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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Public Awareness of Stroke Recognition, Risk factors and Access to Appropriate Treatment: A Hospital-based Cross-sectional Survey from a Tertiary Referral Centre in Southern India
Correspondence Address :
Dr. S Deepthi,
Surabhi, TRA 120 A, Greens Lane, Thekkumoodu, Vanchiyoor P.O.Thiruvananthapuram-695035, Kerala, India.
E-mail : deep178s@yahoo.com
Introduction : Despite recent advances in treatment, awareness regarding stroke remains low. Only a fraction of eligible patients reach hospital within the window period for thrombolysis.
Aim: To assess the public awareness of stroke symptoms, risk factors and access to treatment which will help to design effective and targeted stroke education programs.
Materials and Methods: This cross-sectional hospital-based survey was conducted in the neurology outpatient department in Government Medical College, Trivandrum, Kerala, India from October 2020 to March 2021. Adult relatives of patients, attending the neurology outpatient department, were included in the study. Relatives of patients who had current or previous stroke and individuals who had a personal history of stroke were excluded. Participants had to fill out a structured study questionnaire adapted to local socio-cultural practices assessing awareness of organ involved in stroke, warning symptoms, risk factors and treatment seeking behaviour. Descriptive analysis, Chi-square tests and logistic regression were used to analyse awareness about organ involved in stroke, signs and symptoms, risk factors and treatment for stroke.
Results: A total of 700 completed questionnaires were collected from the respondents. More than 80% of respondents belonged to the low income group and were from rural areas. Overall, 43.3% of the subjects could not identify the brain as the organ identified in stroke, and 28.9% were able to identify only one symptom of stroke. The most common warning symptom of stroke recognised was difficulty in speaking (59.4%). Hypertension was the most common risk factor for stroke identified (77.7%). Total 31.6% were able to identify only one risk factor for stroke, and 82.4% patients were aware that stroke requires immediate treatment with majority preferring to consult the nearest doctor. Only 15.9% of respondents were aware of the stroke helpline. Only 55.9% of respondents were aware about ambulance services in their region.
Conclusion: This study demonstrated low awareness regarding common risk factors like diabetes and smoking on increasing stroke risk. Knowledge regarding stroke helplines, ambulance services and need to rush to hospital emergency department was low. Public stroke education programs should focus on reducing the knowledge gap in these areas.
Ambulance services, Helpline, Stroke education, Thrombolysis, Warning signs
Ischaemic stroke is one of the major causes of disability and death worldwide. About 85.5% of global stroke mortality occurs in developing countries (1). Developing countries also have a higher prevalence of stroke in young individuals and significantly greater stroke-related disability (2),(3). In India, Indian Council of Medical Research (ICMR) data implicated stroke as the fifth most common cause for cause for Disability Adjusted Life Years (DALYs) in 2016. Number of DALYs for cerebrovascular disease increased by 52.9% from 1990 to 2016 (4),(5). In India, systematic reviews have shown that the prevalence of stroke varies from 45 to 487 per 100,000 populations in urban regions and 55 to 388.4 per 100,000 populations in rural population (4),(5),(6).
Intravenous thrombolysis and mechanical thrombectomy have been proven to improve ischaemic stroke outcomes, however due to the narrow therapeutic window (<4.5-6 hours) patients have to reach early to hospital to get the benefits of treatment (7). In recent studies from India, it has been estimated that less than 20% of stroke patients reach a thrombolysis ready centre within the window period and only upto 3.5% of all stroke patients receive thrombolysis [8,9]. Studies have identified prehospital delay as one of the major obstacles to thrombolysis (8),(9),(10). In contrast to door-to-needle time which has reduced considerably, onset-to- door times have not shown much improvement over the years even in developed countries (10). In India, studies have found that the biggest hurdle to thrombolysis was failure to recognise stroke by patients and relatives, accounting for three quarters of delayed arrival. Initial visit to family doctor/private clinic or primary care centre which lacked radiological facilities, transportation delays and financial constraints were other major reasons for under-usage of thrombolysis (8),(9).
Public awareness of symptoms, risk factors, treatment and helpline availability are essential to increase utilisation of therapy (11),(12). This study aimed to assess the public awareness of stroke symptoms, risk factors and access to treatment which will help to design effective and targeted stroke education programs.
This cross-sectional hospital-based survey was conducted in the Neurology outpatient department in Government Medical College, Thiruvananthapuram, Kerala, India from October 2020 to March 2021. The hospital is a tertiary referral centre catering to both urban and rural population situated in Thiruvananthapuram District in Kerala state in the Southern part of India. The study population was formed by the relatives of patients attending the neurology outpatient department.
Inclusion criteria: Relatives, aged more than 16 years, accompanying patients attending the neurology outpatient department were included in the study.
Exclusion criteria: Relatives of patients who had current or previous stroke were excluded from the study. Respondents with a personal history of stroke and those with cognitive or physical disability that interferes with filling the questionnaire were also excluded.
Only one member was included from each family. Individuals more than 16 years of age who consented to the study were asked to fill a questionnaire in Malayalam. Trained medical students were available to explain the questions and answer any queries. Illiterate subjects had the questionnaire read out and explained to them.
