No difference in stroke knowledge between Korean adherents to traditional and western medicine – the AGE study: an epidemiological study
BMC Public Health
No difference in stroke knowledge between Korean adherents to traditional and western medicine - the AGE study: an epidemiological study
Moon Ho Park 1 2
Sangmee Ahn Jo 2
Inho Jo 2
Eunkyung Kim 2
Su- Yong Eun 2
Changsu Han 0 1
Min Kyu Park 1 3
0 Department of Psychiatry, Korea University Medical College , 516 Gojan-1-dong, Danwon-gu, Ansan-si, Gyeonggi-do , Korea
1 The Geriatric Health Clinic and Research Institute (GHCRI), Korea University Medical Center , 516 Gojan-1-dong, Danwon-gu, Ansan-si, Gyeonggi-do , Korea
2 Department of Biomedical Sciences, National Institute of Health , 5 Nokbun-dong, Eunpyung-gu, Seoul , Korea
3 Department of Neurology, Korea University Medical College , 516 Gojan-1-dong, Danwon-gu, Ansan-si, Gyeonggi-do , Korea
Background: Effective stroke intervention and risk reduction depend on the general public's awareness and knowledge of stroke. In Korea, where both traditional Oriental medicine and Western medicine are practiced, estimates of the general public's awareness and knowledge of stroke are poor. The present study sought to describe the inception cohort of the Ansan Geriatric Study (AGE study) and to determine baseline stroke awareness and preferred medical treatment for stroke in this Korean sample. Methods: A total of 2,767 subjects selected randomly from the Ansan Geriatric Study in South Korea were questioned about stroke. Their answers were compared with their sociodemographic data and other variables. Results: Only 44.8% of participants correctly identified stroke as a vascular disease in the human brain. Sudden numbness or weakness was the most frequently identified stroke warning sign (60.2%). Hypertension (66.7%) and mental stress (62.2%) were most frequently identified as stroke risk factors. The contributions of diabetes mellitus and cardiovascular disease to stroke were underestimated; they were identified as risk factors by 28.3% and 18.6% of participants, respectively. The predictors for poor knowledge of stroke warning signs and risk factors were similar irrespective of preference for Western or Oriental medical treatment, and included those with lower levels of education and inaccurate definition of stroke. Television and radio (40.3%) were the most frequent sources of stroke information for both groups. Conclusion: This study shows that knowledge of stroke is similar among Koreans with preferences for either Western or Oriental medical treatment and that misunderstandings about stroke are common among the Korean elderly. In order to prevent and manage stroke effectively, public health education regarding basic concepts of stroke is necessary. This should target those with a lower level of education and a misunderstanding of the definition of stroke.
Stroke is the leading cause of death among Koreans [1,2].
Control of stroke risk factors and, when stroke occurs,
early initiation of treatment, represent primary steps in
stroke prevention and reduction of mortality, sequelae
and length of hospitalization [3,4]. However, inadequate
or incorrect knowledge about stroke among the general
public may hinder prevention and delay the initiation of
appropriate treatment. Thus, it is important to increase
public awareness of stroke signs and symptoms and
potential stroke risk factors [5,6]. Accurate estimation of
public awareness and knowledge of stroke is necessary for
improving understanding among the general public.
While traditional Oriental medicine is considered
'alternative medicine' by most of the world, it is as respected as
Western medicine in South Korea [7,8] and for a long time
has played an important role in disease treatment.
However, few epidemiological reports have addressed
differences in knowledge about stroke between those who
prefer Western and those who prefer traditional Oriental
With the overarching goal of enhancing the success of
primary and secondary stroke care strategies in Korea, the
present study sought to describe the inception cohort of
the Ansan Geriatric Study (AGE study) and to determine
baseline stroke awareness and preferred medical
treatment for stroke in this Korean sample.
Study design and population
The AGE study was initiated in May 2002 to perform
population-based cohort research on the Korean elderly
population, as Korean society is now considered to be one of
the most rapidly aging . The overall objective of the
AGE study is to provide not only basic information on the
medical condition and characteristics of the rapidly
growing Korean geriatric population, but also to identify
genetic and environmental risk factors for various
diseases. As part of a baseline investigation to construct an
elderly cohort in Korea, we sampled the elderly
population living in Ansan, located in the southern part of
Gyeonggi-do province, South Korea. Ansan comprises
rural and urban areas and is now included as a
metropolitan area of Seoul. In August 2002, 36,735
non-institutionalized civilians aged 60 to 84 years were registered as
residing in Ansan . On the basis of a power analysis of
the sample size needed to determine the prevalence of
major chronic diseases and risk factors among the elderly,
a goal of interviewing 3,000 subjects was set.
