健康教育对上海社区居民卒中知晓率影响的调查研究
摘要
背景：卒中预防和紧急救治是减少卒中发生率、死亡率和致残率的有效途径。然而目前卒中预防和急救措施没有得到有效实施，障碍之一在于社区居民不了解卒中的危险因素，卒中发病时患者和旁观者不能及时识别基本的卒中预警症状,以致失去最佳抢救治疗时间。
目的：为了解上海市虹口区社区居民对卒中相关知识的知晓率，探索健康教育对社区居民卒中相关知识知晓率的影响。
方法：参考美国辛辛那提卒中知识调查的内容设计调查问卷,讲座前使用问卷调查上海市虹口区志愿参加本研究的390名社区居民对卒中预警症状和相关危险因素的知晓情况。针对这些人群开展卒中相关知识讲座，发放宣传手册，3-5月后采用相同方式再次调查其对卒中相关知识的知晓情况。
结果：
1第一次调查发现：被调查者对10项卒中危险因素的知晓率分别为2%-80%，只有2%-5%的被调查者知道心脏病、酗酒、不良饮食习惯、缺乏锻炼、心情抑郁/焦虑可导致卒中发生；对5项卒中预警症状知晓率分别为51%-63%；
2开展健康教育后，被调查者中知道糖尿病、血脂异常、吸烟、不良饮食习惯为卒中危险因素的比例与第一次调查比较差异有统计学意义（P值分别为<0.0001，0.0013，0.0431和0.023）；被调查者中知道突发肢体面部麻木无力症状和突发剧烈头痛症状是卒中预警症状的比例与健康教育前比较差异有统计学意义（P值分别为0.0334和0.0076）；被调查者中了解≥2、≥3和≥4项卒中危险因素的比例与第一次调查相比差异有统计学意义（P值均＜0.0001），了解≥3和≥4项预警症状的被调查者比例与第一次调查相比差异有统计学意义（P值分别为0.0025和0.0227）。
结论：
1上海市社区居民对卒中相关知识的知晓率不佳；
2积极的社区卒中相关知识健康教育有助于改善社区居民对卒中危险因素、预警症状的认识。
3卒中相关知识健康教育对卒中发生率、死亡率和致残率的影响是缓慢而长远的，需要一定的时间。可以推测，通过增加社区居民对卒中相关知识的了解，将增加卒中高危人群、卒中患者对一级预防和二级预防用药的理解，提高其对预防措施的依从性，减低卒中发生率和再发率；使卒中患者和旁观者认识卒中预警症状，及时将卒中患者送入急诊治疗，减少入院延迟，减少卒中的致残率和死亡率。
Objective To survey the public knowledge of stroke in Shanghai community and toexplore the methods and role of health education in community on stroke-relatedknowledge.
Methods The stroke knowledge questionnaire was conducted in this study toinvestigate the awareness of warning signs and risk factors of stroke in390residents whovolunteer to join this study in Hongkou District, Shanghai. Community health educationhas been carried out in the form of lecture and brochure after the first survey.3-5monthslater, the re-survey were conducted on the same residents.
Results (1) The first survey showed: The awareness percentage of the ten strokerisk factors ranges from2%to80%respectively, the awareness percentage of the heartdisease, excessive alcohol use, poor eating, lack of exercise, psychosocial stress anddepression as stroke risk factors ranges from2%to5%respectively, the awarenesspercentage of the five stroke warning signs are ranges from51%to63%respectively.(2)After health education, the survey revealed that the proportion of residents who were ableto recognize≥2,≥3,≥4risk factors(both P＜0.0001)and≥3,≥4（P=0.0025,P=0.0227）early symptoms of stroke have significantly improved compared with the first survey，theproportion of residents who were able to recognize diabetes mellitus，dyslipidemia，smoking, poor eating as stroke risk factors have significantly improved compared with thefirst survey（P<0.0001，P=0.0013，P=0.0431, P=0.023）,the proportion of residents whowere able to recognize weakness of body and sudden headache as stroke warningsymptoms have significantly improved compared with the first survey（P=0.0334,P=0.0076）；
Conclusions (1) At present, residents in Shanghai lack public knowledge of stroke.(2) Community health education improves the cognitive level of stroke knowledge.(3) The influence of health education on stroke incidence, mortality and morbidity is important butneed a good deal of time.
