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Stroke has been the second and third leading cause of mortality and morbidity (Disability-Adjusted Life-Years (DALYs) lost globally in 2019) respectively [1]. The burden of stroke changed in 2010 from High-Income Countries (HIC) to Low and Middle-Income Countries (LMIC), with incidence of stroke increasing in East Asia and southern Sub-Saharan Africa (SSA) from 1990 to 2016, and the highest age- standardized incidence being in Africa [2-4].

Revascularization therapy like thrombolysis has been shown to be effective therapy for acute ischemic stroke within 4.5 hours of stroke onset and resulting in improved outcomes (clinical symptoms and dependency in DALYs) with benefits increasing if time to treatment is reduced [5-9]. Patients’ delays have been demonstrated to be the main barrier to thrombolytic therapy in previous studies because of various reasons like arriving late to hospital, few or none using Emergency Medical Transport (EMT), or calling/contacting family members/ family doctor first etc., [10-26]. More than half of patients (50%-70%) in high-income countries compared to Sub-Saharan countries, are transported to hospital by EMT [24,27-33].

About one third (31%) of adults worldwide (1.8 billion people) did not meet the recommended levels of physical activity in 2022, and the trend of physical inactivity among adults has increased by about 5 percentage points between 2010 and 2022 [34,35]. Physical inactivity increases risks of cardiovascular diseases (heart attacks and strokes), stroke risk factors such as type 2 diabetes, in addition to dementia and cancers (breast and colon) [34,35].

It is of paramount importance to recognize stroke symptoms and contact EMS as this will decrease time from stroke onset to hospital arrival might increase the numbers of patients available for therapy and improving outcomes through revascularization [27-33,36-42]. None of the previous studies have investigated awareness for calling EMS based on physical activity intensity levels [12-13,18,20,21,24- 26,29,33,37,41,43-58].

Objectives

1. To determine awareness for calling EMS by acute stroke based on physical activity intensity levels among public and outpatients in Botswana.

2. To investigate if respondents’ sociodemographic and stroke risk factors based on physical activity intensity levels are associated with awareness for calling EMS.

Study design and setting

This was a cross-sectional questionnaire survey study, recruiting participants from Botswana, upper middle-income country (LMIC in SSA). We randomly sampled 2 groups of respondents. The first one was the public with/without stroke risk factors from their homesteads or working places. The second one were outpatients with stroke risk factors in greater Gaborone from healthcare facilities. Recruiting of outpatients and public respondents was done concurrently to avoid participants being interviewed more than once. They were also enquired if they partook in any stroke study recently to avoid bias. Outpatients were recruited from both primary and secondary healthcare facilities while waiting for or after their medical consultation.

Only odd numbers were sampled for outpatients queuing at healthcare facilities while households/workplaces for the public in each area. For the public, we further sampled from different socio-economic levels i.e., high, moderate and low socioeconomic areas within Greater Gaborone.

Sampling of study places and population

In this cross-sectional questionnaire survey study, participants were recruited from Greater Gaborone. It comprises six districts and is the most populated area in the country.

All names of the four districts in Greater Gaborone except Gaborone City and Lobatse town were put in a box, and two names were blindly selected from the box as study places in addition to Gaborone city and Lobatse town. For Gaborone city, all areas were categorized into three socio-economic groups i.e., low, middle and high income. Names of more than three areas with similar socio-economic category were put in a box and three names were blindly selected to represent that specific category. If they were only two areas in the same category, they were both included. Respondents from the public were recruited from their homes or workplaces in both rural and urban areas. Rural areas included Moshupa in the Ngwaketse and Ramotswa in Southeast, while urban area included the capital city, Gaborone. Gaborone was divided into several areas based on socio-economic status i.e., Phakalane and Extension (high income), Blocks and Broadhurst (middle income), Old Naledi, Bontleng, and Tsolamosese (low income).