To construct the sampling framework,
telephone-subscriber data from the Korean Telecommunications
Corporation, a near-monopolist telephone company in Korea,
were compared with residence records. Among the 36,735
non-institutionalized civilians, a total of 19,387 records
(52.8%) were matched to telephone number using name
and address as the key variables; the remaining 17,348
residents (47.2%) did not have matched telephone
numbers. To acquire a probability sample proportional to the
age- and gender-specific population structure of the target
population, a random sample comprising 15,392 persons
(41.9%) aged 60 to 84 years was selected: 10,819
individuals from the group with matched telephone numbers,
and 4,573 from the unmatched group. A letter of
invitation to participate in this study was initially sent to all
15,392 individuals. The telephone-number-matched
group was additionally contacted at least three times by
telephone, and the unmatched group was visited at home
in order to confirm their eligibility. A total of 8,999
individuals were determined ineligible for interview for
'logistical and unknown' reasons such as incorrect telephone
number, incorrect address or change of address, moving,
death, and absence at three attempted visits. Another
1,989 individuals refused our study. This left 4,404
eligible individuals (12% of the target population or 28.6% of
the stratified random sample) for in-home or in-clinic
interview. After excluding persons who refused, provided
incomplete data or were ineligible for a probability
sample proportional to the age- and gender-specific structure
of the target population, the final sample comprised
2,767 elderly Koreans representative of the target
The study was approved by the Institutional Review
Boards of the Korea University Medical Center, Ansan
Hospital. Written informed consent was obtained from all
participants or their relatives after the study's procedures
were fully explained.
Participants were asked to choose between two interview
locations, their home or the Geriatric Health Clinic and
Research Institute (GHCRI) of the Korea University
Hospital, according to their convenience. Approximately half
the study participants (46.3%) were interviewed in their
homes, while 53.7% were interviewed at the clinic. A
survey team composed of trained field surveyors was
instructed in the details of the questionnaires and
measurements before the survey was initiated. A team of two
surveyors interviewed the participants to collect all data.
Each study participant was interviewed by one surveyor,
while a second surveyor asked another member of the
household to confirm the sociodemographic data. To
avoid bias the survey team identified sociodemographic
data only after the completion of the interview.
McNemar's test was used to assess surveyor reliability and
revealed no significant difference (p > 0.05).
A total of 1,552 participants (56.1%) were women and
1,215 (43.9%) were men. The mean (SD) age of the
participants was 68.39 (6.06) years (range 6084 years). The
mean (SD) educational duration of the participants was
6.97 (4.96) years (range 025 years). The distribution of
household income among the participants was as follows:
871 participants (31.5%), < 500,000 Korean won; 706
(25.5%), 500,000999,999 Korean won; 1169 (42.2%), >
1,000,000 Korean won (1 U.S. dollar = 1,055 Korean won
at the time of the interviews). A total of 1,824 participants
(65.9%) were married or cohabitating, and 943 (34.1%)
were single (unmarried, separated, divorced or widowed).
The survey team systematically interviewed the subjects
regarding their knowledge and perceptions of stroke and
stroke treatment, including their understanding of how
stroke was defined, their preferred medical treatment in
the case of stroke, their knowledge of stroke warning signs
and risk factors, and their sources of information about
stroke. To determine respondents' knowledge of
important stroke warning signs, respondents were asked the
following open-ended question: "Can you tell me what the
warning signs or symptoms of stroke are?" The responses
were coded into five pre-existing categories based on those
used by several national organizations (Korean Stroke
Society , American Stroke Association  and
National Institute of Neurological Disorders and Stroke
), which in their educational materials list the
following as important warning signs of stroke: (1) sudden
numbness or weakness of the face, arm or leg, especially
on one side of the body; (2) sudden confusion or
difficulty in speaking or understanding speech; (3) sudden
visual impairment in one or both eyes; (4) sudden difficulty
in walking, dizziness, or loss of balance or coordination;
and (5) sudden severe headache with no known cause.