目的：为了解上海市虹口区社区居民对卒中相关知识的知晓率，探索健康教育对社区居民卒中相关知识知晓率的影响。
方法：参考美国辛辛那提卒中知识调查的内容设计调查问卷,讲座前使用问卷调查上海市虹口区志愿参加本研究的390名社区居民对卒中预警症状和相关危险因素的知晓情况。针对这些人群开展卒中相关知识讲座，发放宣传手册，3-5月后采用相同方式再次调查其对卒中相关知识的知晓情况。
结果：
1第一次调查发现：被调查者对10项卒中危险因素的知晓率分别为2%-80%，只有2%-5%的被调查者知道心脏病、酗酒、不良饮食习惯、缺乏锻炼、心情抑郁/焦虑可导致卒中发生；对5项卒中预警症状知晓率分别为51%-63%；
2开展健康教育后，被调查者中知道糖尿病、血脂异常、吸烟、不良饮食习惯为卒中危险因素的比例与第一次调查比较差异有统计学意义（P值分别为<0.0001，0.0013，0.0431和0.023）；被调查者中知道突发肢体面部麻木无力症状和突发剧烈头痛症状是卒中预警症状的比例与健康教育前比较差异有统计学意义（P值分别为0.0334和0.0076）；被调查者中了解≥2、≥3和≥4项卒中危险因素的比例与第一次调查相比差异有统计学意义（P值均＜0.0001），了解≥3和≥4项预警症状的被调查者比例与第一次调查相比差异有统计学意义（P值分别为0.0025和0.0227）。
结论：
1上海市社区居民对卒中相关知识的知晓率不佳；
2积极的社区卒中相关知识健康教育有助于改善社区居民对卒中危险因素、预警症状的认识。
3卒中相关知识健康教育对卒中发生率、死亡率和致残率的影响是缓慢而长远的，需要一定的时间。可以推测，通过增加社区居民对卒中相关知识的了解，将增加卒中高危人群、卒中患者对一级预防和二级预防用药的理解，提高其对预防措施的依从性，减低卒中发生率和再发率；使卒中患者和旁观者认识卒中预警症状，及时将卒中患者送入急诊治疗，减少入院延迟，减少卒中的致残率和死亡率。
Objective To survey the public knowledge of stroke in Shanghai community and toexplore the methods and role of health education in community on stroke-relatedknowledge.
Methods The stroke knowledge questionnaire was conducted in this study toinvestigate the awareness of warning signs and risk factors of stroke in390residents whovolunteer to join this study in Hongkou District, Shanghai. Community health educationhas been carried out in the form of lecture and brochure after the first survey.3-5monthslater, the re-survey were conducted on the same residents.
Results (1) The first survey showed: The awareness percentage of the ten strokerisk factors ranges from2%to80%respectively, the awareness percentage of the heartdisease, excessive alcohol use, poor eating, lack of exercise, psychosocial stress anddepression as stroke risk factors ranges from2%to5%respectively, the awarenesspercentage of the five stroke warning signs are ranges from51%to63%respectively.(2)After health education, the survey revealed that the proportion of residents who were ableto recognize≥2,≥3,≥4risk factors(both P＜0.0001)and≥3,≥4（P=0.0025,P=0.0227）early symptoms of stroke have significantly improved compared with the first survey，theproportion of residents who were able to recognize diabetes mellitus，dyslipidemia，smoking, poor eating as stroke risk factors have significantly improved compared with thefirst survey（P<0.0001，P=0.0013，P=0.0431, P=0.023）,the proportion of residents whowere able to recognize weakness of body and sudden headache as stroke warningsymptoms have significantly improved compared with the first survey（P=0.0334,P=0.0076）；
Conclusions (1) At present, residents in Shanghai lack public knowledge of stroke.(2) Community health education improves the cognitive level of stroke knowledge.(3) The influence of health education on stroke incidence, mortality and morbidity is important butneed a good deal of time.
引文
1陈竺，全国第三次死因回顾抽样调查报告[M].北京：中国协和医科大学出版社，2008.
2Barsan WG, et al.Urgent therapy for acute stroke: effect of a stroke trail on untreatedpatients[J]. Stroke,1994,25:2132-2137
3Goldstein LB, Bushnell CD, Adams RJ,et al. Guidelines for the Primary Prevention ofStroke: A Guideline for Healthcare[J]. Stroke,2011,42(2):517-84
4Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults:epidemiology and considerations regarding measurement[J]. South Med J,2001,94:613-618.
