2006 GEORGIA STROKE AND HEART ATTACK AWARENESS SURVEY Introduction Cardiovascular disease (CVD) is the leading cause of death in Georgia, accounting for one third (32%) of deaths in 2006. Georgia's CVD death rate is 9% higher than the U.S. average. In 2006, approximately 143,800 hospitalizations occurred due to CVD among Georgia residents, with an average charge of $30,700 per hospitalization. Total hospital charges for CVD in Georgia were $4.4 billion. The overall cost of CVD in Georgia is estimated to be $10.5 billion. This includes direct health care costs and lost productivity from illness and death (indirect costs).1 Stroke is the third leading cause of death in Georgia, accounting for 6% of all deaths. In 2006, Georgia's stroke death rate was 16% higher than the national rate. Significant disparities exist for CVD in Georgia. Death rates for men are 1.4 times higher than for women, and are 1.3 times higher for blacks than for whites. Black males are at particularly high risk for premature death due to CVD: nearly half of those who died from CVD in 2006 were younger than 65. Many Georgians also place themselves at higher risk for CVD by not modifying their risk factors, which include high blood pressure, high cholesterol, overweight/obesity, sedentary lifestyle, smoking, diabetes, and poor diet. Stroke and heart attack are life-threatening conditions. If you cannot identify the symptoms of a stroke or heart attack, you may not obtain medical assistance quickly enough, which may result in permanent damage to the body or death. Even in survival, full abilities may not be regained, and months of costly medical care and rehabilitation may result. Besides symptom recognition, knowing to call 911 immediately for CVD events is critical. Due to the large impact of CVD in Georgia, and the potential for improved outcomes through early detection and treatment, the Georgia Division of Public Health conducted a statewide survey in 2006 to measure: Knowledge of stroke signs Ability to recognize a CVD event and call 911 Knowledge of heart attack signs Knowledge of hypertension Knowledge of modifiable CVD risk factors Sources of information for CVD treatments Results were analyzed to determine if knowledge differed by sex, race, age, income level, highest level of education attained, urban or rural residence, individual or family history of stroke or heart attack, and insurance status. Key Findings 2.7 million Georgians, or 39% of Georgia adults, do not know the signs of stroke 1.3 million Georgians, or 19% of Georgia adults, do not know the signs of heart attack Nearly 2.3 million, or 33% of Georgia adults, do not know the modifiable risk factors for CVD 3.2 million Georgians, or 46% of Georgia adults, cannot recognize a stroke and call 911 More than 2 million Georgians, or 30% of Georgia adults, cannot recognize a heart attack and call 911 Of all the factors affecting knowledge, education level had the greatest impact Other factors significantly predicting knowledge, in order of importance, were: race, income, age, history of stroke, urban or rural residence, history of heart attack, and sex Table of Contents Actions Necessary to Improve Cardiovascular Awareness in Georgia Knowledge of Stroke Signs.......................p.2 Knowledge of Heart Attack Signs................p.3 Ability to Recognize a Cardiovascular In addition to other efforts to improve CVD outcomes in Georgia, interventions to improve awareness of stroke and heart attack signs and risk factors should be targeted to those with the greatest need, in order of importance: 1. Lower education level 2. Non-whites Disease Event and Call 911.......................p.4 Knowledge of Modifiable Cardiovascular Disease Risk Factors...............................p.7 Knowledge of Hypertension.......................p.8 Where Respondents Heard About Cardiovascular Disease Treatments...........p.8 3. Low- to middle-income Changes in Stroke Knowledge from 4. Younger than 45 / older than 65 1999 to 2006.........................................p.9 5. No personal or family CVD history Methodology, References.......................p.10 6. Rural residents 7. Males 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 1 Knowledge of Stroke Signs Total Population 39% of Georgia adults (2.7 million) do not know the signs of stroke Percent of Adults who Identified 1 Stroke Sign, Georgia, 2006 39% Know stroke signs 61% Do not know stroke signs Knowledge of Stroke Signs by Age Respondents between ages 45 and 64 were: 1.4 times more likely* than those ages 18-29 to identify at least one stroke sign 1.1 times more likely than those 65 and older to identify at least one stroke sign Knowledge of Stroke Signs by Sex No significant differences between Males and Females Percent of Adults who Identified 1 Stroke Sign, by Sex, Georgia, 2006 100 80 64 