The Relationship of Perceived Severity and Recurrent Stroke Prevention Behavior at Post-Non-Hemorrhagic Stroke Patients

Abstract


INTRODUCTION
Stroke is a sudden disruption of brain function that lasts more than 24 hours.Stroke pathology is grouped into two types, namely non-hemorrhagic stroke (ischemic stroke) and hemorrhagic stroke. 1 Stroke is the first cause of death and disability in Indonesia. 23World Stroke Organization (WSO) in 2022 stated that more than 12.2 million people suffer from stroke every year. 4Data from Riskesdas in Indonesia in 2018 showed that, based on doctor's diagnosis, the population aged ≥ 15 years was 10.9% or estimated at 2,120,362 people and stroke cases in Central Java Province itself were 11.8%, namely 96,794 people. 5n-hemorrhagic strokes are more common than hemorrhagic strokes. 1 Nonhemorrhagic strokes are found in around 87%. 3 Non-hemorrhagic stroke is a stroke that occurs when blood flow to the brain stops due to a blood clot blocking the blood vessels.6 Blood clots can form from Renny Nafia Rahmawati / The Relationship of Perceived Severity and Recurrent Stroke Prevention Behavior at Post-Non-Hemorrhagic Stroke Patients thrombus that detaches from the walls of large blood vessels to flow distally and attach to smaller downstream vessels. 7Blood clots can originate from the aorta, arteries, heart and veins in the pelvis or lower extremities.8 Risk factors for nonhemorrhagic stroke are grouped into nonmodifiable and modifiable factors. Nnmodifiable risk factors include age, gender, and race.Meanwhile, risk factors that can be modified include hypertension, smoking, physical activity, hyperlipidemia, diabetes mellitus, alcohol consumption and obesity. 2 The main lesion of non-hemorrhagic stroke is cerebral infarction.Stopped blood flow results in a reduction in blood supply to the brain tissue, first there is a reversible loss of tissue function and this is followed by loss of neurons and supporting structures.7 Complete cessation of blood flow to the brain causes loss of consciousness within fifteen to twenty seconds and within seven to ten minutes irreversible brain damage occurs.The basic mechanism of damage is energy deficiency due to ischemia, one of which is embolism. 9The impact of neurological deficits can reduce the quality of life of patients such asrestriction of movement, weakness or paralysis of limbs, communication difficulties and mental problems.10 Neurological deficits prevent individuals from carrying out basic needs such as bathing, eating, dressing, urinating, and others.11 This causes the patient to no longer be able to work or be able to work but with different productivity as before the stroke.Patients who experience this feel irresponsible towards their families and themselves because of financial difficulties and increase the burden of medical costs.10 The treatment carried out is therapy to restore perfusion to brain tissue that has experienced an infarction and prevent repeated strokes.Some of the therapies that can be carried out are intravenous recombinant tissue plasminogen activator (rt-PA) therapy, antiplatelet therapy, anticoagulant therapy, and rehabilitation.Intravenous rt PA therapy within three to four and a half hours after stroke onset has been shown to be effective in randomized clinical trials, and this recommendation has been incorporated into guidelines by the American Stroke Association and the European Stroke Organization.Antiplatelet therapy within 48 hours of initial ischemic stroke can reduce the risk of death and improve patient outcomes by reducing the volume of brain damage caused by ischemia, as well as reducing the risk of recurrent ischemic stroke by 25%.Anticoagulant therapy is usually used to prevent cardioembolic stroke secondarily in the long term in patients with atrial fibrillation.Rehabilitation that can be done by stroke sufferers is physical, occupational and speech therapy. Rabilitation should involve the family with a goal. 1 The many advances in stroke prevention and treatment still make stroke the leading cause of death and disability throughout the world.Patients who survive a first stroke are known to have a significantly increased risk of a second stroke in the future.12 A second stroke is also called a recurrent stroke or secondary stroke. Lack of individual confidence in stroke risk factors, stroke symptoms, and therapy programs to prevent re-strokes causes an increase in the incidence of recurrent strokes.15 For this reason, prevention efforts are needed by changing appropriate healthy behavior patterns, for example avoiding the risk of repeated strokes, taking medication regularly, doing rehabilitation routines, and so on.Human health is greatly influenced by behavior.16 Behavior is a person's action towards external stimuli or perceptions from within him.17 Unhealthy behavior will cause several health problems.18 Several factors can influence a behavior, namely the Renny Nafia Rahmawati / The Relationship of Perceived Severity and Recurrent Stroke Prevention Behavior at Post-Non-Hemorrhagic Stroke Patients individual's belief or belief in the existence of a disease, culture that makes it easier for the individual to behave, knowledge that can influence the individual's mindset, and the individual's means or environment that supports him or her to carry out a behavior.BM has six dimensions, namely perceived severity, perceived severitysusceptibility (perception of vulnerability), perceived benefit (perception of usefulness), perceived barrier (perception of obstacles), selfefficacy (self-confidence), Andcues to action(action of encouragement).The perceived severity dimension is the perception of the seriousness or severity of an illness.A person who has a high perception of seriousness regarding the severity of an illness will have a higher likelihood of taking preventative action against the disease.20 From previous research, the results showed that out of 144 respondents, 55 (71.4%) respondents had a level of perceived severity and unfavorable behavior.21 This study aims to determine the relationship between perceived severity and behavior to prevent recurrent stroke.