Questionnaire: The survey questionnaire was adapted from previous studies (13) and modified to suit local socio-cultural conditions and translated into the vernacular language Malayalam. It was pretested and validated in 30 subjects. The Cronbach’s alpha was 0.7. It was divided into four sections:
1. The first section gathered demographic information- age, gender, education, income and place of residence. Education was categorised into lower, which included illiterates and primary (below 5th standard) and high school (6th standard to 10th standard), and higher, which included plus two and above. Income was classified into upper (Rupees 5000per month), and lower (Rupees 5000 per month) income groups and place of residence into rural and urban.
2. The next section assessed knowledge of the organ involved in stroke and the signs and symptoms of stroke. Knowledge regarding organ involved in stroke was assessed in a single question with four options and no multiple responses were allowed. Six questions assessing the main signs and symptoms of stroke were included with option for multiple responses.
3. The third section assessed knowledge regarding risk factors for stroke. It included nine risk factors with options for multiple responses.
4. The last section of the survey was aimed at finding out the respondents’ response to stroke symptoms, awareness regarding the stroke helpline offered by medical college, Thiruvananthapuram and availability of ambulance services.
STATISTICAL ANALYSIS
Data were entered and analysed using Statistical Package for the Social Sciences (SPSS) software, version 16.0. Descriptive analysis was carried out. Chi-square tests were used to analyse awareness about organ involved in stroke, signs and symptoms and risk factors for stroke in accordance to age, gender, educational level, income and place of residence. For determination of the independent risk factors of poor knowledge, present study used logistic regression. A level of significance of 0.05 was used.
A total of 700 completed questionnaires were collected from the respondents. Males and females were almost equally represented (males 51%, female 49%). About 60% of patients were more than 40 years of age. The mean age was 45±15.1 years. Overall, 52 % had studied up to plus two and above. More than 80% of respondents belonged to the low income group and were from rural areas. Demographic details are shown in (Table/Fig 1).
Knowledge regarding organ involved in stroke: As shown in (Table/Fig 2), 43.3% of the subjects could not identify the brain as the organ identified in stroke. About 32% thought that heart was the organ involved in stroke. In univariate analysis, higher knowledge about the knowledge of brain as the organ involved in stroke was associated with with age> 45 years (p<0.001) and higher education level (plus two and above) (p<0.001).
Symptoms and signs of stroke: The three most common warning signs of stroke recognised were difficulty in speaking (59.4%), followed by weakness of one side of the body, and numbness of one side of face or body (Table/Fig 3).
About 3% of respondents could not identify any symptoms of stroke and 28.9% were able to identify only one symptom of stroke. Only 9% could identify all the six stroke symptoms listed (Table/Fig 4).
On univariate analysis, knowledge regarding stroke symptoms was associated with with higher income (p=0.01) and residence in urban areas (p=0.02) (Table/Fig 5). However, none reached significance in multiple logistic regression.
Stroke risk factors: Hypertension was the most common risk factor for stroke identified (77.7%) and high cholesterol level (32.4%) was the second most common (Table/Fig 6). About 7.1% respondents were not able to identify a single risk factor for stroke and 31.6% were able to identify only one risk factor for stroke. (Table/Fig 7) On univariate analysis, identification of more than one risk factor for stroke was associated with age>45 years (p=0.02), higher income (p<0.001) and residence in urban area (p=0.009) (Table/Fig 5).
Response to identification of stroke symptom: About 82.4% patients were aware that stroke requires immediate treatment. The most preferred response was to go to the nearest doctor (38.6%) and the second most common to attend the nearest government hospital (34.1%). About 30.9% chose to visit the nearest neurologist. 25.3% preferred to attend the nearest medical college and only 4.7% preferred to go to a private hospital (Table/Fig 8).
This study reports the awareness regarding stroke, its symptoms, risk factors and treatment in Thiruvananthapuram district from the southern part of Kerala, India. According to data from the India State-Level Disease Burden Initiative, stroke was the second most common cause of years of life lost (YLL) among both males and females in Kerala (6). It was the 4th most common cause of DALY in Kerala (4.2%) and the burden has increased over the years (6). Trivandrum stroke registry, which is based on a community study in Thiruvananthapuram district, in South India found the age-adjusted incidence rates per 100,000 per year were 135 for total, and 135 (122-148) for urban and 138 (112-164) for rural populations (14).
In this study, 56.7% patients identified the brain as organ involved in stroke which is higher than reported from several other studies from India (Table/Fig 9) (15),(16),(17),(18),(19),(20). In contrast, in a hospital-based study from Jammu and Haryana 81% of patients were able to identify brain as organ involved in stroke (18). However, this study included 20% respondents who had history of stroke in the family. History of stroke in family has been associated with higher awareness of stroke in several studies (15),(21). In developed nations, awareness of brain as organ involved in stroke ranged from 56% in Italy to 87% in Sweden (21),(22). In present study, 32% of the respondents thought that the heart was the organ involved. Similarly, in a study from Telangana 41% of patients thought stroke as heart attack (15). This finding has also been reported from developed countries such as New Zealand where 18% respondents mis-regarded stroke as heart attack (23).