Interviewers were provided with several alternative
wordings for the warning signs. Responses considered incorrect
included shortness of breath, pain in the chest or arm, and
tremor. Loss of consciousness, neck stiffness and seizure
were classified as neither correct nor incorrect responses.
Knowledge of risk factors was assessed by identifying the
following established risk factors as correct responses
: hypertension, smoking, hyperlipidemia,
cardiovascular disease, age, diabetes, race, gender, physical
inactivity, poor diet, obesity and heredity. Stress, overexertion,
low financial status, liver disease, lung disease, kidney
disease and gastrointestinal disease were regarded as
incorrect responses. Alcohol consumption was classified as
neither correct nor incorrect.
Participants' preferred medical treatment for stroke was
assessed using the following question: "If you have a
stroke, where would you go for treatment?" The response
Univariate analyses were used to investigate the
relationship between each answer in the questionnaire and age,
gender, marital status, level of education, financial status,
family history of stroke, definition of stroke, and
preference for Oriental versus Western stroke treatment. Odds
ratios (OD) and 95% confidence intervals (CI) were
generated for all outcomes of interest. Factors determined to
be potentially associated with stroke awareness were
entered simultaneously into a logistic regression model to
assess independence. A previous study by Schneider and
colleagues  using serial surveys showed a statistically
significant difference in knowledge of at least two stroke
risk factors, and Silver and colleagues  used the ability
to name at least two stroke warning signs as the main
outcome measure. Thus, to enable comparisons to previous
studies to be made, the ability to recognize 2 stroke risk
factors and stroke warning signs was used as the main
outcome measure in this study. Logistic regression was used
to determine the significance of various
sociodemographic characteristics and other variables as predictors of
knowledge of at least two stroke risk factors and stroke
warning signs. Logistic regression models were developed
using Enter methods. In all analyses, a probability value of
p < 0.05 was considered statistically significant.
Stroke was most frequently defined as a cerebrovascular
disease (n = 1,214, 44.8%); other definitions (in
decreasing order of frequency) were an aging process in the brain
(n = 179, 6.6%), peripheral nervous disease (n = 70,
2.5%) and convulsive disorder (n = 53, 1.9%). A total of
779 subjects (28.2%) answered that they did not know.
When asked where they would seek treatment for a stroke,
1,625 of the subjects (58.7%) indicated that they would
select Western medical treatment and 1,142 (41.3%)
indicated that they would select traditional Oriental medicine.
The most frequent reason for selecting Western medicine
was that it is more scientific than traditional Oriental
medicine (n = 656, 41.7%). The respondents who selected
traditional Oriental medicine answered that traditional
Oriental medicine has a greater curative effect (n = 462,
53.2%), and this is a general trend that means many other
people select traditional Oriental medicine (n = 150,
The stroke warning sign most frequently identified by
respondents was sudden numbness or weakness (n =
1,667, 60.2%), followed by sudden confusion or
difficulty speaking or understanding speech (n = 607, 21.9%).
There was no significant difference in perception of stroke
warning signs between groups preferring traditional
Oriental and Western medicine (Table 1). Only 623
respondents (24.3%) correctly listed at least two important
warning signs of stroke. In the univariate comparison,
older age (p = 0.013), lower level of education (p < 0.001)
and incorrect knowledge of the definition of stroke (p <
0.001) were predictive of poorer knowledge of the
important stroke warning signs (Table 2).
Respondents' answers relating to the most important risk
factors for stroke are summarized in Table 3.
Hypertension (n = 1,846, 66.7%), stress (n = 1,720, 62.2%),
overexertion (n = 1,325, 47.9%), obesity (n = 1,270, 45.9%)
and smoking (n = 1,216, 43.9%) were the five most
common answers. As was the case with stroke warning signs,
there was no significant difference in perception of stroke
risk factors between groups that favored treatment with
traditional Oriental versus Western medicine. A total of
1,753 respondents (68.3%) correctly identified at least
two established stroke risk factors. In univariate
comparison, knowledge of stroke risk factors was associated with
age (p < 0.001), gender (p < 0.001), marital status (p =
0.004), level of education (p < 0.001), financial status (p
< 0.001), family history of stroke (p < 0.001), knowledge
of the definition of stroke (p = 0.001) and preferred
medical treatment for stroke (p = 0.004) (Table 4).