58 60 40 20 0 M ale s Fem ales Percent of Adults who Identified 1 Stroke Sign, by Age, Georgia, 2006 100 80 62 69 61 60 50 40 20 0 18-29 30-44 45-64 65+ Age Group Knowledge of Stroke Signs by Race Knowledge of Stroke Signs by Income Level Whites were 1.3 times more likely than Blacks to identify at least one stroke sign Percent of Adults who Identified 1 Stroke Sign, by Race, Georgia, 2006 100 Those with incomes of $75,000 or higher were: 1.6 times more likely than those with incomes lower than $20,000 to identify at least one stroke sign 1.3 times more likely than those with incomes between $20,000 and $34,999 to identify at least one stroke sign 80 66 60 40 20 0 White s 52 Black s * All differences presented in results are significant at = .05 Percent of Adults who Identified 1 Stroke Sign, by Income Level, Georgia, 2006 100 80 67 69 70 56 60 45 40 20 0 <$20,000 $20,000 - $35,000 - $50,000 - $75,000+ $34,999 $49,999 $74,999 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 2 Knowledge of Stroke Signs by Education Level College graduates were: 1.8 times more likely than those with no high school degree to identify at least one stroke sign 1.3 times more likely than those with only a high school degree to identify at least one stroke sign Knowledge of Stroke Signs by Insurance Status The insured (70%) were 1.3 times more likely than the non-insured (53%) to know a stroke sign Percent of Adults who Identified 1 Stroke Sign, by Education Level, Georgia, 2006 100 80 72 64 55 60 40 40 20 0 No high High school Som e college College s chool graduate graduate degree Knowledge of Stroke Signs by History of Stroke Those with an individual or family history of stroke (68%) were 1.3 times more likely than those without a history (54%) to know a stroke sign Knowledge of Heart Attack Signs Total Population 19% of Georgia adults (1.3 million) do not know the signs of heart attack Percent of Adults who Identified 1 Heart Attack Sign, Georgia, 2006 19% Know heart attack signs Do not know heart attack signs 81% Knowledge of Heart Attack Signs by Sex No significant differences between Males and Females Percent of Adults who Identified 1 Heart Attack Sign, by Sex, Georgia, 2006 100 81 80 60 40 20 0 M ale s 81 Fem ales Knowledge of Heart Attack Signs by Age Knowledge of Heart Attack Signs by Race Respondents between ages 45 and 64 were 1.2 times more likely than those ages 18-29 and those 65 and older to identify at least one heart attack sign Whites were 1.3 times more likely than Blacks to identify at least one heart attack sign Percent of Adults who Identified 1 Heart Attack Sign, by Age, Georgia, 2006 100 75 82 86 75 80 60 40 20 0 18-29 30-44 45-64 65+ Age Group 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY Percent of Adults who Identified 1 Heart Attack Sign, by Race, Georgia, 2006 100 86 80 60 40 20 0 White s 69 Black s 3 Knowledge of Heart Attack Signs by Income Level Those with incomes of $75,000 or higher were; 1.5 times more likely than those with incomes lower than $20,000 to identify at least one heart attack sign 1.1 times more likely than those with incomes between $20,000 and $34,999 and between $35,000 and $49,999 to identify at least one heart attack sign Percent of Adults who Identified 1 Heart Attack Sign, by Income Level, Georgia, 2006 100 89 91 81 81 80 60 60 40 20 0 <$20,000 $20,000 - $35,000 - $50,000 - $75,000+ $34,999 $49,999 $74,999 Knowledge of Heart Attack Signs by Education Level College graduates were: 1.6 times more likely than those with no high school degree to identify at least one heart attack sign 1.2 times more likely than those with only a high school degree to identify at least one heart attack sign Percent of Adults who Identified 1 Heart Attack Sign, by Education Level, Georgia, 2006 100 85 90 76 80 55 60 40 20 0 No high High school Som e s chool graduate colle ge degree Colle ge graduate Knowledge of Heart Attack Signs by Residence Urban residents were 1.1 times more likely than rural residents to know a heart attack sign Percent of Adults who Identified 1 Heart Attack Sign, by Residence, Georgia, 2006 100 82 76 80 60 40 20 0 Urban Rural Knowledge of Heart Attack Signs by Insurance Status The insured were 1.1 times more likely than the non-insured to know a stroke sign Knowledge of Heart Attack Signs by History of Heart Attack Those with an individual or family history of heart attack were 1.1 times more likely than those without a history to know a heart attack sign Ability to Recognize a Cardiovascular Disease (CVD) Event and Call 911 Total Population: Stroke Response 46% of Georgia adults (nearly 3.2 million) cannot recognize a stroke and call 911 Percent of Adults who Could Recognize a Stroke and Call 911, Georgia, 2006 Total Population: Heart Attack Response 30% of Georgia adults (over 2 million) cannot recognize a heart attack