5Alexander T. Schneider, et al. Trends in Community Knowledge of the Warning Signsand Risk Factors for Stroke[J].JAMA.2003;289(3):343-346
6孙海欣、王文志北京市丰台区社区居民卒中相关知识水平调查[J].中国卒中杂志，2010；8:630-634.
7Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors duringcomprehensive five-year community programme to control cardiovascular diseases (NorthKarelia Project)[J]. Br Med J,1979.2:1173-8.
8Fortmann SP, Flora JA, Winkleby MA et al. Community intervention trials: reflections onthe Stanford Five-City Project Experience[J]. Am J Epidemiol,142(6):576-86.
9Joubert J, Reid C, Barton D. Integrated care improves risk-factor modification afterstroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model[J].J Neurol Neurosurg Psychiatry,2009Mar,80(3):279-84.
10程学铭，杜晓立，吴升平，等．我国七城市卒中危险因素干预试验--发病率的变化[J].中国慢性病预防与控制，1992,2：43—46．
1Morris DL, Rosamond W, Madden K, et al. Prehospital and emergency departmentdelays after acute stroke[J]. Stroke,2000,31:2585-2590.
2Schroeder EB, Rosamond WD, Morris DL, et al. Determinants of use of emergencymedical services in a population with stroke symptoms[J]. Stroke,2000,31:2591-2596.
3Evenson KR, Rosamond WD, Morris DL. Prehospital and in-hospital delays in acutestroke care[J]. Neuroepidemiology,2001;20:65-76.
4Alexander T, Arthur M, Jane C, et al. Trends in Community Knowledge of the WarningSigns and Risk Factors for Stroke Trends in Community[J]. JAMA,2003,289:343-346.
5American Stroke Association Web site. Know the warning signs of stroke[EB/OL].(July,10,2003)[August,11,2010].http://www.strokeassociation.org/presenter.jhtml?identifier=1020.
6National Stroke Association Web site. Recognizing stroke symptoms[EB/OL].(September,10,2003)[August,11,2010].http://www.stroke.org/pages/recog_five.cfm?category=all.
7National Institute of Neurological Disorders and Stroke Information Page. Recognizingstrokesymptoms[EB/OL].(June,11,2002)[August,11,2010].http://www.ninds.nih.gov/health_and_medical/disorders/stroke.htm#What_is_Stroke.
8O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebralhaemorrhagic stroke in22countries (the INTERSTROKE study): a case-control study[J].Lancet,2010,376:112-123.
9Goldstein LB, Bushnell CD, Adams RJ,et al. Guidelines for the Primary Prevention ofStroke: A Guideline for Healthcare[J]. Stroke,2011,42:517-584.
10Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults:epidemiology and considerations regarding measurement[J]. South Med J,2001,94:613-618.
11Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signsand knowledge of potential risk factors[J]. JAMA,1998,279:1288-1292.
12Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors duringcomprehensive five-year community programme to control cardiovascular diseases (NorthKarelia Project)[J]. Br Med J,1979,2:1173-1178.
13Fortmann SP, Flora JA, Winkleby MA et al. Community intervention trials: reflectionson the Stanford Five-City Project Experience[J]. Am J Epidemiol,1995,142:576-586.
14Joubert J, Reid C, Barton D. Integrated care improves risk-factor modification afterstroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model[J].J Neurol Neurosurg Psychiatry,2009,80:279-84.
15程学铭，杜晓立，吴升平，等．我国七城市卒中危险因素干预试验—发病率的变化[J].中国慢性病预防与控制，1992,2：43—46.
1吴江、贾建平、崔丽英.神经病学第2版（八年制临床医学专业用）[M]//刘鸣.脑血管疾病.北京：人民卫生出版社，2010：153
2中华医学会神经病学分会脑血管病学组缺血性卒中二级预防指南撰写组.中国缺血性卒中和短暂性脑缺血发作二级预防指南2010[J].中华神经科杂志，2010，2:154-160.
3Petty G, Brown RJ, Sicks J. Survival and recurrence after first cerebralinfarction: a population-based study in Rochester, Minnesota,1975through1989[J]. Neurology,1998，50:208-216.
4Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapydiscontinuationon mortality after myocardial infarction[J]. Arch InternMed,2006,166:1842-1847.
