Dorien Brouwer

97 Health education in patients with recent stroke or transient ischemic attack PART 2 Outcome If information about stroke is not adequately provided to or received by stroke patients, this is likely to affect their compliance with secondary prevention and long-term outcome. [36] The direct effect of HE on compliance of lifestyle recommendations and consequently on outcome is not easy to measure. The chain of events leading from HE through changes in attitude and behavior to outcome is long, and the effect of interventions is dampened because of the many links in this chain. Outcome is a broadly defined item, which includes case fatality, recurrent vascular events, disability, anxiety or depression and quality of life. Moreover, outcome is influenced by many other factors, like healthcare system, social and physical environment (Fig. 1). Only a few trials are available of the effect of HE on outcome. In a Cochrane review [20] , interventions to deliver HE did not reduce lethality in patients with a recent TIA or stroke, compared with standard management (OR 082, 95% CI 056–121). The intervention consisted of group sessions, educational programmes, stroke nurse, booklets or individualized information delivered by computers. The review showed that HE did not affect the occurrence of anxiety (data from 681 participants in six trials), and depression (data from 956 participants in eight trials). [20] Three studies investigated the effect of a nurse-led support or education programme for stroke patients and their caregivers or spouses. No effects were found on quality of life, well-being [37] or depression [38] and small effects (in subgroup analyses) on social activities. [39] In one trial in which patients were visited at home, perception of health increased and emotional reactions and social isolation decreased significantly. [38] Public stroke knowledge and education Knowledge It is well known that there are deficiencies in public knowledge of risk factors for stroke and of stroke warning signs. Moreover, in many countries the public awareness of acute stroke as a disabling, life-threatening disease, requiring prompt treatment, is far from optimal. [15, 40–55] The proportion of individuals able to mention a single warning sign for stroke varied from 40% to 70%. [56] In studies investigating knowledge of risk factors, at least 20% of the people could not correctly mention at least one risk factor. [17, 42, 44, 50, 57] The proportion of those who identified at least two risk factors was low, and ranged from 25% to 62% [56] Hypertension was the most frequently recalled risk factor, followed by smoking. The most frequently noted sources of stroke knowledge were friends, family and mass media. Less commonly, physicians and hospital personnel were cited as sources. [41, 42, 50, 57] There is some evidence that those who are most at risk, the elderly, are the ones with the lowest level of knowledge. The effect of public educational campaigns aimed at improvement of stroke knowledge is variable. [51, 55, 58, 59] Producing long-term change