies of the
questionnaire were administered to them, same were correctly filled and
returned. After the data collection, split – half method based on the odd and
even number items of the questionnaire was used. Then, Pearson Product
Moment Correlation Coefficient was employed for the data analysis. The
analysis gave a coefficient alpha of the questionnaire to be 0.94. This is
considered high enough for the study.
Method of Data Collection
The researcher went to the 29 villages at several occasions to
administer the instrument to the sampled 297 respondents from each
village. She did that with the help of four (4) research assistants who
were trained for one week on how to interpret correctly to illiterates
and also fill subjects’ responses correctly. The respondents were given the
instrument at their homes (i.e. house to house).The researcher and her
assistants used early mornings and evenings to enable them meet many
subjects at homes. Though, some subjects were not met at once hence many
visits were made by the researcher and her assistants. It took them four
76
weeks to complete the exercise. The instrument was administered to the
8,610 respondents face to face; and this ensured high percentage of the
return rate and also made the researcher and her assistants available to
explain any point the respondents may not understand very well. Eight
thousand, five hundred an eighty-seven (8,587) copies of the questionnaire
were correctly filled and returned, giving a return rate of 99.7 per cent. The
research ethical principles of confidentiality, beneficence and justice were
also assured.
Method of Data Analysis
At the end of data collection exercise, the researcher tallied and coded
the responses to get the aggregate scores of the respondents. Descriptive
statistics of range of scores, frequency, percentage and mean scores were
used in answering the research questions where applicable. While an
inferential statistics of t-test and analysis of variance (ANOVA) were used to
test the variables at .05 level of significance and appropriate degree of
freedom.
The following decision guided the analysis based on scores from the
18 items in the questionnaire.
Range of scores
Percentage
Remarks
11-18
60- 100
Good knowledge
9 -10
50-59
Fair knowledge
0-8
Below 50
Poor knowledge
The questionnaire contained 18 items, range of
scores within 11 – 18 is equivalent to 60 – 100 %
(i.e. good knowledge), range of scores between 9
and 10 is equivalent to 50 – 59 % (i.e. fair
77
knowledge) whereas range of scores within 0 – 8
out of the 18 items is equivalent to below 50 %
(i.e. poor knowledge).
78
CHAPTER FOUR
PRESENTATION AND ANALYSIS OF DATA
The data collected from the field were analyzed and the summaries
presented in the tables below to highlight the findings. The presentation was
done sequentially starting from research questions and then the null
hypotheses.
Research Question 1
Which associated risk factors of stroke are known by adults in Nnewi urban?
Table 1: Frequency and Percentage of the Respondents on their Knowledge
of Associated Risk Factors of Stroke
Item No.
Items
N = 8,587
Frequency
1
Hypertension
5197
60.5
2
Stress
6039
70.3
3
Diabetes Mellitus
4636
54.0
4
Sickle cell disease (anaemia)
4172
48.6
5
Cigarette Smoking
4355
50.7
6
Obesity
4019
46.8
7
Intake of excess alcohol
4722
55.00
8
Use of contraceptives like oral pills
5224
60.8
9
Excess fat intake
4589
53.4
10
High salt intake
4087
47.6
11
Physical trauma like accident with
4386
51.1
Percentage
head injury, fracture of spinal cord or gunshot
12
Menopause (cessation of menses)
4240
49.4
13
Family history of stroke
4448
51.8
14
Transient ischaemic attack
4041
47.1
15
Lack of exercise
4014
46.7
16
Oral infection like dental or gum infection
4194
48.8
17
Long distance/professional driving
4482
52.2
18
Abuse of substances like amphetamines
4095
47.7
79
Table 1 indicates that 70.3% of the respondents got item 2 (stress) correctly,
60.8% of them got item 8 (use of contraceptives) correctly while 60.5% of
them got item 1 (hypertension) correctly.
Furthermore, 55% of the respondents got item 7 correctly, 54%, 53.4%
and 52.2% of them got item 3, 9 and 17 correct respectively. Also, 49.4%,
48.8%, 48.6%, 47.7%, 47.6%, 47.1%, 46.8% and 46.7% got items 12, 16,4,
18, 10, 14, 6 and 15 correct respectively.
Research Question 2
What level of knowledge of associated risk factors of stroke
do adults in Nnewi urban possess?
