title: Can trained field community workers identify stroke using a stroke symptom questionnaire as well as neurologists? Adaptation and validation of a community worker administered stroke symptom questionnaire in a peri-urban Pakistani community.
abstract: BACKGROUND
  Stroke is a leading cause of morbidity and mortality worldwide. There is a paucity of data from South Asia where stroke is highly prevalent. Validated tools administrable by community health workers (CHWs) are required to identify stroke in the community in a resource-strapped region such as this.
  
  
  METHODS
  The study was conducted in a transitional slum in Karachi, Pakistan. Questionnaire to Verify Stroke-Free Status (QVSFS) was adapted and translated into Urdu. Two CHWs, trained by a neurologist, selected 322 community-dwelling subjects using purposive sampling. Each CHW collected data independently, which was validated by a vascular neurologist who directly examined each participant. To assess the effect of audit and feedback, data from the final 10% of the subjects were collected after a second training session for the CHWs. Sensitivity, specificity, and Cohen kappa were determined for the CHW-administered questionnaire against neurovascular assessment.
  
  
  RESULTS
  Mean age of participants was 56.5 years with 71% of participants being women. The sensitivity and specificity of the questionnaire of detecting stroke was 77.1% (confidence interval [CI], 64.1-86.9) and 85.8% (CI, 83.5-87.5), respectively. The chance-corrected agreement using the Cohen kappa statistic was .51 (CI, .38-.60). Kappa ranged from .37 to .58 for each of the 7 stroke symptoms. Hemianesthesia (72.9%) and hemiplegia (64.6%) were the most sensitive symptoms. The performance and agreement improved from moderate to substantial after audit and feedback.
  
  
  CONCLUSIONS
  We found a reasonable sensitivity and specificity and moderate agreement between CHW-administered QVSFS and assessment by a vascular neurologist.
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University.
authors.forename: Maria
authors.initials: M
authors.lastname: Khan
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University. Electronic address: ayeesha.kamal@aku.edu.
authors.forename: Ayeesha Kamran
authors.initials: AK
authors.lastname: Kamal
authors.affiliation: Department of Community Health Sciences, Aga Khan University.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Islam
authors.affiliation: Department of Community Health Sciences, Aga Khan University.
authors.forename: Iqbal
authors.initials: I
authors.lastname: Azam
authors.affiliation: Aman Health, Aman Foundation.
authors.forename: Azam
authors.initials: A
authors.lastname: Virk
authors.affiliation: Aman Health, Aman Foundation.
authors.forename: Alia
authors.initials: A
authors.lastname: Nasir
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University.
authors.forename: Hasan
authors.initials: H
authors.lastname: Rehman
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University.
authors.forename: Anita
authors.initials: A
authors.lastname: Arif
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Jan
authors.affiliation: Stroke Service, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program, Fogarty International Center, National Institutes of Health, Aga Khan University.
authors.forename: Anjum
authors.initials: A
authors.lastname: Akhtar
authors.affiliation: Department of Medicine, Epidemiology and Biostatistics, Aga Khan University.
authors.forename: Minaz
authors.initials: M
authors.lastname: Mawani
authors.affiliation: Department of Emergency Medicine, Aga Khan University and AMAN Health, AMAN Foundation Karachi, Pakistan.
authors.forename: Junaid Abdul
authors.initials: JA
authors.lastname: Razzak
authors.affiliation: Department of Community Health Sciences, Aga Khan University.
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D002983:Clinical Competence; D003150:Community Health Workers; D004522:Educational Status; D005240:Feasibility Studies; D005260:Female; D006429:Hemiplegia / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D010154:Pakistan / Q000453:epidemiology; D010820:Physicians; D015995:Prevalence; D015203:Reproducibility of Results; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology; D011795:Surveys and Questionnaires
keywords: Stroke; detection; developing countries; epidemiology; prevalence