METHOD
The study carried out was a quantitative descriptive analytical research with a cross sectional approach.The research subjects were 70 non-hemorrhagic post-stroke patients at KRMT Wongsonegoro Hospital, Semarang City using consecutive sampling techniques, which were adjusted to the inclusion and exclusion criteria.Inclusion criteria involved non-hemorrhagic poststroke patients who were over forty years old, domiciled in Semarang City, and willing to be respondents.Meanwhile, exclusion criteria include patients with severe physical disabilities and who are uncooperative.

RESULTS
Characteristics of respondents at the KRMT Wongsonegoro Hospital, Semarang City with a total of 70 respondents, it was found that the majority of respondents were aged between 45 years and 65 years with a frequency of 48 respondents (68.6%), respondents aged >65 years were 19 respondents.(27.1%), and 3 respondents aged <45 years (4.3%).Based on gender frequency, the majority of respondents were men, namely 36 respondents (51.4%) and 34 respondents (48.6%) women.The majority of respondents' educational levels were respondents with high school graduates as many as 31 respondents (44.3%), elementary school graduates as many as 14 respondents (20.0%),Diploma/Bachelor graduates as many as 10 respondents (14.3%), as many as respondents who had not attended school.9 respondents (12.9%), and 6 respondents with junior high school graduates (8.6%).Based on employment status, the majority of respondents worked with a frequency of 50 respondents (71.4%) and 20 respondents who did not work (28.6%).
Based on the frequency of marital status, the majority of respondents were married with a total of 64 respondents (91.4%), divorced at death amounted to 5 respondents (7.1%), divorced alive amounted to 1 respondent (1.4%).Based on the frequency of recurrent stroke prevention behavior, 42 respondents Renny Nafia Rahmawati / The Relationship of Perceived Severity and Recurrent Stroke Prevention Behavior at Post-Non-Hemorrhagic Stroke Patients (60%) had adequate recurrent stroke prevention behavior and 28 respondents (40%) had good recurrent stroke prevention behavior.Based on perceived severity, 39 respondents (55.7%) had a sufficient level of perceived severity and 31 respondents (44.3%) had a good level of perceived severity.
Based on table 2. Most respondents haveperceived severitysufficient (55.7%).The statistical test results obtained using the Spearman rank test obtained a p-value of 0.000, where if the value (p<0.05)indicates a significant relationship betweenperceived severitywith recurrent stroke prevention behavior.From the results of the analysis, a correlation coefficient value of 0.916 was also obtained, which shows the strength of the relationship is very strong with the direction of the relationship being unidirectional, meaning that the higher a person's level of perceived severity, the higher the level of behavior to prevent recurrent stroke.