Table 2: Range of Scores, Frequency and Percentages on the Level of
Knowledge of Associated Risk Factors of Stroke
Range of scores
Frequency
Percentage
Remark
Below 50%
3431
40.00
Poor knowledge
50 - 59%
2236
26.00
Fair knowledge
60- 100%
2920
34.00
Good knowledge
Total
8587
100
Table 2 reveals that only 2920 (34%) of the adults in Nnewi urban have a
good knowledge of the associated risk factors of stroke. Then 2236 (26%) of
the adults in the area have a fair knowledge of the associated risk factors of
stroke, while 3431 (40%) of the adults in the area have poor knowledge of
the associated risk factors of stroke.
Research Question 3
What knowledge of associated risk factors of stroke do male and
female adults in Nnewi urban possess?
80
Table 3: Mean Scores of Male and Female Adults 1 Knowledge of the
Associated Risk Factors of Stroke.
Gender
N
X
Remark
Male
3349
53,88
Fair knowledge
Female
5238
55.75
Fair knowledge
Total
8587
54.82
Table 3 reveals that both male and female adults in Nnewi urban have fair
knowledge of the associated risk factors of stroke with the respective mean
scores of 53.88% and 55.75% , though female adults scored higher than
male adults.
Research Question 4
What knowledge of associated risk factors of stroke do adults
of different age groups in Nnewi urban possess?
Table 4:
Mean Scores of the Adults of Various Age Groups on
their Knowledge of Associated Factors of Stroke
N
Age Groups
X%
Remarks
2 4 -4 0
3262 49.19
Poor knowledge
41 -57
3610
Good knowledge
5 8 -7 4
1371 52.75
Fair knowledge
75 and above
344
Poor knowledge
Total
8587 54.82
61.88
46.88
In table 4, it was discovered that all the age groups vary in their
knowledge of the associated risk factors of stroke, those between the
ages of 41 - 57 have good knowledge followed by those of 58 - 74 years of
age with fair knowledge. Finally those within 24 - 40 years of age, and
75 and above years of age have poor knowledge of the associated risk
factors of stroke.
81
Research Question 5
What knowledge of associated risk factors of stroke do adults of
different educational levels in Nnewi urban possess?
Table 5: Mean Scores of Adults on their Knowledge of Associated
Risk Factors of Stroke Based on Educational Level.
Educational level
N
X%
Remark
No formal education
428
48.63
Poor knowledge
Primary level of education
1119
56.69
Fair knowledge
Secondary level of education 3088
53.13
Fair knowledge
Tertiary level of education
3952
56.69
Fair knowledge
Total
8587
54.82
Table 5 shows that not all the adults in all the educational levels have mean
scores within the range of scores for fair knowledge, whereas none has mean
scores within the range of scores for good knowledge. However, those of
tertiary and primary level of education have fair knowledge, followed by
those of secondary level of education, while those of no formal education
have poor knowledge of the associated risk factors of stroke.
Testing the Null Hypotheses
The following null hypotheses were tested at .05 level of significance:
HO1There is no significant difference in the mean scores of male and female
adults on their knowledge of the associated risk factors of stroke.
82
Table 6: t - test on the Mean Scores of Male and Female Adults on
their Knowledge of Associated Risk Factors of Stroke.
Source of variation
Male
N
3349
X%
53.88
Female
5238
55.75
sd
df
Cal.t Crit.t p>0.05
5.72
8585 4.91 1.96 0.05
5.71
.05 = significance
Table 6 shows that at .05 level of significance, and 8585 df, the calculated
t 4.91 is greater than the critical t 1.96. Therefore, the first null hypothesis is
rejected. The researcher then concludes that female adults in Nncwi urban have
more knowledge of the associated risk factors of stroke than male adults.
Null Hypothesis 2
There is no significant difference in the mean scores of adults in their
knowledge of associated risk factors of stroke due to their age groups.
Table 7: ANOVA on the Mean Scores of the Adults from Various
Age Groups on their Knowledge of the Associated Risk Factors
of Stroke.
Source of variation
Between group
Within group
Total
SS
df
7966.30
3
55523.56
8583
63489.86
8586
Ms
Cal.F
Crit.F
p>0.05
410.49
2.60
0.05
2655.43
6.47
Table 7 indicates that at .05 significant level, 3 df numerator and 8583 df
denominator, the calculated f 410.49 is greater than the critical f 2.60.