This similar method was also applied for healthcare facilities and communities in the districts. Outpatients were recruited from both primary and secondary healthcare facilities while waiting for or after their medical consultations after screening by a healthcare facility nurse/ doctor. Primary healthcare refers to first line of healthcare for patients, included medical health clinics for outpatients where there are nurses or/and medical doctors but cannot admit patients. District Health Management Team (DHMT) in every district runs all public health clinics. Primary healthcare included three out of six DHMTs in greater Gaborone (Nkoyaphiri clinic and Phuthadikobo clinic in Kweneng, Ramotswa Railway Station clinic in Southeast, and Moshupa clinic in Ngwaketse). Secondary healthcare refers to where primary healthcare refers to, consists of hospital healthcare staff (general doctors and some specialists (internal medicine, general surgery), nurses, laboratory technicians, etc.), and is capable of admitting patients. Secondary healthcare included a district hospital (Scottish Livingstone hospital in Kweneng) and the only tertiary referral psychiatric hospital in the country (Sbrana Psychiatric Referral hospital in Lobatse). All these are academic institutions for nurses and paramedics, but none of them for doctors as the country did not have any by then.

Sample size

We used finite formula to calculate sample size as demonstrated below. We used 5% as margin of error, 95% confidence interval, 50% population proportion, and population size of 2 million for Botswana for the general public, while for outpatients we used 1/4 of the general population.

Where z is the z score, ε is the margin of error, N is the population size, and p虃 is the population proportion.

For the public, it gave us 385 as the sample size. Since we had 15 characteristics or subgroups classified into 3 categories (sociodemographic, self-reported stroke risk factors, and calculated stroke risk factors). Dividing 15 by 3 gave us 5. Therefore, we multiplied sample size 385 by 5 which gave 1925 as the sample size. For outpatient population size, we calculated 1/4 of the general population sample size which gave 481.

Pilot study

This was carried out on the 10th-13th April 2018 in Southeast District, Otse village, where 36 respondents comprising public and outpatients were interviewed.

Inclusion criteria

For the general public, respondents who reside or work in Greater Gaborone, with or without any risk factor. Outpatients with at least one stroke risk factor visiting healthcare facilities in Greater Gaborone during study period but not admitted. Respondents aged >18 years. Respondents who understood English or local language, Setswana, and capable of consenting. Only respondents from the randomly selected places and not from the pilot study place were included.

Exclusion criteria

Respondents with reduced or loss of cognitive or speech functions. Those who participated in the pilot study.

Data collection instrument

The survey instruments were adapted from previous studies with some modifications to reflect the recent American Heart Association/American Stroke Association (AHA/ASA) guidelines and European Stroke Organization guidelines [43,44,59-61]. We tested the questionnaire in a pilot study with a sample of twenty-five respondents and changes were made in the wording of questions based on the result of the pilot study accordingly. The questionnaire instruments were anonymous, electronic-based, written, and administered in English or local language (Setswana), closed-ended in nature and categorized into sections.

The questionnaire was divided into 4 sections. Section 1 entailed respondents’ sociodemographic factors. Variables included were age (18-34 years, 35-49 years or ≥ 50 years), gender, education (none/ unknown/primary, secondary or tertiary), medical insurance, and residing or working status (same family/working place).

Section 2 included responses to acute stroke, and individual stroke symptoms as described below. We assessed awareness of respondents stratified by levels of physical activities for seeking immediate emergency care and for calling EMS in response to a perceived stroke and specified individual stroke symptoms.

“What would you do when you suspect you are having stroke?” The following were responses: Call 991, 911/997/8 or any emergency number, call a family member/ the pastor/ contact a traditional doctor, go to the pharmacy, no idea/ nothing/ wait and see. Answers were dichotomized into calling EMS vs. other options.

“If you get stroke, how long would you take before seeking medical assistance?” The following were answers: immediately, 7 hours, 1 day, 3 days, 1 week, or no idea/no answer. Responses were then dichotomized into seeking medical assistance immediately vs. other options.

We also investigated the level of medical care respondents would seek if they got specified stroke symptoms in a closed-ended question as follows: “Which of the following would you do first if you suspected that you are having one of the following e.g., acute blurred/ double vision?” Answers were as follows: call 911 EMS, contact medical clinic, no idea, nothing or wait and see. We then trichotomized the responses into calling EMS or medical clinic vs. other options.

Each correct answer in section 2 scored 1 point and was considered being aware. Each incorrect, unanswered or unknown answer scored 0 point and was considered being unaware.

Section 3 and 4 covered respondents’ stroke risk factors and sources of stroke information respectively.