and call 911 Percent of Adults who Could Recognize a Heart Attack and Call 911, Georgia, 2006 46% Could recognize and respond Could not 54% recognize and respond 30% 70% Could recognize and respond Could not recognize and respond 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 4 Ability to Recognize a CVD Event and Call 911: By Sex No significant difference between Males and Females Percent of Adults who Could Recognize a CVD Event and Call 911, by Sex, Georgia, 2006 100 80 57 60 40 20 0 M ale s 71 51 Fem ales Males 69 Fem ales Stroke Heart Attack By Age Respondents between ages 45 and 64 were 1.3 times more likely than those 65 and older to be able to identify a stroke and call 911 Percent of Adults who Could Recognize a CVD Event and Call 911, by Age, Georgia, 2006 100 80 57 61 74 75 62 61 60 43 49 40 20 0 18-29 30-44 45-64 65+ 18-29 30-44 45-64 65+ Age Group Stroke Heart Attack Ability to Recognize a CVD Event and Call 911 by Race Percent of Adults who Could Recognize a CVD Whites were 1.2 times more likely than Blacks to be able to identify a CVD event and call 911 Event and Call 911, by Race, Georgia, 2006 100 74 80 57 60 48 61 40 20 0 White Black White Black Stroke Heart Attack Ability to Recognize a Stroke and Call 911 by Income Level Those with incomes of $75,000 or higher were: 1.7 times more likely than those with incomes lower than $20,000 to be able to recognize a stroke and call 911 1.2 times more likely than those with incomes between $20,000 and $34,999 to be able to recognize a stroke and call 911 Percent of Adults who Could Recognize a Stroke and Call 911, by Income Level, Georgia, 2006 100 80 61 63 60 60 36 50 40 20 0 <$20,000 $20,000 - $35,000 - $50,000 - $75,000+ $34,999 $49,999 $74,999 Ability to Recognize a Heart Attack and Call 911 by Income Level Percent of Adults who Could Recognize a Heart Attack and Call 911, by Income Level, Georgia, 2006 Those with incomes of $75,000 or higher were 1.5 times more likely than those with incomes lower than $20,000 to be able to recognize a heart attack and call 911 100 80 69 72 79 79 60 52 40 20 0 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY <$20,000 $20,000 $34,999 $35,000 $49,999 $50,000 $74,999 $75,000+ 5 Ability to Recognize a Stroke and Call 911 by Education Level College graduates were: Twice as likely as those with no high school degree to be able to recognize a stroke and call 911 1.3 times more likely than those with only a high school degree to be able to recognize a stroke and call 911 Ability to Recognize a Heart Attack and Call 911 by Education Level College graduates were: 1.7 times more likely than those with no high school degree to be able to recognize a heart attack and call 911 1.3 times more likely than those with only a high school degree to be able to recognize a heart attack and call 911 Percent of Adults who Could Recognize a Stroke and Call 911, by Education Level, Georgia, 2006 100 80 58 60 48 40 32 20 0 No high High school Som e s chool graduate colle ge degree 64 Colle ge graduate Percent of Adults who Could Recognize a Heart Attack and Call 911, by Education Level, Georgia, 2006 100 74 80 80 63 60 47 40 20 0 No high s chool degree High school graduate Som e colle ge Colle ge graduate Ability to Recognize a Heart Attack and Call 911 by Residence Urban residents were 1.1 times more likely than rural residents to be able to recognize a heart attack and call 911 Percent of Adults who Could Recognize a Heart Attack and Call 911, by Residence, Georgia, 2006 100 80 72 60 40 20 0 Urban 63 Rural Ability to Recognize a CVD Event and Call 911 by Insurance Status The insured (56%) were 1.3 times more likely than the uninsured (43%) to be able to recognize a stroke and call 911 The insured (72%) were 1.2 times more likely than the uninsured (59%) to be able to recognize a heart attack and call 911 Ability to Recognize a CVD Event and Call 911 by History of Stroke Those with an individual or family history of stroke (59%) were 1.2 times more likely than those without a history (48%) to be able to recognize a stroke and call 911 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 6 Knowledge of Modifiable Cardiovascular Disease (CVD) Risk Factors Total Population 33% of Georgia adults (nearly 2.3 million) do not know the modifiable risk factors for CVD This knowledge, if accompanied by effective action, is key to preventing and reducing CVD events Percent of Adults who Identified 1 Modifiable CVD Risk Factor, Georgia, 2006 33% Know risk factors Do not know risk factors 67% Knowledge of Risk Factors by Sex No significant differences between Males and Females Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Sex, Georgia, 2006 100 80 68 66 60 40 20 0 M ale s Fem ales Knowledge of Risk Factors by Age Respondents between ages 45 and 64 were 1.4 times more likely than those