GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 Indonesian Scholars’ Alliance Open Access Research Article The 1st Cirebon International Health Symposium: Faculty of Medicine, Universitas Swadaya Gunung Jati Update on Non-Communicable Diseases: Global Perspective on Health Challenges and Innovation The Association between Family Knowledge and Response with Pre-hospital Delay among Stroke Patients: A Study from Rural Area of Cirebon, Indonesia Muhammad Nabil Prawira Ivanka1 , Witri Pratiwi2* , Agus Kusnandang1 1 Department of Neurology, Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Swadaya Gunung Jati, Indonesia; 2 Department of Community Medicine and Public Health, Faculty of Medicine, Universitas Swadaya Gunung Jati, Indonesia. *Corresponding author’s e-mail: we3.borneo@gmail.com DOI: 10.35898/ghmj-741111 ABSTRACT Background: Stroke is a non-communicable disease whose prevalence continues to increase in both young and old age groups. Stroke patients require immediate treatment at the hospital to prevent disability and death. Delayed treatment may result in a worse prognosis. Aims: To analyze the relationship between family knowledge and response with pre-hospital delay in stroke patients in Cirebon Regency, Indonesia. Methods: This cross-sectional study was conducted at Waled General Hospital, Cirebon Regency, Indonesia. The sampling technique used was consecutive sampling of patients hospitalized with stroke diagnosis from May 2024 to July 2024. Patients with recurrent stroke were excluded. Data were collected from medical records and questionnaires administered to the patient's families. The Indonesian version of Stroke Recognition Questionnaire (SQR) was used to explore family knowledge, while family responses were explored using the Stroke Action Test (STAT). Results: There were 61 stroke patients recruited in this study. Majority of the sample were delivered to hospital late (78.7%). Most of the patients’ families had poor knowledge (47.5%) and inadequate attitudes (85.2%). In the bivariate analysis, there was a strong correlation between family knowledge of stroke symptoms and pre-hospital delay (p=<0.001; r=0.746). Inadequate family response was associated with pre-hospital delay [p= 0.002; PR 2.596 (95%CI 1.024-6.581)]. Conclusion: There is a positive correlation between family knowledge and response with pre-hospital delay in stroke patients in Cirebon Regency, Indonesia. Keywords: Attitude, Family knowledge, Family response, Pre-hospital delay, Stroke. Received: 26 September 2024 Reviewed: 19 October 2024 Revised: 24 November 2024 Accepted: 30 November 2024 © Yayasan Aliansi Cendekiawan Indonesia Thailand (Indonesian Scholars’ Alliance). This is an open-access following Creative Commons License Deed - Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) mailto:we3.borneo@gmail.com https://doi.org/10.35898/ghmj-741111 https://orcid.org/0009-0002-0717-6343 https://orcid.org/0000-0001-8714-9198 https://orcid.org/0009-0000-4481-3239 Ivanka, et. al. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 158 1. Introduction Stroke is one of non-communicable diseases that causes high morbidity and mortality throughout the world. Globally, stroke is the second leading cause of death and the third leading cause of disability. Based on data from the World Health Organization (WHO), at least 15 billion people worldwide experience stroke each year. Of these, 5 billion of them die and another 5 billion can be saved but live with disability (World Health Organization, 2024). An estimated 70% of stroke cases occur in low- and middle-income countries, including Indonesia (World Health Organization, 2024). Epidemiologic data in Indonesia shows that stroke is the leading cause of death. Based on RISKESDAS 2018, the prevalence of stroke in Indonesia increased from 7 per 1,000 population in 2013 to 10.9 per 1,000 population in 2018. In West Java province, the prevalence of stroke was 11.4% in the population aged ≥15 years. This number continues to increase due to the unhealthy lifestyle of Indonesian people. Stroke also causes a huge economic burden for the National Health Insurance (JKN), so it is called a catastrophic disease. Data shows that JKN financing for stroke treatment is the third largest after heart disease and cancer. The cost reached IDR 1.911 trillion in 2021 and increased to IDR 3.23 trillion in 2022 (Direktorat Jenderal Pelayanan Kesehatan-Kementerian Kesehatan Republik Indonesia, 2023; Kementerian