5Liu M,Wu B,Wang WZ,Lee LM, et al. Stroke in China:epidemiology,prevention,and management strategies[J]. Lancet Neurol,2007,6:456-64.
6Xu GL, Liu XF, Wu WT, et al. Recurrence after ischemic stroke in Chinesepatients: Impact of uncontrolled modifiable risk factors[J]. CerebrovascDis,2007,23:117-120.
7Coull A, Lovett J, Rothwell P. Population based study of early risk ofstroke after transient ischemic attack or minor stroke: implications forpublic education and organisation of services[J]. BMJ,2004,328:326-328.
8Samsa G, Bian J, Lipscomb J, et al. Epidemiology of recurrent cerebralinfarction. A Medicare claims-based comparison of first and recurrent strokeson2-year survival and cost[J]. Stroke,1999,30:338-349.
9Gehi AK, Ali S, Na B, Whooley MA. Self-reported medication adherence andcardiovascular events in patients with stable coronary heart disease: theheart and soul study[J]. Arch Intern Med,2007,167:1798-1803.
10World Health Organization: Adherence to long-term therapies. Evidence foraction2003[EB/OL].(July,10,2003)[March,21,2010].http://www.emro.who.int/ncd/Publications/adherence_report.pdf.
11Wei JW, Wang JG, Huang Y, et al. Secondary prevention of ischemic strokein urban China[J]. Stroke,2010May,41(5):967-74.
12Hillen T, Dundas R, Lawrence E, et al. Antithrombotic and antihypertensivemanagement3months after ischemic stroke.A prospective study in an inner citypopulation[J]. Stroke,2000,31:469-475.
13Brown MT, Bussell JK. Medication adherence: WHO cares?[J]. Mayo ClinProc,2011,86:304-314.
14Bushnell C, Zimmer L, Schwamm L, et al; AVAIL registry. The AdherenceeValuation After Ischemic Stroke Longitudinal (AVAIL) registry: design,rationale, and baseline patient characteristics[J]. Am HeartJ,2009,157:428-435.
15Joint Committee on Terminology (2001). Report of the2000Joint Committeeon Health Education and Promotion Terminology[J]. American Journal of HealthEducation,2001,32,89-103.
16Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledgeof the warning signs and risk factors for stroke[J].JAMA,2003,289:343-6.
17Eldred C, Sykes C. Psychosocial interventions for carers of survivors ofstroke: A systematic review of interventions based on psychologicalprinciples and theoretical frameworks[J].Br J HealthPsychol,2008,13:563-581.
18钮文异.健康教育和健康促进[EB/OL].（2011-7-10）[2012-5-15].http://kejian.5iyixue.com/Category_26/Index_1.aspx?num=2.
19Joubert J, Reid C, Barton D. Integrated care improves risk-factormodification after stroke: initial results of the Integrated Care for theReduction of Secondary Stroke model[J]. J Neurol Neurosurg Psychiatry,
2009,80:279-84.
20Rahiman A, Saver JL, Porter V, et al. In-hospital initiation of secondaryprevention is associated with improved vascular outcomes at3months[J]. JStroke Cerebrovasc Dis,2008,17,5-8.
21Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factorsduring comprehensive five-year community programme to control cardiovasculardiseases (North Karelia Project)[J]. Br Med J,1979,2:1173-1178.
22Fortmann SP, Flora JA, Winkleby MA, Schooler C, et al.Communityintervention trials: reflections on the Stanford Five-City ProjectExperience[J]. Am J Epidemiol,1995,142:576-586.
23Ellis G, Rodger J, McAlpine C, et al. The impact of stroke nurse specialistinput on risk factor modification: a randomized ontrolled trial[J]. Age Ageing,2005,34:389-392.
24Sara Joice, Marie Johnston, Debbie Bonetti, et al. Stroke survivors’evaluations of a stroke workbook-based intervention designed to increaseperceived control over recovery[J]. Health Education Journal,2012,71,17-29.
25Maasland L, Brouwer-Goossensen D, den Hertog HM. Health education inpatients with a recent stroke or transient ischaemic attack: a comprehensivereview[J]. Int J Stroke,2011,6:67-74.
2Barsan WG, et al.Urgent therapy for acute stroke: effect of a stroke trail on untreatedpatients[J]. Stroke,1994,25:2132-2137
3Goldstein LB, Bushnell CD, Adams RJ,et al. Guidelines for the Primary Prevention ofStroke: A Guideline for Healthcare[J]. Stroke,2011,42(2):517-84
4Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults:epidemiology and considerations regarding measurement[J]. South Med J,2001,94:613-618.