ages 18-29 and those 65 and older to identify at least one modifiable CVD risk factor Knowledge of Risk Factors by Race Whites were 1.5 times more likely than Blacks to identify at least one risk factor Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Race, Georgia, 2006 100 75 80 60 49 40 20 0 White s Black s Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Age, Georgia, 2006 100 80 70 76 56 56 60 40 20 0 18-29 30-44 45-64 65+ Age Group Whites were significantly more likely than Blacks to identify these modifiable CVD risk factors: High cholesterol Tobacco use Physical inactivity Obesity Diet Knowledge of Risk Factors by Income Level Those with incomes of $75,000 or higher were: 2.1 times more likely than those with incomes lower than $20,000 to identify at least one modifiable CVD risk factor 1.2 to 1.4 times more likely than those with incomes between $20,000 and $74,999 to identify at least one modifiable CVD risk factor Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Income Level, Georgia, 2006 100 87 80 68 74 61 60 41 40 20 0 <$20,000 $20,000 - $35,000 - $50,000 - $75,000+ $34,999 $49,999 $74,999 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 7 Knowledge of Risk Factors by Education Level College graduates were: 2.5 times more likely than those with no high school degree to identify at least one modifiable CVD risk factor 1.6 times more likely than those with only a high school degree to identify at least one modifiable CVD risk factor 1.2 times more likely than those with only some college to identify at least one modifiable CVD risk factor Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Education Level, Georgia, 2006 100 80 74 60 52 40 34 20 0 No high High school Som e s chool graduate colle ge degree 85 Colle ge graduate Knowledge of Risk Factors by Residence Urban residents were 1.3 times more likely than rural residents to know a modifiable CVD risk factor Percent of Adults who Identified 1 Modifiable CVD Risk Factor, by Residence, Georgia, 2006 100 80 70 55 60 40 20 0 Urban Rural Knowledge of Risk Factors by Insurance Status Insured respondents were 1.3 times more likely than non-insured respondents to know a modifiable CVD risk factor Knowledge of Risk Factors by History of Stroke Respondents with an individual or family history of stroke were 1.1 times more likely than those without a history to know a modifiable CVD risk factor Knowledge of Risk Factors by History of Heart Attack Respondents with an individual or family history of heart attack were 1.1 times more likely than those without a history to know a modifiable CVD risk factor Knowledge of Hypertension Where Respondents Heard About Cardiovascular Disease Treatments Question % answering correctly High blood pressure (BP) can cause strokes 96 People taking medication for hypertension should take it 96 daily High BP can cause heart attacks 95 Weight loss usually decreases BP 90 160/100 is high BP 87 Eating salt usually increases BP 78 Exercising usually decreases BP 77 High BP can NOT cause cancer 77 Hypertension usually lasts a lifetime 69 High BP can cause kidney disease 68 130/80 is normal BP 58 Most people with high BP feel fine/are asymptomatic 57 Drinking 1+ alcoholic drinks daily usually increases BP 56 Source % Newspaper, magazine, medical 33 journal TV, radio 24 Hospital, doctor's office, 23 healthcare facility Internet 16 Brochure, poster, flyer 14 * Respondents could select more than one option 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 8 Changes in Stroke Knowledge from 1999 to 2006 Knowledge of Stroke Signs: Total Population and By Sex In 2006, respondents (61%) were 1.6 times more likely to know 1 stroke sign than in 1999 (39%) In 2006, males were 1.6 times more likely and females were 1.5 times more likely to know 1 stroke sign than in 1999 Percent of Adults who Identified 1 Stroke Sign, by Sex, Georgia, 1999 and 2006 1999 2006 100 80 64 58 60 39 38 40 20 0 M ale s Fem ales By Race In 2006, both Whites and Blacks were 1.6 times more likely to know 1 stroke sign than in 1999 Percent of Adults who Identified 1 Stroke Sign, by Race, Georgia, 1999 and 2006 1999 2006 100 80 66 60 42 40 52 32 20 0 White s Black s By Education Level Ability to identify 1 stroke sign increased from 1999 to 2006 for respondents with the following education: High school graduate Some college College graduate Percent of Adults who Identified 1 Stroke Sign, by Education Level, Georgia, 1999 and 2006 100 80 60 40 40 31 1999 55 31 2006 64 39 20 0 No high High school Som e school graduate college degree 72 53 Colle ge graduate By Age In 2006, respondents in all age groups except those 65 and older were more likely to know 1 stroke sign than in 1999 Percent of Adults who Identified 1 Stroke Sign, by Age, Georgia, 1999 and 2006 100 80 60 50 40 27 20 0 18-29 1999 62 38 2006 69 47 30-44 