Respondents’ stroke risk and other factors: Included hypertension, family history of stroke, heart diseases or both (at least in one family member in the first generation), history of Human immunodeficiency virus (HIV/AIDS): (yes or no), psychiatric diseases (depression/ anxiety): (yes or no), smoking (non-smokers, former, or current), alcohol drinking (non-drinkers, former, or current), dietary status (perceived healthy or unhealthy) and one or more of four less common cardiovascular risk factors (CVDS: diabetes, dyslipidemia, prior stroke, or heart diseases). In addition, perceived BMI categories (underweight, normal, overweight or obesity), and physical activity levels (none, light, moderate or high physical intensity).

For current drinkers or smokers, they were individuals who drank alcohol regularly or smoked at least one tobacco product daily in the previous 12 months, including those who had quit within the past year. Former drinkers/smokers had quit more than 1 year earlier, while nondrinkers/ non-smokers had never used alcohol/tobacco products.

Participants were inquired on how they perceived their weight that is as underweight, normal, overweight or obese. Weight and height were taken, BMI calculated, and classified as underweight as BMI <18·5 kg/ m², normal BMI 18.5-<25 kg/m², overweight 25-<30 kg/m², and obesity as ≥ 30 kg/m² according to the World Health Organization (WHO) and National Institutes of Health (NIH) [62-63]. Height was measured twice to the nearest millimeter using a fixed plastic, non-elastic stadiometer, and average height calculated. Body weight was measured in kilograms (to the second decimal place) by a self-zeroing digital weight scale for adults dressed in light clothes without shoes. Safeway self-zeroing digital weight scales (Safeway Scale, South Africa) were used after calibration. These were used to calculate BMI for everyone.

We obtained information about physical activity at work, at home, during recreational sport, and leisure-time activities. This was done using part of the International Physical Activity Questionnaire with comparable variables [64]. Questions were asked about frequency of regular specific activities the individual performs that increase breathing rate for at least 10 minutes: The total duration per day, the number of days in a week, and whether they perceived the activity as heavy, moderate, light, or no activity. For each participant, the recorded activities were converted to Metabolic Equivalent Task (MET)- minutes per week (min/wk) [64]. They were divided into 3 groups as follows: Those participating in activities <3.5 MET-min/wk as no activity (sedentary lifestyle), 3.5-<600 MET-min/wk as low, 600-<3000 MET-min/wk as moderate, and >3000 MET-min/wk as high level of physical activity. Moderate and high physical activity intensities were later combined into one subgroup when assessing association with awareness for calling EMS by acute stroke.

Sources of stroke information: We investigated stroke sources of information based on levels of physical activity intensity in a closed-ended question with six answers as follows, “Where did you get information about stroke?” Answers included family/ friends, television/ radio, newspaper/ magazines, doctors/ nurses, social media (internet, Facebook, Instagram, WhatsApp), and others (own experience, school, or patients).

Statistical analysis

Continuous variables were expressed as mean ± Standard Deviation (SD) or 95% Confidence Interval (CI). Categorical and ordinal variables were expressed as absolute frequency (n) and proportion (%) of the overall sample or subgroups. Outpatients and public groups’ physical activity intensity levels-based awareness of stroke and sources of stroke information were compared using chi-square test. Awareness for calling EMS by acute stroke was further analyzed based on physical intensity levels stratified by sociodemographic factors using chi-square test.

Mann-Whitney U/Kruskal-Wallis H was used to investigate association of calling EMS by acute stroke with physical activity intensity-based respondents’ sociodemographic and stroke risk factors. Bonferroni correction was used for multiple comparisons. Statistical tests were two-tailed and reported statistically significant at p<0.05. All statistical analyses were completed using SPSS 29 statistical software (SPSS Inc., Chicago, Illinois, USA).

We interviewed 2987 respondents in a cross-sectional study in greater Gaborone from June-October 2019, excluded 151 from the public and 28 outpatients because of missing substantial information (Supplementary Figure 1). We had a valid response of 2013 from the public (93.0%) and 795 outpatients (96.6%). The public’s mean age was 36.1 ± 14.5 years with age range 18-90 years, while for outpatients the mean age was 37.4 ± 12.7 years with range 18-80 years. Public and outpatients comprised 45.5% and 41.9% males respectively. More information on respondents’ characteristics is elucidated in Table 1.

Table 1: Sociodemographic and stroke risk factors among respondents.

Physical activity intensities stratified by sociodemographic factors-based responses to calling EMS by acute stroke

There were no significant awareness differences for calling EMS by acute stroke among respondents (Figure 1a).