Kesehatan Republik Indonesia, 2018). One of the problems faced in the management of stroke patients is the delay in patients coming to the emergency room so that it is late to provide optimal treatment. Pre-hospital delay is the prolonged time from the onset of symptoms until the patient arrives at the hospital (Wang et al., 2021). If stroke patients are immediately given appropriate treatment, it can provide a better prognosis, namely preventing death and disability. Pre- hospital delay includes delay in recognizing stroke symptoms and delay in responding to deliver patient to health service. In this case, the family plays a very important role (Wanichanon et al., 2024). Knowing the description of family knowledge about stroke symptoms, their responses, and its relationship with pre-hospital delay is very important. It can illustrate the burden in stroke management, especially from the patient's family factor. However, such data is still very limited, including in Cirebon Regency, Indonesia. Therefore, this study was conducted with the aim of finding out the description of stroke patient family knowledge regarding stroke symptoms and their responses. In addition, this study also aimed to determine the relationship between family knowledge and response with pre-hospital delay in stroke patients at Waled General Hospital, Cirebon Regency, Indonesia. Our study focuses on first-ever stroke patients, where rapid treatment greatly affects the outcome (Prasanna & Forshing, 2023; Randhawa et al., 2022; Wechsler et al., 2023). 2. Methods Study design and participants This is a cross-sectional study conducted at Waled General Hospital, as one of the largest referral hospitals in Cirebon district. The sample was hospitalized patients with a stroke diagnosis from May 2024 to July 2024 and their families. The diagnosis of stroke was known through the diagnosis sheet in the medical record based on neurologist assessment. The sampling technique used was consecutive sampling. The calculation of the sample size used the proportion estimation formula and obtained 61 samples. The inclusion criteria in this study were patients with acute ischemic and hemorrhagic stroke. The inclusion criteria of the patient's family were >18 years old, living in the same house with the patient and knowing the patient's condition. We excluded patients with transient ischemic attack (TIA), recurrent stroke and patients who were not accompanied by their families. Data collection and definition of variables Data for this study were collected through medical records and questionnaires completed by the patients’ families. Stroke patient characteristics (gender, age and type of stroke) and arrival time to the hospital emergency department were collected from patients’ medical records. Families accompanying the patients in the inpatient ward were asked about stroke onset, distance from home to hospital, transportation to hospital and family 159 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 Ivanka, et. al. characteristics (gender, age, education level). Families were also asked to complete a questionnaire exploring family knowledge and responses. Family knowledge Family knowledge is the level of knowledge of the patient's family regarding stroke symptoms. Data on family knowledge was collected using validated Indonesian version of the Stroke Recognition Questionnaire (SRQ) (Herliani, 2023). There were 17 questions with "yes" and "no" answer options. Family knowledge of stroke symptoms was categorized as poor if they could answer <56% of the questions correctly, sufficient if 56-75% and good if >75-100%. Family response Family response was defined as actions taken by the family in several conditions related to the occurrence of stroke. It was measured using the Stroke Action Test (STAT) which consists of 21 questions. Response options in this questionnaire include: [1]"immediately call an ambulance or go to the emergency room", [2] "immediately call or visit a doctor", [3] "wait 1 hour then decide to take the patient to the hospital" and [4] "wait 1 day to decide to take the patient to the hospital". Family response was categorized as inadequate if ≤77% of the selected answers are [1] and [2]. Adequate response if >77% of the selected answers were [3] and [4] (Sumarsono, 2019). Pre-hospital delay The operational definition of pre-hospital delay in this study iss the duration of time between the onset of stroke and the patient's arrival at the hospital emergency