After coronary heart disease and cancer of all types, stroke is the third commonest cause of death worldwide.1 Stroke remains one of the most devastating of all neurologic conditions, causing an estimated 5.7 million deaths in 2005.2 Stroke is a major cause of adult disability, both in terms of its initially debilitating symptoms and, in many cases, because of the severe long-term impairment in activities such as walking and speech.3, 4 Knowledge about the risk factors of stroke is mostly based on North American or European studies, with few data from developing countries.
The highest prevalence rate of stroke (included only door-to-door studies) of 3370 of 100,000 was recorded in European countries mainly in Croatia5 and the lowest recorded in an Arabic country (Tunisia) 42 of 100,000.6 According to the data collected by Zhang et al,7 the incidence of stroke in 5 European countries ranging from 114 cases per 100,000 persons per year in France for first-ever stroke to 350 cases per 100,000 persons per year in Germany for all strokes.
There are few community-based studies from Arabic countries; 3 of them have been performed in Egypt. Such studies are more informative than hospital-based data in countries with a large rural population such as Egypt where people may not be able to come to hospital for treatment. The first study was in Assiut Governorate (Nile valley)8; where the age-adjusted prevalence rate was 699 of 100,000 whereas in the second study9 in the Al-Kharga district, New Valley, the crude prevalence rate was 566 per 1000 population, the third one in Al Quseir district with a crude prevalence rate of 655 of 1000.10
Because these rates are higher than in neighboring Arab countries, we performed a second survey in a Nile governorate to provide additional confirmatory evidence for the high prevalence rate in Egypt. We hope that estimation of stroke frequency in Egyptian populations in different governorates will provide evidence for formulating a strategy to prevent and control stroke in Egypt.
Subjects and Methods
A cross sectional community-based study was implemented in the south Upper Egypt, Qena governorates. The Nile valley is at its narrowest in Egypt here and the arable land, a green strip only 1 or 2 km on either side of the river, is bordered by barren desert on both sides. The Qena governorate's total area covers 10,798 km2, representing 1.1% of the Republic's area. Qena is an agricultural and industrial governorate. According to the preliminary results of the 2006 census, the population is about 3 million; 21.4% of them live in urban areas and 78.6% in rural areas. Qena governorate consists of 2 cities and 11 districts. Qena and Nagh Hammadi are considered as urban areas. Qena city is the capital of Qena governorate. It is situated on the east bank of the Nile. It is most famous for its proximity to the ruins of Dendera. The population is 230,392. Nagh Hammadi is located on the west bank of the Nile in Qena governorate. It is an industrial city as sugar, aluminum, and cement are produced there. It has a population of about 30,000. The 11 districts are considered as rural areas, which are distributed around the Nile, where most of the people were farmers.
The sample size was based on an expected prevalence of .4% among adults, with 2 percentage points' error and a 95% confidence interval, allowing for a 10% refusal to participate. The study was conducted over a 2-year period from September 1, 2011 to August 31, 2013. August 31, 2013 was considered the prevalence day. So, any positive subject fulfilling the diagnostic criteria of stroke before the prevalence day at any time of their lives was considered as a prevalent case, and any subject who gave a history suggestive of stroke developing during the period of the survey was considered an incident case of stroke.
Sampling Methodology
First Stage: Selection of the Study Sites
A simple random sample of 10 study areas was selected randomly from Qena Governorate.
First, according to the geographic location we selected 3 districts randomly of 11 districts, then we selected 2 villages (areas) from each district, that is, Nagada (in the west bank of Nile), Qift (in the east of Nile), Dishenna (in the north bank of the Nile) with a total of 6 villages considered as rural populations. We selected urban areas from each city (Qena city and Nagh Hammadi city), with a total of 4 urban areas using simple random technique and according to local security safety.
Selection of the households: a systematic random sample of households in the 10 areas was then taken by selecting every third household in each of the 10 study sites. If families refused the examination, we replaced them with the family next door.
Second Stage
Initial diagnosis was based on a general two-part screening questionnaire with part I recording sociodemographic details and part II involving a stroke screening questionnaire translated into Arabic as previously discussed in details by Khedr et al.8 We used this questionnaire for individuals who were interviewed directly unless aphasic or mentally impaired; in such cases, relatives or caregivers answered the questions.
The survey team comprised 10 social workers (education level of at least 10 years) who used the screening questionnaire, headed by 2 neurologists and a psychiatrist (master's degree with at least 5 years of experience) who confirmed the diagnosis by reusing the screening questionnaire and referring the positive cases to hospital. The team received 3 weeks of training on how to carry out the protocol before starting the study.
Third Stage
This involved neurologic examination of all the positive cases after referral to the Neuropsychiatric Department at Qena University Hospital. In individuals with suspected stroke, the history was obtained, CT of the brain and laboratory investigations were performed as previously done in the survey of Assiut governorate. Each case was scored using the following: (1) Mini Mental State Examination (MMSE)11 and (2) National Institute of Health Stroke Scale.12 The date of the stroke and the presence of recurrent events were recorded.
Statistical Analysis
Different scales were reviewed, and open-ended questions were coded and entered using a simple spreadsheet. Analysis followed after data verification and correction. All data were analyzed with the aid of the SPSS version 16 (www.spss.com). The results were expressed as mean ± standard deviation.
Results
A total of 8027 inhabitants (1076 families) were included in the study. The family which refused participation (40 families) was replaced by the next-door family in the survey. Of the study population, 5628 (70%) were more than 20 years of age. Details of other age and gender specific groups with the prevalence rates are given in