5Alexander T. Schneider, et al. Trends in Community Knowledge of the Warning Signsand Risk Factors for Stroke[J].JAMA.2003;289(3):343-346
6孙海欣、王文志北京市丰台区社区居民卒中相关知识水平调查[J].中国卒中杂志，2010；8:630-634.
7Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors duringcomprehensive five-year community programme to control cardiovascular diseases (NorthKarelia Project)[J]. Br Med J,1979.2:1173-8.
8Fortmann SP, Flora JA, Winkleby MA et al. Community intervention trials: reflections onthe Stanford Five-City Project Experience[J]. Am J Epidemiol,142(6):576-86.
9Joubert J, Reid C, Barton D. Integrated care improves risk-factor modification afterstroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model[J].J Neurol Neurosurg Psychiatry,2009Mar,80(3):279-84.
10程学铭，杜晓立，吴升平，等．我国七城市卒中危险因素干预试验--发病率的变化[J].中国慢性病预防与控制，1992,2：43—46．
1Morris DL, Rosamond W, Madden K, et al. Prehospital and emergency departmentdelays after acute stroke[J]. Stroke,2000,31:2585-2590.
2Schroeder EB, Rosamond WD, Morris DL, et al. Determinants of use of emergencymedical services in a population with stroke symptoms[J]. Stroke,2000,31:2591-2596.
3Evenson KR, Rosamond WD, Morris DL. Prehospital and in-hospital delays in acutestroke care[J]. Neuroepidemiology,2001;20:65-76.
4Alexander T, Arthur M, Jane C, et al. Trends in Community Knowledge of the WarningSigns and Risk Factors for Stroke Trends in Community[J]. JAMA,2003,289:343-346.
5American Stroke Association Web site. Know the warning signs of stroke[EB/OL].(July,10,2003)[August,11,2010].http://www.strokeassociation.org/presenter.jhtml?identifier=1020.
6National Stroke Association Web site. Recognizing stroke symptoms[EB/OL].(September,10,2003)[August,11,2010].http://www.stroke.org/pages/recog_five.cfm?category=all.
7National Institute of Neurological Disorders and Stroke Information Page. Recognizingstrokesymptoms[EB/OL].(June,11,2002)[August,11,2010].http://www.ninds.nih.gov/health_and_medical/disorders/stroke.htm#What_is_Stroke.
8O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebralhaemorrhagic stroke in22countries (the INTERSTROKE study): a case-control study[J].Lancet,2010,376:112-123.
9Goldstein LB, Bushnell CD, Adams RJ,et al. Guidelines for the Primary Prevention ofStroke: A Guideline for Healthcare[J]. Stroke,2011,42:517-584.
10Rowe AK, Frankel MR, Sanders KA. Stroke awareness among Georgia adults:epidemiology and considerations regarding measurement[J]. South Med J,2001,94:613-618.
11Pancioli AM, Broderick J, Kothari R, et al. Public perception of stroke warning signsand knowledge of potential risk factors[J]. JAMA,1998,279:1288-1292.
12Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors duringcomprehensive five-year community programme to control cardiovascular diseases (NorthKarelia Project)[J]. Br Med J,1979,2:1173-1178.
13Fortmann SP, Flora JA, Winkleby MA et al. Community intervention trials: reflectionson the Stanford Five-City Project Experience[J]. Am J Epidemiol,1995,142:576-586.
14Joubert J, Reid C, Barton D. Integrated care improves risk-factor modification afterstroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model[J].J Neurol Neurosurg Psychiatry,2009,80:279-84.
15程学铭，杜晓立，吴升平，等．我国七城市卒中危险因素干预试验—发病率的变化[J].中国慢性病预防与控制，1992,2：43—46.
1吴江、贾建平、崔丽英.神经病学第2版（八年制临床医学专业用）[M]//刘鸣.脑血管疾病.北京：人民卫生出版社，2010：153
2中华医学会神经病学分会脑血管病学组缺血性卒中二级预防指南撰写组.中国缺血性卒中和短暂性脑缺血发作二级预防指南2010[J].中华神经科杂志，2010，2:154-160.
3Petty G, Brown RJ, Sicks J. Survival and recurrence after first cerebralinfarction: a population-based study in Rochester, Minnesota,1975through1989[J]. Neurology,1998，50:208-216.
4Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapydiscontinuationon mortality after myocardial infarction[J]. Arch InternMed,2006,166:1842-1847.
5Liu M,Wu B,Wang WZ,Lee LM, et al. Stroke in China:epidemiology,prevention,and management strategies[J]. Lancet Neurol,2007,6:456-64.
6Xu GL, Liu XF, Wu WT, et al. Recurrence after ischemic stroke in Chinesepatients: Impact of uncontrolled modifiable risk factors[J]. CerebrovascDis,2007,23:117-120.
7Coull A, Lovett J, Rothwell P. Population based study of early risk ofstroke after transient ischemic attack or minor stroke: implications forpublic education and organisation of services[J]. BMJ,2004,328:326-328.
8Samsa G, Bian J, Lipscomb J, et al. Epidemiology of recurrent cerebralinfarction. A Medicare claims-based comparison of first and recurrent strokeson2-year survival and cost[J]. Stroke,1999,30:338-349.
9Gehi AK, Ali S, Na B, Whooley MA. Self-reported medication adherence andcardiovascular events in patients with stable coronary heart disease: theheart and soul study[J]. Arch Intern Med,2007,167:1798-1803.
10World Health Organization: Adherence to long-term therapies. Evidence foraction2003[EB/OL].(July,10,2003)[March,21,2010].http://www.emro.who.int/ncd/Publications/adherence_report.pdf.
11Wei JW, Wang JG, Huang Y, et al. Secondary prevention of ischemic strokein urban China[J]. Stroke,2010May,41(5):967-74.
12Hillen T, Dundas R, Lawrence E, et al. Antithrombotic and antihypertensivemanagement3months after ischemic stroke.A prospective study in an inner citypopulation[J]. Stroke,2000,31:469-475.
13Brown MT, Bussell JK. Medication adherence: WHO cares?[J]. Mayo ClinProc,2011,86:304-314.
14Bushnell C, Zimmer L, Schwamm L, et al; AVAIL registry. The AdherenceeValuation After Ischemic Stroke Longitudinal (AVAIL) registry: design,rationale, and baseline patient characteristics[J]. Am HeartJ,2009,157:428-435.
15Joint Committee on Terminology (2001). Report of the2000Joint Committeeon Health Education and Promotion Terminology[J]. American Journal of HealthEducation,2001,32,89-103.
16Schneider AT, Pancioli AM, Khoury JC, et al. Trends in community knowledgeof the warning signs and risk factors for stroke[J].JAMA,2003,289:343-6.
17Eldred C, Sykes C. Psychosocial interventions for carers of survivors ofstroke: A systematic review of interventions based on psychologicalprinciples and theoretical frameworks[J].Br J HealthPsychol,2008,13:563-581.
18钮文异.健康教育和健康促进[EB/OL].（2011-7-10）[2012-5-15].http://kejian.5iyixue.com/Category_26/Index_1.aspx?num=2.
19Joubert J, Reid C, Barton D. Integrated care improves risk-factormodification after stroke: initial results of the Integrated Care for theReduction of Secondary Stroke model[J]. J Neurol Neurosurg Psychiatry,
2009,80:279-84.
20Rahiman A, Saver JL, Porter V, et al. In-hospital initiation of secondaryprevention is associated with improved vascular outcomes at3months[J]. JStroke Cerebrovasc Dis,2008,17,5-8.
21Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factorsduring comprehensive five-year community programme to control cardiovasculardiseases (North Karelia Project)[J]. Br Med J,1979,2:1173-1178.
22Fortmann SP, Flora JA, Winkleby MA, Schooler C, et al.Communityintervention trials: reflections on the Stanford Five-City ProjectExperience[J]. Am J Epidemiol,1995,142:576-586.
23Ellis G, Rodger J, McAlpine C, et al. The impact of stroke nurse specialistinput on risk factor modification: a randomized ontrolled trial[J]. Age Ageing,2005,34:389-392.
24Sara Joice, Marie Johnston, Debbie Bonetti, et al. Stroke survivors’evaluations of a stroke workbook-based intervention designed to increaseperceived control over recovery[J]. Health Education Journal,2012,71,17-29.
25Maasland L, Brouwer-Goossensen D, den Hertog HM. Health education inpatients with a recent stroke or transient ischaemic attack: a comprehensivereview[J]. Int J Stroke,2011,6:67-74.