In the multivariate logistic regression model, a lower level
of education and incorrect knowledge of the definition of
stroke were associated with poorer knowledge of
important stroke warning signs. Older age, lower level of
education and incorrect knowledge of the definition of stroke
Sudden numbness or weakness
Sudden confusion, or difficulty speaking, or understanding speech
Sudden difficulty walking, dizziness or loss of coordination
Sudden severe headache
Sudden visual impairment
were significant predictors of poorer knowledge of stroke
risk factors (Table 5).
The most popular sources of information about stroke
were certain components of the mass media (i.e.
television and radio, n = 1,091, 40.3%). Other sources of
information (in order of decreasing frequency) were family
member or other relative (n = 387, 14.3%), newspapers or
magazines (n = 173, 6.4%), medical institute (n = 151,
5.6%), school (n = 5, 0.2%) and the Internet (n = 3,
0.1%). Those participants who preferred Western
medicine for stroke treatment obtained their information and
knowledge from television or radio (n = 718, 47.5%), a
family member or other relative (n = 194, 7.9%) and
newspapers or magazines (n = 138, 9.1%). Participants
who preferred Oriental medicine for stroke treatment
derived most of their information about stroke from
television or radio (n = 373, 35.3%) and a family member or
other relative (n = 193, 18.2%) (2 = 126.035, degrees of
freedom = 7, p = 0.001).
Evaluating general public awareness can help to improve
public information programs about stroke, but our
estimates indicate that stroke awareness among Koreans is
generally poor. Only 44.8% of the subjects in this study
answered correctly that stroke is a vascular disease in the
brain. The inability of many Koreans to define stroke
correctly may be attributable to the strong influence of
traditional Oriental medicine, which defines stroke as
'paralysis by lack of harmony of negativity and positivity'
and considers stroke a disease of both the peripheral
nervous and cerebrovascular systems . Traditional
OrienPreferred medical treatment*
Western Oriental Traditional
Correct knowledge %
*unmarried, separated, divorced, or widowed
tal and Western medicine have equal social and cultural
status in the treatment of stroke in Korea; indeed, the
Chinese character 'Poong' (meaning wind) has spread to the
Western medical terminology for stroke [7,8]. However,
we found that preference for Oriental versus Western
medicine for stroke treatment did not significantly affect
awareness of stroke warning signs and risk factors. The
lack of difference may be attributable to Korea's
modernization and industrialization, which have led to the
dissipation of traditional concepts and the emergence of
Western medicine campaigns by groups such as the
Korean Stroke Society .
Public knowledge of stroke warning signs is important for
ensuring timely access to emergency medical care
[14,16,17]. Our results show numbness and weakness to
be the most frequently (and correctly) identified signs and
symptoms of stroke (60.2%). A higher proportion of
respondents recognized numbness and weakness as a
stroke warning sign. In four previous studies, the most
common stroke warning signs listed by respondents were
dizziness (24%) and numbness (19%) , weakness
(26%) , blurred vision (24%) , and numbness
(45%) and speech difficulties (38%) . Differences in
the medical systems and location of the sample
populations make it difficult to compare the present study with
other population studies. However, it is possible that the
variation in stroke warning signs identified by the study
participants reflects differences in their perceptions of the
importance or severity of symptoms. It was encouraging
that more than 60% of respondents in this study reported
the correct signs of stroke.
Preferred medical treatment*
Western Traditional Oriental
Stroke prevention is dependent on the ability to recognize
and control stroke risk factors [5,6,21]. Increased public
awareness of potential risk factors will help to reduce the
prevalence of stroke and increase treatment compliance.
The proportion of respondents considering hypertension
to be a risk factor of stroke was higher in our study
(66.7%) than in a previous study in Korea (28.3%) .
The better understanding of potential hypertension risks
in our study may be attributable to the special campaigns
conducted by the National Hypertension Center of the
Korean government over the past few years [22,23]. As in
previous studies, diabetes mellitus and cardiovascular
disease were underestimated as risk factors, while mental
stress and overexertion were considered important
[5,8,18]. Given the lack of evidence that mental stress and
overexertion are stroke risk factors, it is important to
emphasize the contributions of diabetes mellitus,
cardiovascular disease, obesity and smoking to stroke . In
this study, answers to the questionnaire differed
significantly depending on whether or not the respondent was
able to define stroke correctly. This suggests that
understanding of the basic concepts of stroke may play a crucial
role in public health.
previous study  reporting that younger age, female
gender, higher level of education and high cholesterol
were all associated with the correct identification of stroke
warning signs. We also found that older age, lower level of
education, family history of stroke and incorrect
definition of stroke were independent predictors of poorer
knowledge of stroke risk factors. Blades and colleagues
 also showed that younger respondents and women
were more likely to identify stroke risk factors correctly.