Figure 1a: Awareness of calling emergency medical services by acute stroke stratified by physical activity intensities.

There was optimal awareness for calling EMS by acute stroke among all levels of physical activity intensities (75.2%-81.3% for public vs. 70.3%-86.2% for outpatients) except among public with low intensity physical activity with 62.7%. Highest awareness rates for calling EMS were among those with moderate intensity physical activity (81.3% public vs. 85.2% outpatients, p=0.763), outpatients with sedentary lifestyle (86.2%), and public with high intensity physical activity (79.7%). There were no significant differences for seeking medical assistance immediately by acute stroke among respondents with various intensities of physical activities, with awareness rates ranging between 87.0%-93.2% for public vs. 90.9%-97.3% for outpatients. (Figure 1b).

Figure 1b: Awareness of seeking medical services by acute stroke stratified by physical activity intensities.

Based on age, educational level, and medical insurance status, there were no significant differences of calling EMS by acute stroke between outpatients and the public among each physical intensity level (Figure 1c-Figure 1e).

Figure 1c: Awareness of calling EMS by acute stroke by physical activity intensities stratified by age.

Figure 1d: Awareness of calling EMS by acute stroke by physical activity intensities stratified by education levels.

Figure 1e: Awareness of calling EMS by acute stroke by physical activity intensities stratified by medical insurance.

Based on residing status, outpatients not residing together were more aware than the public for calling EMS by acute stroke (92.4% vs. 76.3%, p=0.027) (Figure 1f).

Figure 1f: Awareness of calling EMS by acute stroke by physical activity intensities stratified by residing together status.

Among those with sedentary lifestyle, odds of calling EMS immediately by outpatients was 4.8 times higher than of calling EMS not immediately (p<0.001) (Table 2). There were no significant differences among respondents with other levels of physical activity intensity.

Table 2: Physical activity intensities based-awareness of calling EMS and seeking immediate medical Assistance.

Acute individual stroke symptoms responses stratified by physical activity intensity levels

For blurred/double vision, among those with moderate intensity physical activity, outpatients were more likely than the public to contact medical clinic (62.7% vs. 41.5%, p=0.041) (Table 3). Most of the respondents would contact medical clinic (41.5%-53.1% of public vs. 57.0%-64.1% of outpatients), followed by calling EMS (19.0%-42.5% of public vs. 20.4%-38.2% of outpatients) by acute stroke symptoms with the following exceptions: the general public would take other actions (wait and see, no idea, or do nothing) than calling EMS when having either dizziness/loss of balance, acute headache, blurred/double vision, or confusion.

Lowest awareness among public and outpatients was for confusion, while highest among public was for numbness/dead sensation on one side of body and among outpatients was for blurred/ double vision. There were no significant differences in calling EMS or contacting medical clinic by acute stroke symptoms among respondents with sedentary lifestyle, low intensity and high intensity physical activities (Table 3). Among those with sedentary lifestyle respondents, most respondents would contact medical clinic (50.4%-56.5% of public vs. 50.8%-54.5% of outpatients), followed by calling EMS (27.1%-45.5% of public vs. 27.3%-43.4% of outpatients) whenever they get acute stroke symptoms. Lowest awareness among both public and outpatients was for confusion, while highest awareness among public was for numbness/ dead sensation on one side of body and among outpatients was for facial muscles weakness on lower part on one side.

Table 3: Acute individual stroke symptoms responses stratified by physical activity intensities.

Among those with low intensity physical activity, most respondents would contact medical clinic (48.0%-65.3% of public vs. 54.1%-70.3% of outpatients), followed by calling EMS (8.0%-36.0% of public vs. 10.8%- 32.4% of outpatients) by acute stroke symptoms except for dizziness/ loss of balance, acute headache, blurred/double vision among the general public, and confusion among both respondent types. Lowest awareness among both public and outpatients was for confusion, while highest among public was for weakness on one side of body, and among outpatients was for speech impairment and numbness/ dead sensation on one side on body.