Therefore, the second null hypothesis is rejected. The researcher concludes
that the adults in Nncwi urban differ in their knowledge of the associated
risk factors of stroke due to their age.
83
Null Hypothesis 3
The adults in Nnewi urban do not differ significantly in the
knowledge of associated risk factors of stroke due to their educational levels.
Table 8: ANOVA on the Mean Scores of the Adults'
Knowledge of the Associated Risk Factors of Stroke
Based on Educational Level.
Source of variation
SS
df
Between group
1088.09
3
Within group
62401.77
8583
Total
63489.86
8586
Ms
Cal.F
Crit.F
p>0.05
2.60
0.05
362.70
7.27
49.89
In table 8, it was observed that at .05 level of significance, 3 df numerator
and 8583 df denominator, the calculated f 49.89 is greater than the critical f
2.60. Therefore, the third null hypothesis is rejected. The researcher then,
concludes that the adults differ significantly in their knowledge of the
associated risk factors due to their educational level.
Summary of Findings
From the analysis, the following findings were made:
1. The commonest associated risk factors of stroke known by adults in Nnewi
urban include stress, use of contraceptives like oral pills and hypertension,
followed by intake of excess alcohol, diabetes mellitus, excessive fat intake,
long distance/professional driving, family history of stroke, physical
trauma like accident with head injury, fracture of spinal cord or gunshot;
and cigarette smoking.
2. Only 2920 (34%) of the adults have good knowledge of the associated
risk factors of stroke. Hence, their level of knowledge is low.
84
3. The male and female adults differ significantly in their knowledge of the
associated risk factors of stroke. Female adults are more knowledgeable
than male adults.
4. Adults of different age groups differ significantly in their knowledge of the
associated risk factors of stroke. Adults within the age group of 4 1 - 5 7
years are more knowledgeable than others.
5. The adults differ significantly in their knowledge of the associated risk
factors of stroke based on their educational levels. Adults with tertiary and
primary levels of education are more knowledgeable than others.
85
CHAPTER FIVE
DISCUSSION OF RESULTS, CONCLUSION AND
RECOMMENDATIONS
This chapter discusses the results of the study based on the research
questions with references made to the studies contained in the reviewed
literature.
Discussion of Results
The results were discussed under the following sub – themes:
 Knowledge of associated risk factors of stroke
 Overall knowledge of associated risk factors of stroke
 Knowledge based on Gender
 Knowledge based on age
 Knowledge based on educational levels
Knowledge of Associated Risk Factors of Stroke:
Adults in Nnewi urban know very well that stress, use of
contraceptives like oral pills, and hypertension are associated risk factors of
stroke. Their good knowledge of stress as a risk factor of stroke concurs with
that of Snider (1982) and Engler and Engler (1995). Also their knowledge of
use of contraceptives like oral pills was supported by Snider (1982),
American Heart Association (2009), Park (2002), Smeltzer and Bare (2000)
and Edwards, Bouchier, Haslett and Chilvers (1995), whereas their
knowledge of hypertension as a risk factor of stroke is in line with the views of
National Institute of Neurological Disorders and Stroke (2009), American
Heart Association (2009), Department of Health and Human Services
Centers for Disease Control and Prevention (2007), Okoye (2006) and also
finding by Sutterer, Carey, Silver and Nash (2005), showed that 73 percent of
respondents know about hypertension as a risk factor of stroke.
86
More so, the adults possessed fair and poor knowledge of some risk
factors of stroke which the researcher observed the adults in Nnewi urban
abused most. For instance, cigarette smoking, intake of excess alcohol, intake
of excess salts, abuse of substances, diabetes mellitus, lack of exercise and
they need to be educated on them very well. Cigarette smoking limits the
blood's oxygen - carrying capacity by displacing oxygen with carbon
monoxide thereby leading to the cells' starvation and death and finally to
stroke. The researcher opined that this habit should be strictly controlled and
Federal Government can assist by prohibiting the importation of cigarette.
In the same vein, alcohol should be taken in moderation and excessive
intake of it should strictly be avoided. This is because apart from resulting to
stroke, it can cause other aliments like fatty degeneration of heart and liver,
and so on. Intake of excess salt as a habit must be avoided because the
sodium content of salt has high affinity for water. As a result, it draws water
into the tissues leading to oedema (accumulation of fluid) and increase in
blood volume leading to hypertension and finally to stroke. The researcher
hereby states that excessive salt intake includes cooking food with excess
salt and even addition of raw salt to already cooked food.