The overall implication of the present study's findings is
that these populations should be specifically targeted with
public health education about stroke.
Despite the tendency among Koreans to respect and
follow the decisions of the oldest member of their families
(who tend to prefer traditional Oriental medicine ),
Western medicine was preferred over traditional Oriental
medicine for medical treatment of stroke. The customary
idea in Korea that stroke should be treated by traditional
Oriental medicine may lead to the expectation that
traditional Oriental medicine produces better results.
However, the actual effectiveness of traditional Oriental
medicine for stroke is controversial . One of the main
reasons that patients are not admitted to a hospital early
enough in Korea is that they seek treatment with
traditional Oriental medicine beforehand .
The mass media (television, radio, newspapers and
magazines) were the most popular sources of information for
stroke knowledge; this should be considered when
promoting public knowledge of stroke and the associated risk
factors . In contrast, our findings suggest that
hospitals and medical schools do not provide effective public
education. Public education promoting awareness of the
seriousness of stroke and provision of access to emergency
care during the narrow therapeutic time window may lead
to changes in behavior . A previous study evaluating
the effectiveness of different media in increasing public
awareness of stroke found that television advertising is
often promoted owing to its ability to reach across
demographic groups based on gender, age and education .
The second most popular source of information about
stroke was a family member or other relative, suggesting
that acquisition of information from personal contacts
could become an effective method for dispersing accurate
medical information. Ensuring that patients and their
families retain simple and accurate information on stroke
as they progress through stroke rehabilitation may be an
effective means of disseminating this information to the
general public .
In the multivariate logistic regression model, a lower level
of education and incorrect definition of stroke were
independent predictors of poorer knowledge of stroke
warning signs. These finding are consistent with those of a
This study has a number of limitations. The study was
conducted on a Korean population, and there may be
significant differences with respect to the awareness of stroke
warning signs and risk factors in other geographic and
Correct knowledge %
*unmarried, separated, divorced, or widowed
racial and ethnic communities. Moreover, because the
sample was drawn from a limited geographic area within
Korea, the results may not generalize to the national
population. However, many rural districts in Korea are
quickly urbanizing, and Ansan is a good example of the
nation's many urbanized areas. The relatively low sample
size may also affect the study's generalizability, although
the sampling design does represent a random age- and
gender-stratification. There is also the possibility of
noncoverage and non-response bias because those not
sampled in this study may have a different level of stroke
awareness than those who participated. Aside from
generalizability, another limitation of the study is that it does
not address whether there is a causal relationship between
stroke knowledge and behavior such as risk factor
modification and rapid seeking of medical attention in the event
of stroke symptoms.
Our study has confirmed the need for more public
education about stroke, targeted in particular at those who are
less educated, currently unaware of the correct definition
of stroke, or elderly, regardless of whether they prefer
Western or traditional Oriental medicine. This education
should include information about risk factors, warning
symptoms and the methods used to prevent and manage
Park MH and Jo SA: principle investigators of the study.
They were involved in the study planning, discussion of
Knowledge of at least two stroke warning signs
Incorrect knowledge of stroke definition
Knowledge of at least two stroke risk factors
Family history of Stroke
Incorrect knowledge of stroke definition
Preferred medical treatment to traditional Oriental medicine
the project, and manuscript writing. Jo I: main research
assistant of study. He managed and cleaned the data set,
analyzed the data for this study. Kim E: main
data-manager. She was involved in the study planning and was
responsible for data collection and data analysis. Eun SY:
internal statistician. She was involved in study planning,
definition of outcome, statistical analysis, and draft
writing. Han C: lead investigator. He was involved in
coordinating the 2003 GHCRI study and contributed to the
intellectual discussion of the concept of the article. Park
MK: principal investigator. He was involved in
coordinating the 2002 GHCRI study and was contributed in the
intellectual discussion of the concept of the article and the
idea of data analysis. All authors read and approved the
This study was supported by Biomedical Brain Research Center Grant from
the Ministry of Health and Welfare (A040042 to Dr. Sangmee Ahn Jo)
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