department. We asked the patient's family when the patient felt the stroke symptoms and recorded arrival time from medical record. If the time duration is ≥24 hours then the patient is categorized as pre-hospital delay. Data analysis This data is presented in tables and graphs to describe the frequency and percentage values of the variables. Numerical data for age variable is described through median, interquartile range and min-max values. Bivariate analysis to determine the relationship between family knowledge and pre-hospital delay was carried out using the Spearman Rank test to obtain the p-value and correlation coefficient. The relationship between family response and pre-hospital delay was performed using Fisher’s exact test. A p value of <0.05 was considered as statistically significant. Analysis was performed using SPSS Version 26 software. Ethical approval Respondents were given informed consent regarding the research procedures before data was collected. Those who agreed were then asked to sign the consent form. This study has obtained ethical approval from the Ethics Committee of Waled General Hospital No: 000.9.2/060/KEPK/V/2024. 3. Results In this study, 61 stroke patients were recruited as samples during the study period. The characteristics of stroke patients during the study period are summarized in Table 1. Most of stroke patients were male (60.7%). Based on age, stroke was dominated by the 50-59 years age group, with an age range of 25-85 years. This study also found that stroke occurred in younger age groups, namely 20-29 years (4.9%) and 30-49 (14.8%). A total of 85.2% of the samples experienced ischemic stroke. Most stroke patients lived close to the hospital (80.3%), and there were 8.2% whose homes were quite far from the hospital (>20 km). As many as 24.6% of stroke patients were brought to the hospital by ambulance. Figure 1 shows that as many as 78.7% of stroke patients arrived late at the hospital. Pre-hospital delay occurred in 76.9% of ischemic stroke and 88.9% of hemorrhagic stroke (Figure 2). Ivanka, et. al. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 160 Table 1. Characteristics of stroke patients (n=61) Figure 1. Proportion of pre-hospital delay in stroke patients 78.7% 21.3% Delay Not Delay Characteristics Frequency Percentage Gender Male 37 60.7 Female 24 39.3 Age (years) 20-29 30-49 50-59 ≥60 Median Q1-Q3 Min-max 3 9 26 23 58 50-64 25-85 4.9 14.8 42.6 37.7 Types of stroke Ischemic stroke Hemorrhagic stroke 52 9 85.2 14.9 Distance from home to hospital <10 km 10-20 km >20 km 49 7 5 80.3 11.5 8.2 Transportation to hospital Ambulance Others 15 46 24.6 75.4 161 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 Ivanka, et. al. Figure 2. Pre-hospital delay based on type of stroke The characteristics of stroke patients’ families are summarized in Table 2. In this study, 45.9% of the patients' families were male and 54.1% were female. The families were mostly aged 30-49 years (62.3%), with a median age of 40 years and an interquartile range 34-49.5 years. The majority of families were junior high school graduates (44.3%) and 21.3% were elementary school graduates. Nearly half of the respondents were taken to hospital and accompanied by their wives or husbands. This study found that most of patient's families had poor knowledge of stroke symptoms (47.5%). In addition, most of them also had inadequate responses in taking action when stroke symptoms occurred (85.2%). 76.9% 88.9% 23.1% 11.1% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Ischemic stroke Hemorrhagic stroke Delay Not Delay Table 2. Characteristics of stroke patients’ families (n=61) Characteristics Frequency Percentage Gender Male 28 45.9 Female 33 54.1 Age (years) 20-29 8 13.1 30-49 38 62.3 50-59 12 19.7 ≥60 3 4.9 Median Q1-Q3 40 34-49.5 Level of education Elementary school 13 21.3 Junior high school 27 44.3 Senior high school 16 26.2 University 5 8.2 Family relationship Wife or husband Parent Child Others 29 7 20 5 47.5 11.5 32.8 8.2 Knowledge of stroke symptoms Poor Moderate Good 29 20 12 47.5 32.8 19.7 Family response Inadequate Adequate 52 9 85.2 14.8 Ivanka, et. al. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 162 The families’ knowledge of stroke symptoms and their responses were shown in Table 3. Most male (50%) and female (45.5%) families had poor knowledge of stroke symptoms. Poor knowledge was dominant in families aged ≥30 years, while in families aged 20-29 years more than half had moderate and good knowledge. The results showed that families with a low level of education had less knowledge. All families, whether wives, husbands, parents, children or others, mostly had poor knowledge. Present study showed that both male and female families mostly had inadequate responses. Inadequate responses were also seen predominantly in all age groups, education levels and family relationships. Table 3. Families’ knowledge of stroke symptoms and their response by characteristics; n(%) The results showed that there was a strong relationship between family knowledge of stroke symptoms and pre-hospital delay in stroke patients (p<0.001; r=0.746). The better family's knowledge about stroke symptoms, the less frequent the pre-hospital delay (Table 4). The results of bivariate analysis also showed that there was a relationship between family response and pre-hospital delay (PR 2.596; 95%CI 1.024-6.581), as listed in Table 5. Table 4. The correlation between family knowledge with pre-hospital delay in stroke patients Knowledge of stroke symptoms Pre-hospital delay p-value r Yes No Poor Moderate Good 29 (100) 19 (95.0) 0 0 1 (5.0) 12 (100) <0.001 0.746 Table 5. The correlation between family response with pre-hospital delay in stroke patients Family response Pre-hospital delay p-value PR; 95%CI (upper-lower) Yes No Inadequate Adequate 45 (86.5) 3 (33.3) 7 (13.5) 6 (66.7) 0.002 2.596; 1.024-6.581 Characteristics of family Knowledge of stroke symptoms Family response Poor Moderate Good Inadequate Adequate Gender Male Female 14 (50.0) 15 (45.5) 8 (28.6) 12 (36.4) 6 (21.4) 6 (18.2) 24 (85.7) 28 (84.8) 4 (14.3) 5 (15.2) Age (years) 20-29 1 (12.5) 4 (50.0) 3 (37.5) 7 (87.5) 1 (12.5) 30-49 21 (55.3) 10 (26.3) 7 (18.4) 32 (84.2) 6 (15.8) 50-59 5 (41.7) 5 (41.7) 2 (16.7) 10 (83.3) 2 (16.7) ≥ 60 2 (66.7) 1 (33.3) 0 3 (100) 0 Level of education Elementary school 9 (69.2) 2 (15.4) 2 (15.4) 12 (92.3) 1 (7.7) Junior high school 14 (51.9) 6 (22.2) 7 (25.9) 21 (77.8) 6 (22.2) Senior high school 6 (37.5) 7 (43.8) 3 (18.8) 15 (93.8) 1 (6.3) University 0 5 (100) 0 4 (80.0) 1 (20.0) Family relation Wife or husband Parent Child Others 14 (48.3) 3 (42.9) 11 (55.0) 1 (20.0) 8 (27.6) 2 (28.6) 8 (40.0) 2 (40.0) 7 (24.1) 2 (28.6) 1 (5.0) 2 (40.0) 25 (86.2) 6 (85.7) 18 (90.0) 3 (60.0) 4 (13.8) 1 (14.3) 2 (10.0) 2 (40.0) 163 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 Ivanka, et. al. 4. Discussion Characteristics of stroke patients Our results showed that stroke was more common in males than females. A multicenter study conducted in Surabaya, Indonesia also obtained similar results, with 57.94% males and 42.06% females (Minalloh et al., 2022). Likewise, data from the Indonesian Health Survey in 2023 showed that the prevalence of stroke in males population aged ≥15 years was 8.8 ‰ (95%CI 8.3-9.3), higher than that of females (7.9‰; 95%CI 7.4-8.4) (Kementerian Kesehatan Republik Indonesia, 2023). However, a study at Hasan Sadikin Hospital in Bandung, Indonesia found that more females (53.4%) experienced stroke than males (46.6%), although not significantly different (Jamilatul Badriyah et al., 2018). The incidence of stroke in males may be closely related to the higher prevalence of smoking in males compared to females, even at a young age. Based on Indonesian health survey data in 2023, 43.8% (95%CI 43.5-44.2) of males aged ≥18 years in Indonesia smoked every day (compared to 0.7% of females) (Kementerian Kesehatan Republik Indonesia, 2023). Based on meta-analysis, it was found that smoking was associated with an increased incidence of all types of stroke, with a pooled OR of 1.61; 95%CI 1.34-1.93 (Pan et al., 2019). Cigarettes contain more than 7,000 harmful ingredients that cause inflammation, endothelial dysfunction, dyslipidemia and prothrombotic states. Additionally, there is also impaired vasodilation and reduced nitric oxide bioavailability. Atherosclerosis, an increased risk of thrombosis leads to impaired brain perfusion which then leads to ischemic stroke. Smoking increases the risk of hemorrhagic stroke through disruption of vascular wall structure and rupture of aneurysm (Luo et al., 2022). Interestingly, present study examined that a higher proportion of stroke in young adults, namely 4.9% at ages 20-29 years and 14.8% at ages 30-49 years. Research conducted at Hasan Sadikin Hospital in Bandung, Indonesia found stroke at the age of 15-24 years was 0.6%, 25-34 years was 2.6% and 35-44 years was 9% (Jamilatul Badriyah et al., 2018). These