Furthermore, abuse of substances like amphetamine, cocaine and
many others should also be strictly avoided because most of these substances
contain items that can constrict blood vessels leading to arteriosclerosis and
others can limit the blood's oxygen -- carrying capacity. The researcher
observed that adults in Nnewi urban abuse these substances most especially at
motor parks (Nkwo Nnewi Market Garage). Diabetes mellitus is another factor
that affects many adults in Nnewi urban and they need to be educated that it is
a risk factor of stroke. This will increase their adherence to dietary regimen and
treatment to achieve a control. Lack of exercise should be made known to
adults in Nnewi urban as a risk factor of stroke because most people think
that exercise is only for sports men and women. Exercise is very necessary
for fitness and healthiness as it promotes adequate circulation of blood to all
87
parts of the body thereby making oxygen available for the cells. Hence
adults in Nnewi urban need to be well educated on most of these risk
factors of stroke.
However, adults' poor knowledge of these above mentioned risk
factors contradicted the views of American Heart Association (2009), Okoye
(2006), Okafor (2006), Kwasnica (2008). The contradiction may be because
of the type of respondents and area of the study used by them. The
researcher opined that adults in Nnewi urban had poor knowledge of risk
factors of stroke, since they had good knowledge of only three items out of
eighteen items. Again some stroke victims out of ten met during the study
disclosed that evil people inflicted the stroke on them.
Overall Knowledge of Associated Risk Factors of Stroke:
Only 34 per cent of the adults scored 60 to 100 per cent indicating
good knowledge, 26 percent of them scored 50 to 59 per cent indicating fair
knowledge, whereas 40 per cent of the adults scored below 50 per cent
indicating poor knowledge. The researcher therefore opined that since
greater percentage (i.e. 40%) scored below 50, the adults in Nnewi urban
had low knowledge of associated risk factors of stroke. Hence, there is a great
need for health education programme concerning associated risk factors of
stroke for adults in Nnewi urban; not only adults but for all ages including
school children (i.e. our future adults). The researcher also agrees with the
suggestion by Steve (2008) that education on stroke should start with kids;
and that every child as part of the high school curriculum should have a field
trip to their local hospital with a stroke ward to show them what happens to
stroke patients.
Knowledge Based on Gender:
From the study, it was deduced that both male and female adults have
fair knowledge of the associated risk factors of stroke, though their mean
88
scores differ. Females scored higher than males, but none of them possessed
good knowledge of the associated risk factors of stroke. Females scored
higher than males possibly because of ante natal clinic and immunization
clinic the female adults attend and they gain knowledge from health talk given
to them. More so, table 6 of t-test on their mean scores proved the first null
hypothesis rejected.
Hence, adults in Nnewi urban differ significantly in their knowledge
associated risk factors of stroke. This result is consistent with Opara and
Onuzuluike (2006) who found that female students are more cognizant of
health consequences of tobacco smoking than male students. Therefore male
and female differ in their knowledge.
Knowledge Based on Age:
From the study, it was observed that all the age groups differ in their
knowledge of associated risk factors of stroke with ages of 41 - 57 having good
knowledge and ages of 58 - 74 having fair knowledge. Finally, ages 24 - 40,
and 75 and above having poor knowledge of the associated risk factors of
stroke. The findings that age of 41 - 57 having good knowledge may be
attributed to the facts that ages within 40 to 65 years have been called the
years of stability and consolidation (Berman, Snyder, Kozier & Erb, 2008).
The results also was supported by the work of Nordhorn et al (2006) which
observed that increased knowledge of stroke risk factors was significantly
associated with younger age.
Furthermore, ages 75 years and above have poor knowledge. This
finding corroborated earlier observations by Robinson and Merrill (2003)
that stroke education efforts should be targeted at the very elderly. Result of
poor knowledge in ages 24 to 40 years is quite surprising to the researcher
because at this age group, adults are very young, vibrant, and ready to seek
for information. More so, table 7 of ANOVA on the mean scores of adults
from various age groups on their knowledge of associated risk factors of
89
stroke proved the second null hypothesis rejected. Hence, adults in Nnewi
urban differ significantly in their knowledge of the associated risk factors of
stroke based on age groups.