In this study, 97% respondents could identify atleast one warning symptom of stroke and 93% could identify at least 1 risk factor which was higher than reported from other Indian studies (Table/Fig 9). This can be attributed to the high literacy level of the population. The findings in the present study are comparable to those from developed countries, where studies have shown that 67-97% respondents can identify at least one warning sign for stroke (21),(23),(24),(25) and 59-89% patients could identify at least 1 risk factor for stroke (24),(26). In this study 68% could identify more than 1 warning symptom which was higher than reported from Sweden (56%) and Italy (44%) (21),(22). However 28.9% were able to identify only one warning symptom and only 9% could identify all six warning symptoms. In contrast in the United States, 69% were able to identify all five stroke warning signs (25). In this study, 60% could identify more than one risk factor and 30% could identify more than two. This was similar to studies from Sweden, where 60% recognised more than one risk factor and 46% correctly listed three or more (22).
The most common warning sign of stroke identified was difficulty speaking followed by one- sided weakness of face and/or body and numbness of one side. In other studies from India, weakness was most commonly recognised warning sign (15),(16),(17),(18),(19),(20),(21). Compared to other studies from India, trouble speaking was identified by more patients and other warning signs were similar (Table/Fig 9). World-wide one sided weakness and numbness, facial weakness and trouble speaking are the most commonly identified stroke signs indicating that lesser recognised stroke symptoms such as visual symptoms and headache and vertigo should emphasized in awareness studies (21),(22),(23),(24),(25),(26).
Hypertension followed by dyslipidaemia were the two most commonly identified risk factors and lack of exercise, poor diet and obesity were identified by a quarter of patients. Hypertension is the best recognised risk factor in studies from India as well as from other countries (15),(16),(17),(18),(19),(20),(21),(22),(23). World-wide hypertension, smoking, stress and obesity were the most frequently identified risk factors (22),(24),(26). Only one-fifth were able to identify diabetes and smoking as risk factors for stroke inspite of its high prevalence in Kerala. In the Trivandrum registry, nearly 85% of population had hypertension and half had diabetes mellitus and a quarter were smokers (14).
Higher awareness regarding stroke was associated with with higher age, higher income, higher education and residence in urban area. Higher education, higher income and residence in urban areas have been reported to be the major factor influencing stroke awareness in several studies from India as well as developed countries (16),(19),(22),(26),(27). Male gender has been associated with higher (17),(18) as well as lower (23),(28) awareness in previous studies but gender was not significantly associated with awareness in this study.
About 82.4% of patients were aware that stroke requires immediate treatment which is higher than from other Indian studies (16),(18),(19),(20) and similar to studies from Spain and New Zealand (24),(25). However, majority were not aware of the need to rush to hospital with 70% of respondents choosing to go to a nearby doctor in response to the development of symptoms. About 44.1% respondents were not aware regarding ambulance services in their region. This differs markedly from developed nations where 60-94% reported that they would call EMS (Emergency Medical Services) or would go to the hospital (22),(26),(27).
Various studies have revealed that knowledge about stroke symptoms and thrombolysis, use of EMS and ambulance services, perception of initial symptoms as serious and presence of major deficits such as haemiparesis are important determinants of early arrival to hospital whereas visiting family doctor or primary care centre first, referral from another hospital and private transport to hospital are associated with delayed arrival (9),(10),(19). Due to hospital prenotification, EMS use is further associated with reduction in door to needle time (10).
Of those deciding to go to hospital, majority chose a nearby government hospital, followed by medical college. This shows the importance of providing emergency stroke care and thrombolysis services at the level of local government hospitals. Local healthcare providers other than neurologists should also be educated regarding thrombolysis and made aware of hospitals offering thrombolysis in their locality. Awareness regarding the stroke helpline operated by the medical college was low with 84% being unaware indicating the need for dissemination of information through multiple channels. A state/national level helpline may help to stream line the process (28).
Limitation(s)
The results on stroke awareness may have been overestimated and may not be extrapolated to the general population as it was conducted in a hospital setting and the population that attends a hospital is likely to be more aware regarding health related issues. The questionnaire used multiple choice questions with limited options which may have encouraged guessing. Identification of stroke symptoms and risk factors are poorer in open ended questionnaires (29).
This study demonstrated awareness regarding warning signs symptoms and risk factors for stroke, while being much below desired levels, were comparable to developed countries. However, effects of common risk factors like diabetes and smoking on increasing stroke risk were not understood. Knowledge regarding stroke helplines, importance of ambulance services and need to reach hospital emergency department was low and stroke education programs should target these areas. The respondents, who were largely from rural areas and lower income groups depended on local physicians and local government hospitals for emergency stroke care and policy makers should target improving stroke care resources at this level.
DOI: 10.7860/JCDR/2022/51505.16599
Date of Submission: Jul 21, 2021
Date of Peer Review: Nov 22, 2021
Date of Acceptance: Apr 07, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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