results are also in line with national data from RISKESDAS 2018 which showed a shift in stroke patients to a younger age, even at the age of 18-24 years. (Kementerian Kesehatan Republik Indonesia, 2018; Saraswati, 2021). Stroke in young adults is defined as stroke experienced by an individual aged <50 years. The prevalence trend of stroke in young adults continues to increase worldwide and is closely related to morbidity. It is influenced by several risk factors, such as hypertension, dyslipidemia, heart disease, obesity, diabetes mellitus, smoking, sedentary lifestyle and unhealthy eating habits in young adults (Andriyani et al., 2020; Balgis et al., 2022; Bukhari et al., 2023; Effendi et al., 2022; Faruq et al., 2021; Harlianti et al., 2018; Pratiwi & Surgana, 2024; Rachmawan et al., 2024). The increasing trend of stroke incidence in young adults occurs in many countries and needs serious attention. It has major consequences, especially in terms of psychosocial aspects of stroke sequelae in survivors, as well as being a huge burden for individuals, families and the government (Bukhari et al., 2023). The current study found that ischemic stroke was more common than hemorrhagic stroke. Previous research at Hasan Sadikin Hospital Bandung, Indonesia also showed similar results that ischemic stroke occured in 66,4% of patients and hemorrhagic stroke in 33,6% (Jamilatul Badriyah et al., 2018). However, a study conducted at Kandou Hospital Manado, Indonesia obtained different results that hemorrhagic stroke (58%) was more common than ischemic stroke (42%) (Barahama & Tangkudung, 2019). Pre-hospital delay The results examined that 78.7% of stroke patients arrived at the hospital late (>24 hours from the onset of symptoms). As many as 76.9% of pre-hospital delays occurred in ischemic stroke and 88.9% in hemorrhagic stroke. Studies showed better outcomes in stroke patients who received treatment sooner than those who had missed the therapeutic window. The outcomes in stroke patients are time-dependent so treatment should be given as soon as possible, especially within 60 minutes of symptom onset (golden hour) (Advani et al., 2017; Anderson, 2016). Moreover, references showed better outcomes in the first 30 minutes of symptom onset, which is called the platinum 30 minutes (Randhawa et al., 2022). Ivanka, et. al. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 164 The proportion of pre-hospital delays in this study was higher compared to several previous studies in Indonesia. A study in Manado, Indonesia showed a lower proportion of pre-hospital delay than our study, which was 48.5% (Barahama & Tangkudung, 2019). Previous study in Banjarmasin, Indonesia found that the proportion of pre-hospital delays was 34.7%. However, this study used a cut off of 3 hours to categorize delays (Julianto et al., 2023). The high proportion of pre-hospital delays in this study may be closely related to the characteristics of the rural population in this study, which is dominated by residents with low levels of education. Based on the type of stroke, pre-hospital delay was more common in hemorrhagic stroke compared to ischemic stroke, namely 88.9% and 76.9%. It is in line with a study in Manado, Indonesia that pre-hospital delay occurred 99.6% in hemorrhagic stroke and 0.4% in ischemic stroke, with a cut-off time of 4 hours (Tangkudung et al., 2019). The relationship between family knowledge about stroke symptoms, family responses and pre-hospital delay in stroke patients Our findings showed that most patients' families had poor knowledge of stroke symptoms, especially in those with low level of education. Family knowledge of stroke symptoms was strongly related to pre-hospital delay in stroke patients. These results are similar with previous studies in Gorontalo and Lombok, Indonesia (Ishak et al., 2020; Jusuf et al., 2023). Good family knowledge about the symptoms of stroke leads to the perception that the patient's condition is an emergency. Therefore, the patient's family will respond quickly by bringing the patient to health services. Conversely, poor family knowledge leads to the perception that the symptoms experienced by the patient are normal, so the patient is brought to the hospital after the condition worsens (Putri & Santoso, 2020). Results also found that the majority of families had inadequate responses. It was known that an adequate family response can reduce the risk of pre-hospital delay. Pre-hospital delay mainly occurs when the