Among those with high intensity physical activity, most would contact medical clinic (42.0%-55.1% of public vs. 40.9%-59.1% of outpatients), except for speech impairment among outpatients where similar number would call also EMS (40.9%). This would be followed by calling EMS (18.8%-44.9% of public vs. 18.2%-45.5% of outpatients) except dizziness/loss of balance, acute headache, and confusion among both respondent types, and blurred/double vision among outpatients. The least awareness rate for calling EMS among both the public and outpatients was for confusion, while the highest among both public and outpatients was for numbness/dead sensation on one side of body. In addition outpatients had also facial muscles weakness on lower part on one side as the highest.

Sources of stroke information based on physical activity levels

Among those with sedentary lifestyle, more outpatients than the public (56.1% vs. 42.1%, p<0.05) had magazines/ newspapers as sources of information (Supplementary Table 1). Otherwise, there were no significant differences between the public and outpatients based on low, moderate and high intensity physical activities. Among all levels of physical activities, respondents were most likely to get stroke information from family/ friends (58.7%-68.1% of public vs. 43.2%- 65.0% of outpatients) and TV/radio (40.0%-60.8% of public vs. 54.1%- 65.7% of outpatients) while lowest from others (less than 26% for each respondents group in each physical activity level).

Awareness for calling EMS by acute stroke based on sources of information stratified by physical activity intensity levels

 Among those with sedentary lifestyle who got stroke information from TV/radio, outpatients had higher awareness than the public for calling EMS by acute stroke (88.5% vs. 72.7%, p=0.039) (Supplementary Table 2). Among all physical activity intensities, awareness for calling EMS by acute stroke by all sources of information was at least 70% except among outpatients with sedentary lifestyle who got information from others category, public with low intensity physical activity who got information from family/friends and others category, and outpatients with high intensity physical activity who got information from others category.

Association of physical activity intensities-based respondents sociodemographic and stroke risk factors with calling EMS immediately by acute stroke

Various physical activity intensity levels-based factors were associated with lower awareness for calling EMS as shown below (p<0.05) (Supplementary Table 3).

Sociodemographic factors: Among both public and outpatients with each physical activity intensity level except public with sedentary lifestyle, it was associated with those residing /working together among both public and outpatients with sedentary lifestyle, it was associated with male gender, and no medical insurance. Among public with sedentary lifestyle, it was associated with age >50 years, and primary education. Among outpatients with moderate-high intensity physical activity, it was associated with no medical insurance.

Self-reported risk factors: Among both public and outpatients with sedentary lifestyle and moderate-high intensity physical activity, it was associated with no history of HIV/AIDS. Among outpatients with sedentary lifestyle and low intensity physical activity, it was associated with history of psychiatric diseases. Among the public with moderatehigh intensity physical activity, it was associated with family history of heart diseases, and family history of both stroke and heart diseases. Among the public with sedentary lifestyle, it was associated with history of current smoking, current drinking, and non-healthy diet.

Calculated risk factors: Among outpatients with sedentary lifestyle, it was associated with normal BMI while among those with moderate-high intensity physical activity, it was underweight.

Worldwide, this is the first study investigating awareness for calling EMS by acute stroke based on the levels of physical activity intensity among respondents. Awareness rates for calling EMS and for seeking immediate medical assistance were adequate (at least 70% and 87% respectively) among respondents and there were no significant differences between the public and outpatients. The only exception being among the public with low intensity physical activity who possessed 62.7% awareness rate for calling EMS by acute stroke probably due to that they are not frequently in contact with healthcare professionals as compared to outpatients and are not healthy conscious. The public with low physical activity intensity are likely not even aware that low physical intensity is a stroke risk factor in addition to knowing actions necessary to take when they get stroke. There were some parities and disparities in factors associated with calling EMS by acute stroke among respondents.

Awareness for calling EMS by acute stroke was high among outpatients based on levels of physical activity intensity (70.3%-86.2%). Most of patients’ studies have shown lower rates than ours (15.0%- 73.0%) [12-13,18,20,21,24-26,29,33,37,41,43,45,46,58]. This is also supported by one previous study that demonstrated that time from symptom onset to seeking medical assistance contributed 45% of the prehospital delay among stroke patients [15]. In our study, awareness for calling EMS among the public was also high (62.7%-81.3%). Some public studies also demonstrated some similar results despite some having lower awareness for calling EMS (26.9%-89.9%) [26,44,47- 55,57,58]. Despite high awareness of stroke symptoms in real life, some studies have shown that still a good number fails to call EMS by acute stroke [37,46,55-56]. These variations with other studies can be explained by that previous studies were not stratified by physical activities intensities, differences in study population (respondents’ age, gender distribution, time and place of study, type of patients, characteristics awareness is based on, and comorbidities) and nature of questions (closed- or open-ended). This could also be due to that the population has probably better awareness now than in the past since stroke as a global burden have been emphasized a lot in the past years using various sources of information in order to reach as many people as possible.