DISCUSSION
Health Belief Model(HBM) is a theoretical framework or framework used to predict individual behavior related to or related to health. 22Human behavior is an important determinant of the effectiveness of strategies to prevent or control a disease. 23his model identifies factors that influence individual behavior in dealing with an illness. 22Evidence shows that people's perceived seriousness can significantly influence their response to a threat.Previous research shows that populations and individuals with higher levels of risk perception are more likely to have infection prevention behaviors to reduce the risk of infection and disease transmission. 23e research results showed that the majority of respondents (55.7%) own perceived severityand adequate recurrent stroke prevention behavior.From the results of the Spearman rank analysis, a p-Renny Nafia Rahmawati / The Relationship of Perceived Severity and Recurrent Stroke Prevention Behavior at Post-Non-Hemorrhagic Stroke Patients value of 0.000 (p < 0.05) was obtained, which shows that there is a significant relationship between perceived severity and behavior to prevent recurrent stroke in non-hemorrhagic post-stroke patients.This is in line with research by Khazaeian et al (2020) which states that people who have a high perception of disease severity tend to take good preventive measures. 24In addition, research by Zewdie et al ( 2022) stated that the level of severity felt by the individual significantly predicted healthy behavior.However, this is not in line with research by Shah et al (2021) which states that the public's perception of the level of severity does not change people's behavior in preventing a disease.The lack of response to the severity of an illness may be due to an external locus of control, namely an individual's beliefs regarding changes in behavior that are significantly influenced by environmental factors that the individual himself is unable to influence. 25 Perceived severitycan originate from individual beliefs due to the illness suffered in their life. 26Individuals will utilize information and signs and symptoms felt by individuals to form a perception. 27The perception of the severity or seriousness of an illness will stimulate individuals to take preventive action to prevent the severity of an illness. 16In this study, the majority of respondents had a sufficient level of perceived severity with the average perception being that respondents had difficulty speaking due to the stroke they suffered so that respondents had regular control and carried out speech therapy.Difficulty speaking is one of the disorders experienced by stroke sufferers due to neurological deficits due to blockage of blood vessels in the brain. 28Respondents who have such perceptions are expected to motivate respondents to take proactive treatment or prevention strategies so as to improve respondents' health behavior. 27spondents who have a high perception of the seriousness of the effects of a disease have a higher likelihood of taking preventive action against that disease. 20For example, respondents in this study who experienced a stroke will take preventive measures so as not to experience the serious effects of a stroke.The severity of stroke itself is paralysis of the extremities, visual impairment, speech impairment, neuropsychiatric disorders and recurrent stroke. 9The consequence of recurrent stroke is more extensive cerebrovascular disorders resulting in physical and cognitive disability, as well as significant social impacts.The risk of stroke recurrence may be related to previously undetected risk factors that were overlooked. 14creasing the adaptive behavior of recurrent stroke patients regarding health is an effective step to prevent recurrent stroke.Behaviors that can improve health include behaviors that are spontaneous, easy to implement, and carried out continuously to maintain or improve an individual's health. 27Recurrent stroke prevention behavior carried out by stroke sufferers can include regular check-ups with doctors, compliance with taking medication according to doctor's recommendations, healthy diet, routine blood pressure control, and physical activity. 29Two of the behaviors to prevent recurrent stroke that the majority of respondents carried out were avoiding consuming soda and maintaining an ideal body weight.Soda drinks or soft drinks are carbonated drinks that have added sweeteners or flavourings.The sweeteners used are sugar-based sweeteners and artificial sweeteners. 30Sweeteners added to carbonated drinks increase the risk of hypertension, type 2 diabetes and stroke. 31xcessive sugar in the blood vessels can cause an increase in LDL cholesterol (Lowdensity lipoprotein) resulting in atherosclerosis. 32Maintaining an ideal body weight is an action to prevent obesity.Obesity is a body mass index that is more than the normal limit.Too much food energy in the body and not used by the body can cause obesity. 33

CONCLUSION
The majority of respondents had a sufficient level of perceived severity, amounting to 39 respondents (55.7%).The majority of respondents had sufficient behavior to prevent recurrent stroke, amounting to 42 respondents (60%).There is a very strong relationship between perceived severity andRecurrent stroke prevention behaviorin non-hemorrhagic post-stroke patients at KRMT Wongsonegoro Hospital, Semarang City.The higher the perceived severity, the higher it isRecurrent stroke prevention behavior.
carried out using a questionnaire.The questionnaire used in the research is the Questionnaire Perceived

Table 2 The
Relationship between Perceived Severity and Recurrent Stroke Prevention Behavior