decision to refer a patient requires the agreement of several family members. In this study, children as decision maker caused more pre-hospital delay compared to husbands or wives as decision makers. These results are in line with those obtained by previous study (Rahmawan et al., 2020). The low level of knowledge and family response that led pre-hospital delays in this study was closely related to education level. Previous study found that low education level increased the risk of pre-hospital delay with an AOR of 2.29; 95%CI 1.12-5.1 (Kazadi Kabanda et al., 2024). Public health campaigns on stroke prevention can increase public awareness of stroke, including knowledge, recognition of stroke symptoms and immediate access to health services (Jiayi et al., 2021). Through the results of this study, the government also needs to develop emergency medical services to reduce pre-hospital delays for stroke patients, for example by improving accessibility to ambulances and emergency calls for stroke patients. However, this study did not examine this further and may provide direction for future research (Gude et al., 2023). The limitation of this study is the possibility that the families who filled out the questionnaire were not the ones who decided whether or not to refer the patient to hospital. The decision to refer the patient to hospital could have been the result of extended family discussion. In this case, selection bias may occur. 5. Conclusion Based on the results of this study, the proportion of pre-hospital delay in stroke patients at Waled General Hospital, Cirebon Regency, Indonesia was 78.7%. Most of the patients’ families had poor knowledge of stroke symptoms and inadequate responses. It also concluded that family knowledge and response were associated with pre-hospital delay in stroke patients in Cirebon Regency, Indonesia. Health education and promotion programs on early symptoms of stroke need to be encouraged to increase public knowledge about stroke symptoms. The public also needs to be educated about the importance of referring patients with stroke symptoms immediately to the emergency room so that patients get optimal treatment. In addition, further research is needed to analyze other factors besides the role of the family that influence pre-hospital delay in stroke patients. 165 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 Ivanka, et. al. Conflict of Interest There is no conflict of interest to declare. References Advani, R., Naess, H., & Kurz, M. W. (2017). The golden hour of acute ischemic stroke. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 25(1), 54. https://doi.org/10.1186/s13049-017-0398-5 Anderson, J. A. (2016). Acute ischemic stroke: The golden hour. Nursing Critical Care, 11(3), 28–36. https://doi.org/10.1097/01.CCN.0000482731.69703.82 Andriyani, F. D., Biddle, S. J. H., Arovah, N. I., & Cocker, K. D. (2020). Physical activity and sedentary behavior research in indonesian youth: A scoping review. International Journal of Environmental Research and Public Health, 17(20), 7665. https://doi.org/10.3390/ijerph17207665 Balgis, B., Sumardiyono, S., & Handayani, S. (2022). Hubungan antara prevalensi hipertensi, prevalensi dm dengan prevalensi stroke di indonesia (analisis data riskesdas dan profil kesehatan 2018). Jurnal Kesehatan Masyarakat (Undip), 10(3), 379–384. https://doi.org/10.14710/jkm.v10i3.33243 Barahama, D. V., & Tangkudung, G. (2019). Faktor-faktor yang berhubungan dengan keterlambatan kedatangan pasien stroke di rsup prof. Dr. R. D. Kandou manado. Jurnal e-Clinic, 7(1). Bukhari, S., Yaghi, S., & Bashir, Z. (2023). Stroke in Young Adults. Journal of Clinical Medicine, 12(15), 4999. https://doi.org/10.3390/jcm12154999 Direktorat Jenderal Pelayanan Kesehatan-Kementerian Kesehatan Republik Indonesia. (2023, October 29). World stroke day 2023, greater than stroke, kenali dan kendalikan stroke. https://yankes.kemkes.go.id/read/1443/world-stroke-day- 2023-greater-than-stroke-kenali-dan-kendalikan-stroke Effendi, D. E., Nugroho, A. P., Handayani, S., Novita, R., Purwoko, S., & Agustina, Z. A. (2022). Tobacco consumption among young population in rural indonesia: Prevalence and associated factors. Open Access Macedonian Journal of Medical Sciences, 10(E), 1178–1183. https://doi.org/10.3889/oamjms.2022.10011 Faruq, N. N., Pratiwi, W., & Satrianugraha, M. D. (2021). Hubungan kebiasaan sarapan pagi dan frekuensi konsumsi makanan cepat saji terhadap berat badan berlebih pada siswa SMAN 1 Kota Cirebon. Tunas Medika Jurnal Kedkteran & Kesehatan, 7(2). Gude, M. F., Valentin, J. B., Christensen, H. C., Mikkelsen, S., Søvsø, M. B., Andersen, G., Kirkegaard, H., & Johnsen, S. P. (2023). Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Internal and Emergency Medicine, 18(8), 2355– 2365. https://doi.org/10.1007/s11739-023-03349-x Harlianti, L., Pratiwi, W., Nauphar, D., & Suhaeni, E. (2018, August). Effect of Physical Activity and Fast Food Consumption Frequency on Overweight Level Among High School Adolescent. In Proceedings of the International Conference on Applied Science and Health (No. 3, pp. 274-278). http://publications.inschool.id/index.php/icash/article/view/783/663 Herliani, Y. K. (2023). Psychometric properties indonesian stroke recognition questionnaire (SRQ) untuk pasien dengan hipertensi, diabetes mellitus, dan penyakit jantung. Jurnal Keperawatan Sriwijaya, 10(1), 1–9. Ishak, S. J., Yueniwati, Y., & Kapti, Ns. R. E. (2020). Factors related about family delay bring stroke patient to emergency departments of Labuha hospital. International Journal of Science and Society, 2(4), 657–672. https://doi.org/10.54783/ijsoc.v2i4.260 Jamilatul Badriyah, N., Amalia, L., & Suwarman, S. (2018). Gambaran faktor risiko kejadian stroke di RSHS Bandung periode Januari 2015– Desember 2016. Jurnal Neuroanestesi Indonesia, 7(3), 134–139. https://doi.org/10.24244/jni.vol7i3.18 Jiayi, T., Sheena, R., MClinRes, Sok, Y. L., & Wei, L. C. (2021). Effectiveness of public education campaigns for stroke symptom recognation and response in non-elderly adults: A systematic review and meta-analysis. Journal of Stroke and Cerebrovascular Diseases, 31(2). https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106207 Julianto, J., Solikin, & Firdaus, M. (2023). Hubungan prehospital delay dengan tingkat keparahan pada pasien stroke di rumah sakit banjarmasin. Journal of Nursing Invention, 3(2), 108–116. https://doi.org/10.33859/jni.v3i2.274 Jusuf, M. I., Pomalango, Z. B., & Suleman, I. (2023). Factors associated with family delays in bringing stroke patients to aloei saboe hospital, Gorontalo City. Jambura Nursing Journal, 5(1), 26–38. https://doi.org/10.37311/jnj.v5i1.17429 Kazadi Kabanda, I., Kiangebeni Ngonzo, C., Emeka Bowamou, C.-K., Divengi Nzambi, J.-P., Kiatoko Ponte, N., Tuyinama Madoda, O., Nkodila Natuhoyila, A., M’Buyamba-Kabangu, J.-R., Longo-Mbenza, B., Banzulu Bomba, D., & Kianu Phanzu, B. (2024). Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa. Heliyon, 10(7), e28311. https://doi.org/10.1016/j.heliyon.2024.e28311 Kementerian Kesehatan Republik Indonesia. (2018). Laporan nasional RISKESDAS. https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/Laporan%20Riskesdas%202018%20Nasional.pdf Kementerian Kesehatan Republik Indonesia. (2023). Survei kesehatan indonesia (SKI). https://drive.google.com/file/d/1rjNDG_f8xG6-Y9wmhJUnXhJ-vUFevVJC/view Luo, J., Tang, X., Li, F., Wen, H., Wang, L., Ge, S., Tang, C., Xu, N., & Lu, L. (2022). Cigarette smoking and risk of different pathologic types of stroke: A systematic review and dose-response meta-analysis. Frontiers in Neurology, 12, 772373. https://doi.org/10.3389/fneur.2021.772373 Minalloh, R. H., Machin, A., Mardiana, W., Suansanae, T., Chulavatnatol, S., & Nathisuwan, S. (2022). Pre-hospital and in- hospital delay in acute ischemic stroke patients in indonesia: A multi-center study. Indonesian Journal of Pharmacy. https://doi.org/10.22146/ijp.2036 https://doi.org/10.1186/s13049-017-0398-5 https://doi.org/10.1097/01.CCN.0000482731.69703.82 https://doi.org/10.3390/ijerph17207665 https://doi.org/10.3390/ijerph17207665 https://doi.org/10.14710/jkm.v10i3.33243 https://doi.org/10.3390/jcm12154999 https://yankes.kemkes.go.id/read/1443/world-stroke-day-2023-greater-than-stroke-kenali-dan-kendalikan-stroke https://yankes.kemkes.go.id/read/1443/world-stroke-day-2023-greater-than-stroke-kenali-dan-kendalikan-stroke https://doi.org/10.3889/oamjms.2022.10011 https://doi.org/10.1007/s11739-023-03349-x http://publications.inschool.id/index.php/icash/article/view/783/663 https://doi.org/10.54783/ijsoc.v2i4.260 https://doi.org/10.24244/jni.vol7i3.18 https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106207 https://doi.org/10.33859/jni.v3i2.274 https://doi.org/10.37311/jnj.v5i1.17429 https://doi.org/10.1016/j.heliyon.2024.e28311 https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/Laporan%20Riskesdas%202018%20Nasional.pdf https://drive.google.com/file/d/1rjNDG_f8xG6-Y9wmhJUnXhJ-vUFevVJC/view https://doi.org/10.3389/fneur.2021.772373 https://doi.org/10.22146/ijp.2036 Ivanka, et. al. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 4 166 Pan, B., Jin, X., Jun, L., Qiu, S., Zheng, Q., & Pan, M. (2019). The relationship between smoking and stroke: A meta-analysis. Medicine, 98(12), e14872. https://doi.org/10.1097/MD.0000000000014872 Prasanna, T., & Forshing, L. (2023). Acute stroke. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535369/ Pratiwi, W., & Surgana, M. B. (2024). Profile of diabetic nephropathy patients at waled general hospital, cirebon district, indonesia: High prevalence in productive age group, female and housewives. Journal of Law and Sustainable Development, 12(6), e3746. https://doi.org/10.55908/sdgs.v12i6.3746 Putri, Z. R., & Santoso, B. R. (2020). Family perception of diseases related to the reference time in stroke patient: Literature review. Journal Of Nursing Practice, 4(1), 107–116. https://doi.org/10.30994/jnp.v4i1.113 Rachmawan, Y. P., Pratiwi, W., & Hanifah, A. N. (2024). Prediabetes, dyslipidemia, and hypertension in acute coronary syndrome patients: A cross-sectional study at a tertiary hospital in cirebon district, indonesia. South East European Journal of Cardiology, 5, 26–29. https://doi.org/10.3889/seejca.2024.6071 Rahmawan, F. A., Yueniwati, Y., & Suharsono, T. (2020). Perception of severity level and decision making of family correlation toward departing interval of ischemic stroke patient. 6(2). Randhawa, A. S., Pariona-Vargas, F., Starkman, S., Sanossian, N., Liebeskind, D. S., Avila, G., Stratton, S., Gornbein, J., Sharma, L., Restrepo-Jimenez, L., Valdes-Sueiras, M., Kim-Tenser, M., Villablanca, P., Conwit, R., Hamilton, S., & Saver, J. L. (2022). Beyond the golden hour: Treating acute stroke in the platinum 30 minutes. Stroke, 53(8), 2426–2434. https://doi.org/10.1161/STROKEAHA.121.036993 Saraswati, R. D. (2021). Transisi epidemiologi stroke sebagai penyebab kematian pada semua kelompok usia di indonesia. Sumarsono, E. (2019). Analisis faktor determinan yang mempengaruhi keterlambatan kedatangan pasien stroke di RSUD Bangil [STIKES Widyagama Husada]. https://repositori.widyagamahusada.ac.id/id/eprint/221/1/150714201398.pdf Tangkudung, G., Pertiwi, J. M., Tongku, A., S., & Ate, A. (2019). Characteristics of factors associated with admission time of stroke patients in hospital. Jurnal Sinaps, 2(3), 5–8. Wang, P.-Y., Tsao, L.-I., Chen, Y.-W., Lo, Y.-T., & Sun, H.-L. (2021). “Hesitating and puzzling”: The experiences and decision process of acute ischemic stroke patients with prehospital delay after the onset of symptoms. Healthcare, 9(8), 1061. https://doi.org/10.3390/healthcare9081061 Wanichanon, W., Ananchaisarp, T., Tantarattanapong, S., & Chamroonkiadtikun, P. (2024). Prevalence and factors influencing pre-hospital delays in patients with acute stroke. Journal of Public Health and Emergency, 8, 23–23. https://doi.org/10.21037/jphe-24-30 Wechsler, L. R., Adeoye, O., Alemseged, F., Bahr-Hosseini, M., Deljkich, E., Favilla, C., Fisher, M., Grotta, J., Hill, M. D., Kamel, H., Khatri, P., Lyden, P., Mirza, M., Nguyen, T. N., Samaniego, E., Schwamm, L., Selim, M., Silva, G., Yavagal, D. R., … Yaghi, S. (2023). Most promising approaches to improve stroke outcomes: The stroke treatment academic industry roundtable xii workshop. Stroke, 54(12), 3202–3213. https://doi.org/10.1161/STROKEAHA.123.044279 World Health Organization. (2024). Stroke, cardiovascular accident. https://www.emro.who.int/health-topics/stroke- cerebrovascular-accident/index.html Cite this article as: Ivanka, M. N. P., Pratiwi, W., & Kusnandang, A. (2024). The Association between Family Knowledge and Response with Pre-hospital Delay among Stroke Patients: A Study from Rural Area of Cirebon, Indonesia. GHMJ (Global Health Management Journal), 7(4), 157–166. https://doi.org/10.35898/ghmj-741111 https://doi.org/10.1097/MD.0000000000014872 https://www.ncbi.nlm.nih.gov/books/NBK535369/ https://doi.org/10.55908/sdgs.v12i6.3746 https://doi.org/10.30994/jnp.v4i1.113 https://doi.org/10.3889/seejca.2024.6071 https://doi.org/10.1161/STROKEAHA.121.036993 https://doi.org/10.1161/STROKEAHA.121.036993 https://repositori.widyagamahusada.ac.id/id/eprint/221/1/150714201398.pdf https://doi.org/10.3390/healthcare9081061 https://doi.org/10.21037/jphe-24-30 https://doi.org/10.1161/STROKEAHA.123.044279 https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html https://doi.org/10.35898/ghmj-741111