However, when respondents were asked how they would respond to each of the specific stroke symptoms without reference to stroke, awareness rates for calling EMS by any specific stroke symptom were low (less than 50% for each level of physical activity intensity) for each symptom among both outpatients and public, and without any significant differences between them. This is in line with some public studies, that had lower awareness rates for calling EMS by blurred/ double vision (23.6%-33.3%) compared to all levels of physical activity intensity (25.5%-33.2%) except low intensity physical activity that had even lower awareness rate (16%) [7,44,57]. This also resonates with weakness on the body (41.9%-59%) in which ours demonstrated awareness of 36.0%-42.9% among all levels of physical activity intensity even though those with low intensity physical activity had lower awareness (36.0%) [7,44,57,65]. Our study demonstrated low awareness for speech impairment (37.1%-40.8%) except those with low intensity physical activity that had lower (25.3%). This resonates also with these public studies [7,44,57,65] that showed low awareness for speech impairment (41%-44%) but contrasts one that had higher awareness (72.4%) [57].

These studies had awareness rates of 30.3%-51.0% [7,44,57,65] for dead sensation, and this resonates with ours that had 32.0%-45.5% for all various levels of physical intensity activity. In addition, our study demonstrated lower rates for calling EMS by facial muscles weakness on one lower side (29.3%-43.7%) while one study had higher awareness (64.3%) [65]. We showed higher awareness for calling EMS by dizziness among all levels of physical activity intensity (20.0%-30.3%). This is higher than the findings from one previous study (3.2%) [44]. In addition, awareness for calling EMS by headache in our study was higher compared to a previous study that had 6.7% [44]. Outpatients with moderate intensity physical activity had higher awareness than the public (p<0.05) for contacting medical clinic by blurred/ double vision (62.7% vs. 41.5%). This is in line with one previous that showed similar findings even though it was not physical activity intensity stratified. This could be explained by lack of awareness of EMSs existence in rural areas, those with moderate intensity physical activity are healthy conscious, and in addition to that outpatients visit the medical clinics more than the public. Unlike our study, another study demonstrated that outpatients had also higher awareness than the public for contacting medical clinic by acute headache, speech impairment, dizziness/loss of balance, weakness on one side of the body, and confusion even though results were not physical activity intensity level stratified. Differences in findings of these studies can be attributed to differences in study population, and in that ours was stratified for intensity of physical activity.

Among all intensities of physical activity, both the public and outpatients had family/ friends and TV/ radio as highest sources of information of stroke. This is in line with other studies that showed doctors or healthcare professionals as one of the lowest sources of information among patients and public except for the public with high intensity physical activity in our study where they were among one of the best sources of information [25,44,45,50,58,59,65,66]. Among all intensities of physical activity, highest sources of information at >40% among outpatients and the public were TV/radio, family/friends, while magazines/newspapers and doctor/nurse among the public with sedentary lifestyle, and magazines/newspaper among outpatients with sedentary lifestyle and moderate intensity physical activity. This is in line with other studies that reported family, and friends in addition to mass media as highest sources of stroke information [44,45,50,58,59,65,66]. Among those with sedentary lifestyle, outpatients had higher awareness for calling EMS than the public among those who got stroke information from TV/radio. This might be because outpatients get most information from TV/radio about their diseases. This is still surprising because one would have expected them to have gotten information from healthcare professionals (doctors/nurses) instead.