45-64 61 47 65+ Age Group By Income Level Ability to identify 1 stroke sign increased from 1999 to 2006 for respondents with incomes of: $20,000-$34,999 $35,000-$49,999 $75,000+ Percent of Adults who Identified 1 Stroke Sign, by Income Level, Georgia, 1999 and 2006 100 80 60 43 45 40 1999 2006 56 31 67 33 69 56 70 43 20 0 <$20,000 $20,000- $35,000- $50,000- $75,000+ $34,999 $49,999 $74,999 By Residence Urban residents were 1.7 times more likely to know 1 stroke sign in 2006 than in 1999 Percent of Adults who Identified 1 Stroke Sign, by Residence, Georgia, 1999 and 2006 100 1999 2006 80 62 60 37 40 59 43 20 0 Urban Rural Would Call 911 for Stroke In 2006, respondents (86%) were 1.2 times more likely to say they would call 911 for stroke compared to 1999 (70%) * Rates not corrected for knowledge of stroke signs (see Methodology for details) 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 9 Methodology In 2006, the Georgia Division of Public Health conducted a statewide, random-digit dialed telephone survey (N=3,000) on stroke and heart attack awareness. This was a follow-up to a study conducted in 1999, which was limited to the metro Atlanta area and measured awareness of stroke signs only. For the 2006 study, an adult was selected at random from each household for interview. The sample was comprised of three groups of Georgia counties stratified by cardiovascular disease (CVD) death rate. Each stratum contained 1,000 respondents. With this design, analysis could account for geographic differences in CVD death rates. Weighted data were analyzed using SAS and SAS-callable SUDAAN. Knowledge was measured using open-ended questions, which provide a more accurate assessment than multiple choice questions.2,3 A sample question measuring knowledge of stroke symptoms is: "What are the signs or symptoms of a person having a stroke? Try to tell me as many as you can." The interviewer would then let the respondent state as many symptoms as they could, without prompting the respondent or giving any suggestions. Respondents were coded positive for knowledge if they stated at least one item in the respective category: Stroke signs Weakness or numbness in face, arm, or leg Sudden confusion or difficulty speaking Dizziness or loss of coordination or balance Headache Vision problems Heart attack signs Chest pain Shortness of breath Arm or shoulder pain or discomfort Feeling weak, faint, or lightheaded Jaw, neck, or back pain or discomfort Modifiable cardiovascular disease risk factors High blood pressure High cholesterol Overweight/obesity Sedentary lifestyle Smoking Diabetes Poor diet A combination of questions was used to measure the ability to recognize a CVD event and call 911. Example for "Ability to recognize a stroke and call 911": What are the signs or symptoms of a person having a stroke? (open-ended) If you or someone you know experiences any + signs or symptoms of a stroke, what should you do? (open-ended) Only respondents who correctly answered both questions were considered able to recognize and respond to a stroke. If they could not answer the first question right, even if they knew that you should call 911 for a stroke, in a real-life situation the respondent might not recognize the stroke and therefore might not take the proper action. Improper analysis of such items can result in highly inflated knowledge estimates. In this survey, 86% of respondents said they would call 911 in the event of a stroke. However, after screening out those who could not identify at least one stroke sign, the true prevalence was found to be 54%. Response Rates CASRO rate Cooperation rate Overall response rate 45.3% 75.6% 18.5% For response rate definitions, please see the 2005 Behavioral Risk Factor Surveillance System Data Quality Report Handbook at: http://www.cdc.gov/brfss/technical_infodata/surveydata/2005/2005DQRHandbook.rtf References 1 Derived from national estimates published by the American Heart Association. Heart Disease and Stroke Statistics- 2004 Update. Dallas, TX: American Heart Association; 2004. 2 Schneider AT, Pancioli AM, Khoury JC, et al. Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke. JAMA. 2003;289:343-346. Available from: http://jama.ama-assn.org/cgi/content/full/289/3/343 3 Croft JB, Greenlund KJ, Ayala C, et al. Awareness of Stroke Warning Signs --- 17 States and the U.S. Virgin Islands, 2001. MMWR. 2004 May 7;53(17):359-62. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5317a2.htm Suggested citation: Clarkson, LS. 2006 Georgia Stroke and Heart Attack Awareness Survey. Georgia Department of Human Resources, Division of Public Health, October 2008. Publication Number: DPH08/335. For more on cardiovascular disease in Georgia, please visit http://health.state.ga.us or email ga-cvh@dhr.state.ga.us 2006 GEORGIA STROKE & HEART ATTACK AWARENESS SURVEY 10