Knowledge Based on Educational Levels:
From the study, it can be deduced that adults in primary level,
secondary level and tertiary level have mean scores within the range of scores
for fair knowledge, while those who have no formal education have mean
scores within the range of scores for poor knowledge. Although, none of
them possessed good knowledge of the associated risk factors of stroke. Based
on their mean scores, those of tertiary and primary levels of education scored
higher.
However, the result of tertiary level agrees with the views of Nordhorn
et al (2006) that increased knowledge of stroke risk factors was significantly
associated with a higher educational level. This finding implies that
knowledge is power and is acquired through learning or education,
especially empirical knowledge. Again, this finding also agrees with the
view of Anso (2009), which indicated that people have become educated,
and have more knowledge about health and illness (health wise). More so,
people with no formal education have poor knowledge of associated risk
factors of stroke. This result concurs with the idea of Robinson and Merrill
(2003) that stroke education effort be targeted to those who have less than a
college education. With these findings, one can conclude that education
has an important role to play on the knowledge of the adults concerning
associated risk factors of stroke.
In the same vein, table 8 of ANOVA on the mean scores of the adults'
knowledge of the associated risk factors of stroke based on educational level
proved the third null hypothesis rejected. Therefore adults in Nnewi urban
differ significantly in their knowledge of associated risk factors of stroke
based on their educational levels.
The mean scores of primary level of education which is higher than
that of secondary level of education is very surprising to the researcher,
90
though it may be attributed to gain of knowledge through interaction with
other people and not necessarily through formal education. This group of
adults is mainly motorcycle riders popularly called "okada", traders, motor
conductors and drivers; and at their different places of work like market
areas, motor parks/garage, carpentry workshop, mason sites, painting areas
and so on, they freely interact and discuss about certain issues like some risk
factors of stroke examples, hypertension, diabetes mellitus, and stress.
Therefore, they gain knowledge from such discussion.
Conclusion
Having examined the findings emanating from this study on
knowledge of the associated risk factors of stroke among adults in Nnewi
urban, the following conclusions have been reached:
i. Adults in Nnewi urban know few of the associated risk factors of
stroke and also few adults (about 1/3 of the population) in Nnewi
urban possessed good knowledge of associated risk factors of stroke.
Hence, it calls for health promotion and health teaching in schools,
health facilities and community. Again, health education is very vital
as it provides knowledge thereby creating health consciousness and
self-awareness in adults in Nnewi leading to attitudinal, behavioural
and social changes towards effective decision making.
ii. Male and female adults possessed fair knowledge of associated risk
factors of stroke, though the mean scores of the female adults is
higher than that of the male adults.
iii. Adults between ages 41 to 57 have good knowledge of associated
risk factors of stroke while those of 58 to 74 years possessed fair
knowledge; and those of 24 to 40 and 75 and above years have poor
knowledge. Hence, the researcher opines that those of 24 lo 40 years
can possess good knowledge if they lend themselves to learning
91
because they are still young and active.
iv. Adults with tertiary, secondary and primary school levels of
education possessed fair knowledge of associated risk factors of
stroke, though none had good knowledge. Those of tertiary and
primary levels of education scored higher than those of secondary
level of education.
Implications of the Study
Health education is central to prevention of stroke and promotion of
health. The findings implied that health educators should program seminar
on associated risk factors of stroke with emphasis on intake of excess of
salt, lack of exercise, cigarette smoking, abuse of drugs and so on. The
knowledge gained from the seminar will help the adults in Nnewi adopt
healthy lifestyles. Again adults’ low level of knowledge can be improved by
routine seminar being organized by health educators, through proper health
education using mass media, religious group, health clinics and community
based health promotion programme by Non-Governmental Organizations
(NGOs).
The findings also implied that Federal government should stand firm
on their campaign that smokers are liable to die young and cigarette
smoking is dangerous to health. They can as well prohibit its importation
into the country. Finally, it implied that health education and awareness
campaign programme should be encouraged to improve adults’ knowledge
of associated risk factors of stroke by the Ministry of Health.
Recommendations
In view of the findings of the study on the knowledge of associated
risk factors of stroke among adults in Nnewi urban and implications of the
findings, the following recommendations were made:
1. For poor knowledge of risk factors of stroke like sickle cell disease,
obesity, high salt intake, menopause, transient ischaemic attack,
92
lack of exercise, oral infection and abuse of substances like
amphetamines, the researcher recommended that health educators
should organize seminars to educate the people on those risk factors.
