Impact of Regional Differences in Stroke Awareness and Income on EMS in China

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Impact of Regional Differences in Stroke Sympton Awareness and Low-Income Status on Seeking Emergency Medical Service in China

Stroke represents a critical public health challenge in China, accounting for one of the highest incidences globally. Despite advancements in acute stroke management, pre-hospital delays remain a significant barrier to effective treatment. This study examines how regional disparities in stroke symptom awareness and low-income status influence the decision to seek emergency medical services (EMS) in China, utilizing data from the China National Stroke Screening Survey (CNSSS).

Background and Significance

China’s socioeconomic diversity and vast geographic disparities create unique challenges in healthcare access. While poverty rates have declined, rural areas still grapple with income inequality, with 5.51 million people below the poverty line in 2019. Stroke prevalence in adults aged 40+ was 2.06% in 2014, with annual incidence rising by 8.3% between 2002 and 2013. Reperfusion therapy, the gold standard for acute ischemic stroke, hinges on timely EMS activation. However, 39.1% of stroke patients in China fail to call EMS, partly due to low symptom awareness (18.1%) and financial constraints. This study investigates how the interplay of these factors varies across regions, informing targeted interventions.

Methodology

The FAST-RIGHT study, a subset of the CNSSS, analyzed 187,723 adults aged ≥40 from 69 counties across China’s six regions (North and Northeast, East, Central, South, Southwest, Northwest). Data were collected via face-to-face interviews using standardized questionnaires. Key variables included:

  1. Awareness of Stroke Symptoms: Participants were tested on recognizing sudden facial droop, arm weakness, or speech disturbances as stroke indicators.
  2. Income Status: Annual income below 5,000 RMB (~$714) was classified as low-income.
  3. Intention to Call EMS: Respondents chose between “home observation,” “waiting for family,” or “immediate ambulance call.”

Participants were categorized into four groups:

  • Unaware and low-income (6.3% of the sample).
  • Unaware-only (11.9%).
  • Low-income-only (21.5%).
  • Aware and regular income (60.4%).

Statistical analyses included multivariate logistic regression adjusted for age, sex, education, residency (urban/rural), insurance type, family living status, stroke history in acquaintances, and vascular risk factors (hypertension, diabetes, etc.). Sensitivity analyses excluded individuals with prior stroke history.

Key Findings

1. National-Level Associations

  • Unaware and low-income individuals had the highest odds of not calling EMS (OR: 3.21, 95% CI: 3.07–3.35).
  • Unaware-only status followed (OR: 2.38, 95% CI: 2.31–2.46), while low-income-only showed moderate risk (OR: 1.67, 95% CI: 1.63–1.71).
  • Older adults (≥65 years) were less likely to call EMS (OR: 1.52, 95% CI: 1.43–1.62), though this trend reversed in the East, Central, and South regions.

2. Regional Disparities

  • Unaware and Low-Income Concentration:
    • Northwest: 23.1% of the population, with 69.1% failing to call EMS.
    • Southwest (7.7%) and South (9.3%) also showed high prevalence.
    • In contrast, North and Northeast (1.9%) and East (3.1%) had lower rates.
  • Unaware-Only Burden:
    • South (15.4%), Central (13.2%), and East (12.6%) had the highest proportions.
    • In the East, 66.3% of unaware-only individuals delayed EMS activation.
  • Low-Income-Only Challenges:
    • North and Northeast (29.2%) and Southwest (28.7%) had the most affected populations.
    • Despite awareness, 35.6–58.0% in these regions still avoided EMS due to financial concerns.

3. Age-Region Interaction

  • Adults ≥65 in North and Northeast (OR: 1.16), Southwest (OR: 1.38), and Northwest (OR: 1.70) were less likely to call EMS.
  • Conversely, older adults in East (OR: 0.91) and Central (OR: 0.87) showed better EMS utilization, highlighting regional disparities in health literacy and resource access.

Implications for Policy and Practice

  1. Targeted Education Campaigns:

    • The Northwest and Southwest require interventions addressing both awareness and poverty. Programs like Stroke 120, which educates on recognizing facial droop (1), arm weakness (2), and speech difficulty (0 for emergency calls), should be intensified.
    • The East and Central regions benefit from awareness-focused initiatives, as financial barriers are less prevalent.

  2. Economic Support Mechanisms:

    • In North and Northeast, subsidies for EMS costs or insurance coverage expansions could mitigate low-income-related delays.

  3. Aging Population Considerations:

    • Tailored messaging for older adults in high-risk regions, leveraging family-based education and community health workers, may improve EMS uptake.

  4. Regional Resource Allocation:

    • Strengthening EMS infrastructure in rural Northwest and Southwest is critical, given their high unmet needs.

Limitations and Future Directions

  • Self-reported income and intention (vs. actual behavior) may introduce bias.
  • EMS availability metrics (e.g., response times) were not analyzed but could influence decisions.
  • Future studies should explore cultural attitudes toward healthcare and trust in EMS.

Conclusion

This study underscores the dual burden of low awareness and poverty on stroke outcomes in China, with distinct geographic patterns. The Northwest’s high prevalence of unaware and low-income individuals demands urgent action, while the East and Central regions require awareness reinforcement. By aligning interventions with regional profiles, China can reduce stroke-related morbidity and mortality, advancing toward health equity.

doi.org/10.1097/CM9.0000000000001604

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