We showed that among the public with sedentary lifestyle, lower awareness for calling EMS by acute stroke was associated with age >50 years, and primary education. This is in line with some studies that demonstrated lower education and older age to be associated with lower knowledge even though it was not based on physical activity intensities [47,58]. Among both public and outpatients with sedentary lifestyle, lower awareness for calling EMS by acute stroke was associated with male gender, and no medical insurance. Similar findings were observed also among outpatients with moderate-high intensity physical activity. This is in line with other studies which showed association with no medical insurance but contrasts others that did not demonstrate any association with medical insurance, even though they were not physical activities stratified [24,29,47,58]. However, our study contrasts some studies that showed older age was associated with higher awareness for calling EMS and those that did not demonstrate any association with age and education [24,29,33,37,44]. We demonstrated association of lower awareness with residing/working together among both outpatients and public with all various levels of physical activity intensity except public with sedentary lifestyle. This is in line with one previous study but contrasts a study that showed association with those living alone and another one that did not demonstrate any association [24,37,58]. Among both public and outpatients with sedentary lifestyle, lower awareness for calling EMS by acute stroke was associated with male gender. This is in line with some studies that had similar findings but contrasts some that did not show any association with gender [24,33,47,58]. In our study, among public with moderate-high intensity physical activity, lower awareness was associated with family history of heart diseases, and family history of both stroke and heart diseases while among public with sedentary lifestyle, it was with history of current smoking, current drinking, and non-healthy diet. In addition, our study showed no association of awareness with marital status, or history of cardiovascular diseases. It is in line with some studies that did not demonstrate any association with prior stroke [24,29,33,37,58,66-69]. On the other hand, it contrasts one previous study that demonstrated association of higher awareness for calling EMS with married ones, history of cholesterol and history of angina [44]. Different findings in these studies can be due to differences in study population including types of respondents, and that previous studies were not stratified by physical activity intensity levels.

Despite adequate awareness for calling EMS or seeking immediate medical services by acute stroke, there are still gaps in awareness among some subgroups. Therefore, results call for educational campaigns on awareness for calling EMS/ seeking immediate medical assistance by stroke targeting these subgroups using all available sources of information if we are to reduce the burden of stroke in Africa.

Our study is one of the very few studies worldwide if not the first investigating physical activity levels-based awareness for calling EMS by acute stroke among public and outpatients concurrently. Our results we compared with mostly previous closed-ended studies. Our survey was conducted in communities with various socio-economic backgrounds, therefore all communities in the country were represented. Some of the limitations to this study are as follows.

 First, despite all similarities and variations between studies, some studies considered better/ high awareness differently with some either considering awareness based on sums of awareness questions while we resorted to lowest or highest mean score. Second, self-reported factors/ characteristics are prone to bias. Lastly, there may be differences in sociodemographic and other factors between responders and nonresponders that we are unable to account for. Despite all these, a reasonable high response rate (94%) was attained and therefore results represent current awareness of respondents in greater Gaborone.

Consent for publication

All authors have read and approved the manuscript for submission. All eligible respondents were given oral and written information on the study including publication of the results, and written informed consent sought prior to inclusion in the study.

Participation consent

All eligible respondents were given oral and written information on the study including publication of the results, and written informed consent sought prior to inclusion in the study. Questionnaires were anonymous.

Trained research assistants interviewed respondents verbatim. Each interviewer conducted a standardized, structured, one-to-one interview, according to a questionnaire designed to guide interview and avoid bias. For the public, no more than 2 respondents from same family/compound/ company were interviewed. The interviewer intervened only if asked to clarify any question, without giving correct answers. We sampled only odd numbers for outpatients in a queue at healthcare facilities and households for the public in each area. For the public, we further sampled from various socio-economic levels i.e., high, moderate and low socio-economic areas within greater Gaborone.

Ethical statement

Ethical clearance for this study in accordance with the Helsinki declaration for medical research was obtained from the following institutional review committees: Human Research Ethics of University of Botswana, Ministry of Health and Wellness in Botswana, Health Research and Development Division (ref. no. HPDME: 13/18/1) together with Regional Committee for Medical Research Ethics South East Norway, section C (ref. 2018/774/REK), Norway.

Availability of data and materials

The datasets used and analyzed during the current study are available in the attached file.

Competing interests

Authors declare that there is no conflict of interest.

Funding

Botswana and Norway governments’ collaboration in the health sector. The funders had no role in the study methodology, data collection, analysis and interpretation, and producing the manuscript.

Grant number: not applicable.

Publication funding

The publication charges for this article have been funded by a grant from the publication fund of Sidilega Private Hospital, Gaborone, Botswana

The authors thank the chief medical officers, hospital superintendents and their staff in greater Gaborone and the funders for this survey research study.

Author contributions

All authors contributed substantially in producing this manuscript (i.e., planning of the study, collecting data, analyzing data and writing of the manuscript).

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