Also the health educators should educate the people on healthy life
styles and encourage them to adopt such in their homes and society.
2. For the finding that only 34 per cent of the adults have good
knowledge of the associated risk factors of stroke, the researcher
recommended that public enlightenment and health education
should be extended to the entire community using the community
facilities through the town union meeting, age grade, religious
associations and trade union. This could be done by public health
workers through giving health talks to people during town union
meeting, age grade meeting, and religious meeting and so on. Also
periodic community mobilization and sensitization campaign should
be carried out by health educators at the grassroots on risk factors and
preventive measures of stroke.
3. From the finding of knowledge based on gender, the researcher
also recommended that the health educators should use every
opportunity at their disposal to reveal and teach the associated
risk factors of stroke to the male adults for instance during HIV/
AIDS free counseling and testing, health talks at general outpatient department and also reach out for male adults in men
organizations in the community. This will help to increase the
knowledge of associated risk factors of stroke possessed by male
adults in Nnewi urban.
93
4. Age groups of 24 – 40, and 75 and above possessed low
knowledge , hence the researcher recommended that the health
educators should organize brief health talks on the risk factors of
stroke for adults in Nnewi urban in the market square especially
during the weekly or monthly market prayer days. This will assist
those within age groups 24 – 40, while the health educators
should use home visiting program to reach out for those within
the age groups of 75 and above. They should carry out some
screening tests like checking of blood pressure, urinalysis / blood
sugar level, weighing and so on as well as health educating the
adults.
5. From the findings of knowledge based on educational levels, the
researcher recommended that mass literacy program should be
organized for those with no formal education to improve their
knowledge of risk factors of stroke. For secondary level of
education, curriculum should be looked into and reviewed to
cover this area of topic.
.
Limitations of the Study
There were literature on stroke in the internet and books but there were
not many studies carried out on knowledge of associated risk factors of
stroke and none in Nnewi urban precisely. However, this did not affect the
researcher’s results.
94
Suggestions for Further Research
• Further research should be conducted on knowledge of adults about
prevention of stroke.
• Research on knowledge of the associated risk factors of stroke should
be extended to other urban areas like Onitsha, Awka and so on.
• Research on the experiences and health behaviours of stroke patient.
• Perception of utilization of health and social facilities by the stroke
victims.
95
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APPENDIX A
QUESTIONNAIRE ON ASSOCIATED RISK FACTORS OF STROKE
Human Kinetics and Health Education
Department,
Nnamdi Azikiwe University, Awka,
Anambra State.
Dear Respondent,
1 am a post graduate student of the above named department and
institution. This questionnaire is for research purpose and is designed to ascertain
the knowledge of associated risk factors of stroke among adults in Nnewi urban.
The thesis is one of the pre-requisites for the M.Sc degree programme.
Please, honest and genuine answers will be appreciated. Please assist in
supplying
the
required
information demanded
by filling out
questionnaire. Your response will be treated with utmost confidentiality.
Thanks for your anticipated co-operation.
Yours Sincerely,
Nwankwo, C.U.(Mrs.)
this
105
Please tick (  ) to indicate your appropriate response.
Section A
1. Which of the following age groups do you belong to?
(a) 24 -40
(b) 41 -57
(c) 58 -74
(d) 75-above
2. Gender
(a) Male
3.
(b) Female
Highest level of education
(a) No formal education
(b) Primary level of education
(c) Secondary level of education
(d) Tertiary level of education
Section B
Questions to Ascertain Knowledge of the Associated Risk Factors of Stroke.
For each item below, there are four options, one of which is a risk factor
associated with stroke while the others are not. You are required, for each item
to identify which of them is a risk factor and indicate so by ticking ( ) in the
box that is provided on the right. Be sure you do not tick more than one option
for each number.
