Barriers Associated with Help-Seeking for Stroke Symptoms Despite Public Awareness Campaigns: A Cross-Sectional Study

The nationally advertised mass media campaign Act-FAST UK, delivered in multiple waves since its launch in 2009, has increased public awareness of stroke symptoms. However, many stroke patients still delay in calling for help and reach the hospital too late to receive emergency treatments. The reasons for this cognitive dissonance between recognition of symptoms and urgent seeking of emergency medical services (EMS) are unclear.

This study aimed to quantify cognitive, psychological, and knowledge-based barriers to help-seeking in patients with acute stroke or transient ischaemic attack (TIA), as well as in intervening witnesses, and to examine their association with the use of EMS as the initial point of contact.

We interviewed patients admitted to a hyperacute stroke unit with a stroke or transient ischaemic attack (TIA) from 2013 to 2016. People who contacted emergency services on the patient's behalf (intervening witnesses (IWs)) were also interviewed when available. Reasons given for delays in calling for help were related to correct symptom recognition, and whether/at what time, emergency services were contacted after symptoms onset.

A total of 602 patients (429 with stroke, 173 with TIA) along with 128 witnesses who intervened in calling for help in those cases (IWs) were interviewed. In the subset of patients with both measures available, there was a strong positive correlation between NIHSS score and number of FAST symptoms (Spearman's rho = 0.645, p < 0.001), providing supportive evidence for the use of FAST symptom count as a proxy measure of stroke severity. A total of 469 (77.9%) of the patients were aware of a media education campaign about stroke, but only 145 (24.1%) had attributed their own symptoms to stroke at onset. However, correct self-diagnosis of stroke was not associated with direct calls to the EMS (OR 1.43, 95% CI 0.84-2.45). Cognitive, psychological or emotional barriers to help-seeking, as reported by prior published studies, were reported by 463 (81.2%) of the patients we interviewed but in only 63 (53.3%) of the IWs (p < 0.001). Amongst the patient cohort, "not thinking symptoms were serious" (275, 45.7%) and "waiting to see if symptoms would go away" (285, 47.3%) were most strongly negatively associated with EMS use (OR 0.52, 95% CI 0.32-0.84 and OR 0.34, 95% CI 0.21-0.55, respectively). Only 55 (9.1%) of the patients interviewed had been aware of any time-critical stroke treatment prior to their stroke. Eighteen stroke patients (4.2%) reached hospital in time to receive thrombolysis, but an additional 170 (39%) could have been considered for this treatment (i.e., had no apparent other contraindications from a notes review) had they arrived within 4 h of symptom onset.

Future public education campaigns may be more effective if they specifically address factors associated with delays in calling for help after stroke symptoms and emphasise the existence of emergency treatments, which are also time-critical. More effective public education may have the potential to increase the proportion of patients arriving in time to benefit from such treatments.