Stroke is a major health problem in Malaysia. Many stroke patients do not know how to recognize stroke symptoms quickly or when to seek emergency help. The BEFAST mnemonic (Balance, Eyes, Face, Arm, Speech, Time) is a simple tool to help people remember stroke warning signs. This study tests whether a single stroke education session based on BEFAST improves knowledge, attitudes, and emergency response intentions among stroke patients admitted to a Malaysian tertiary hospital. The study will use a pre-post intervention design with follow-up at one month. Participants will be the stroke patients admitted to the neurology ward. They will receive a one-hour structured education module covering BEFAST symptoms, risk factors, and the importance of reaching a hospital within 4.5 hours. Education will is delivered by doctors and nurses using presentations, pamphlets, posters, videos, and follow-up WhatsApp messages.

Outcomes will be assessed using a validated questionnaire measuring knowledge, attitudes, and practices at three time points: before the intervention, immediately after, and at one month. Associations between demographic factors and outcomes will also be explored.

Study Overview

This is a single-centre, pre-post intervention study that will be conducted from September 2024 to September 2025 at Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, a major tertiary hospital. The study will evaluate the effectiveness of a structured BEFAST-based stroke education module on knowledge, attitudes, and practices (KAP) among hospitalised stroke patients.

Study Setting and Population

The study will enroll stroke patients admitted to the neurology ward using consecutive sampling. Participants will be adults (≥18 years) with a confirmed diagnosis of acute stroke (ischemic or hemorrhagic) by MRI or CT scan according to WHO criteria. Patients must be clinically stable, cognitively able to participate, and understand Malay or English.

Exclusion criteria include age under 18 years, significant cognitive impairment, severe aphasia precluding participation, medical instability, pre-existing dementia, severe visual or hearing impairments, and expected discharge within 24 hours.

Sample Size

Based on a power of 80%, significance level of 0.05, and expected effect size of 0.5 for knowledge improvement (derived from meta-analytic findings), the minimum required sample needed is 64 participants. To account for 15% potential dropout and enable subgroup analyses, the target recruitment is 120 patients.

Intervention: BEFAST-Based Stroke Education Module

The structured education module is based on ANGELS Initiative International protocols and is delivered during a single 60-minute session per participant. The intervention will use a multi-modal approach:

1. Direct health education: One-hour PowerPoint presentation delivered by doctors during admission
2. Nurse-led reinforcement: Education by stroke nurses to all patients during admission
3. Ward round reinforcement: Daily BEFAST mnemonic reinforcement by doctors and nurses
4. Printed materials: Informative pamphlets in the participant's preferred language (Malay or English)
5. Visual aids: Awareness posters displayed in the ward and at bedside lockers
6. Digital resources: Educational videos
7. Post-discharge follow-up: WhatsApp messages reinforcing key messages

Educational content covers:

1. Stroke definitions and types (ischemic vs. hemorrhagic)
2. BEFAST mnemonic components (Balance disturbance, Eyes/visual disturbance, Facial drooping, Arm weakness, Speech difficulties, Time to call emergency services)
3. Modifiable and non-modifiable risk factors
4. Appropriate emergency actions with emphasis on the 4.5-hour therapeutic window for thrombolysis
5. Preventive measures and lifestyle modifications

Data Collection Instruments

The study will use a validated questionnaire developed from a previous Malaysian stroke awareness study, aligned with Malaysian clinical practice guidelines.

The self-administered questionnaire comprises two parts with "yes"/"no" responses:

Part 1: Sociodemographic characteristics (age, gender, ethnicity, education, employment, marital status) and medical history (smoking, alcohol, diabetes, hypertension, previous heart attack or stroke)

Part 2 (KAP domains):

Knowledge (0-50 points): Organs affected, causes, risk factors, warning signs (BEFAST components), preventability, effects on daily activities

Attitudes (0-4 points): Preferences for conventional, traditional, faith-based, or combined treatment approaches

Actions (0-6 points): Intended emergency responses and time sensitivity of seeking care

Data Collection Timeline

Assessments occur at three time points:

1. Pre-intervention: During hospital admission, before any education
2. Immediate post-intervention: Immediately following the 60-minute educational session
3. One-month follow-up: Telephone interview to assess knowledge retention and behavioural implementation

Statistical Analysis

Analyses will be performed using SPSS version 29.0. Descriptive statistics will summarize baseline characteristics. McNemar's test will compare pre-post changes in individual KAP items. Wilcoxon signed-rank test will compare pre-post KAP domain scores and total scores. Multiple linear regression will examine associations between demographic factors and KAP outcomes. Statistical significance will be set at p < 0.05.

Ethical approval was obtained from the Ethics Committee Involving Human Subjects Universiti Putra Malaysia (Reference No: JKEUPM-2024-257). Written informed consent will be obtained from all participants before enrolment. All procedures are performed in accordance with the Declaration of Helsinki and Malaysian Good Clinical Practice guidelines.

Inclusion Criteria:

1. Over 18 years old
2. Diagnosed with acute stroke (either ischemic or hemorrhagic) confirmed via MRI or CT scan according to WHO criteria
3. Clinically stable as determined by the attending neurologist using standardized assessment protocols
4. Cognitively able to participate
5. Able to understand Malay or English language as confirmed through structured communication assessment

Exclusion Criteria:

1. Under 18 years of age
2. Significant cognitive impairment preventing informed consent
3. Severe aphasia precluding meaningful participation as assessed by speech-language pathologists
4. Too medically unstable to participate as determined by the clinical team
5. Previous documented diagnosis of dementia or other neurodegenerative conditions
6. Severe visual or hearing impairments preventing educational material comprehension
7. Expected to be discharged within 24 hours of admission

Individual participant data (IPD) will not be shared publicly due to participant confidentiality and ethical restrictions approved by the Universiti Putra Malaysia Ethics Committee. The informed consent obtained from participants did not include provisions for public data sharing. While data may be available from the corresponding author upon reasonable request, no formal IPD sharing plan exists.