I.
a. Ma laria
b. Hypertension or high blood pressure
e. Typhoid fever
d. Hepatitis (infection of the liver)
106
2.
a. Stress
b. Anorexia (loss of appetite)
c. Psychiatric illness
d. Leprosy
3.
a. Peptic ulcer
b. Diabetes mellitus
c. Yellow fever
d. Tuberculosis
4.
a. Oedema (accumulation of fluid in the tissues
b. Glaucoma (a type of eye problem)
c. Sickle cell disease (anaemia)
d. Meningitis (inflammation of meninges)
5.
a. Intake of bitter kola
b. Intake of contaminated water
c. Intravenous infusion (drip)
d. Cigarette smoking
6.
a. Underweight
b. Obesity
c. Starvation
d. kwashiorkor
7.
a. Intake of excess alcohol
b. Intake of excess milk
c. Intake of less milk
d. Intake of excess water
107
8.
a. None use of contraceptives
b. Use of contraceptives like oral pills
c. Use of natural family planning (billings method)
d. Vasectomy or tubal ligation.
9.
a. Excess fat intake e.g. fried foods
b. Excess protein intake e.g. meat, fish
c Excess vitamin intake e.g. fruits
d. Excess roughage intake e.g. vegetables
10.
a. Low salt intake
b. High salt intake
c. High fluid intake e.g. juice, water
d. Low fluid intake e.g. juice, water
11.
a. Fracture of femur (the thigh bone)
b. Dislocation of the arm
c. Psychological trauma like rape.
d. Physical trauma like accident with
head injury, fracture of the spinal cord or gunshot.
12.
a. Menorrhegia (an excess flow of menses)
b. Menopause (cessation of menses)
c. Lactation (breast feeding)
d. Ovulation (dropping of eggs)
108
13.
a. Family history of stroke like one's mother or father suffered
stroke
b. Cultural background, that stroke is common in one's
society/culture.
c. Racism, that stroke is common with the blacks or Caucasians
d. Religion, that stroke is common with a particular religion.
14.
a. Heart attack
b. "Jazz" attack, charm or juju
c. Spiritual attack
d. Transient Ischaemic attack (warning sign, you may
have fallen from a chair or bed on trying to get up and unable to
get up on your own that other person(s) come to your rescue.
15.
16.
17
a.
Excessive sleep
b.
Lack of exercise
c.
Excessive walking
d.
Excessive rest
a.
Eye infection like conjunctivitis
b.
Ear infection like otitis media
c.
Oral infection like dental infection or gum infection
d.
Gastro intestinal infection like diarrhea and vomiting
Occupations like:
a.
b.
c.
d.
Taxi driving
Motorcycle riding
Long distance/professional driving
Private driving
109
18.
Substance abuse like
a.Abuse of decaffeinated coffee
b.Abuse of caffeinated coffee
c. Abuse of Lipton tea
d. Abuse of amphetamines
110
APPENDIX B
PREVIOUS RECORD OF STROKE FROM NNAMDI AZIKIWE
Age range
TEACHING HOSPITAL, NNEWI
Frequency
2004
2005 2006
2007
2008
M F
M F
M F
M
F
M
F
6
Total
5 years
24
-40
1
3
2 1
3
2
4
1
1
41
-57
6
9
12 13
10
8
12
12
10 9
101
58
-74
8
5
8 16
6
7
7
9
8
9
83
75
-above
9
6
10 12
7
13
7
9
5
12 90
24
23 32 42
30
31 24 36 298
Total
26 30
No of stroke cases in 2004 = 47
2005 = 74
2006 = 56
2007 = 61
2008 = 60
M stands for male
F stands for female
No of stroke cases in 2004-2008 = 298
No of males affected in 2004-2008 = 136
No of females affected in 2004-2008 = 162
No of cases within ages 24-40 in 2004-2008 =24
No of cases within ages 41-57 in 2004-2008 = 101
No of cases within ages 58-74 in 2004-2008 = 83
No of cases within ages 75-above in 2004-2008 = 90
24
111
APPENDIX C
AREA OF STUDY
FOUR MAIN TOWNS
29 VILLAGES
A. Nnewichi
Abubor, Oduda,
Okpuno, Obiofia
B. Otolo
Umuenem, Okpuno-umuenem,
Umuanuka, Mbanagu, Ndiakwu,
Ndimgbu,Ezekwuabo
Umuzu, Okofia.
C. UMUDIM
Akammiri, Umudimkwa,
Okpuno, Umunnealam,
Umuezena,Ebeleogu
D. URUAGU
Edoji,Akabo-Edoji,
Akaboezem,Akaboukwu,
Umuezeagu,Umumeagbu,
Ndi –Ojukwu, Okpuneze,
Ndiakwu, Umu-umejiaku.