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Original Article
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areerat Ananchaisarp, M.D., Kanyaphim Sa-a, M.D.
Division of Family and Preventive Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, ailand.
Knowledge of Stroke and Planned Response among
Patients Living with Diabetes Mellitus and
Hypertension in a Primary Care Unit
ABSTRACT
Background: Stroke is an important worldwide public health problem. Lack of knowledge in prevention methods,
warning symptoms and planned response of acute stroke are associated with a longer prehospital time, which aect
the morbidity and mortality of patients.
Objective: e primary objective was to assess knowledge of stroke prevention methods and warning symptoms
among patients living with diabetes and/or hypertension. e secondary objectives were to dene planned responses
when suspecting acute stroke, and identify associated factors with stroke knowledge scores and planned responses.
Materials and Methods: A cross-sectional study was conducted in patients living with diabetes and/or hypertension,
who had continuous follow up at the primary care unit of Songklanagarind Hospital. e outcomes of this study
were assessed by a questionnaire, which was developed from a literature review.
Results: is study included 312 participants. Median age was 64.0 years (Q1, Q3 = 58.0, 71.0), and 59.6% were
female. Median score of knowledge of stroke prevention methods were 9, from 12 points (Q1, Q3 = 8, 10), and
warning symptoms were 7, from 10 points (Q1, Q3 = 6, 8); with 80.1% of them knowing all 3 warning symptoms,
according to the acronym FAST. Only 22.8% of participants would go to the hospital immediately, by calling
an ambulance when they experienced symptoms of a suspected acute stroke. Participants who had income had
statistically signicant higher knowledge of stroke prevention methods; while participants under 60 years of age,
who had a longer duration of diagnosed diabetes mellitus were associated with appropriate planned responses
when suspecting acute stroke.
Conclusion: Patients living with diabetes mellitus and hypertension, who are at a high risk for developing cardiovascular
diseases, still do not have enough knowledge about acute stroke and had little concern about developing a stroke;
especially the elderly and those with a short duration of having been diagnosed with diabetes mellitus.
Keywords: acute stroke, knowledge, prevention methods, warning symptoms, planned response (Siriraj Med J
2022; 74: 75-84)
Corresponding author: areerat Ananchaisarp
E mail: thareerat.a@psu.ac.th
Received 1 August 2021 Revised 19 November 2021 Accepted 24 November 2021
ORCID ID: https://orcid.org/https://orcid.org/0000-0002-3386-242X
http://dx.doi.org/10.33192/Smj.2022.10
INTRODUCTION
Stroke is an important public health problem worldwide;
because stroke is life threatening
1
and is the second
leading cause of death and disability worldwide.
2
Risk
factors of stroke are categorized as non-modiable risk
factors and modiable risk factors; such as, underlying
diabetes mellitus (DM) and hypertension (HT); which
are the highest risk factors of stroke (Odds ratio = 3.55
and 2.06, respectively).
3
Although, various studies have
shown that reducing risk factors can prevent stroke,
only 27.0-37.0% of the population recognized stroke
risk factors.
4
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the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
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ere are two types of stroke: ischemic and hemorrhagic
stroke. When patients develop acute stroke they should
receive appropriate treatment promptly in order to
reduce mortality rate and disability.
5,6
Public health
systems realize the importance of receiving prompt
treatment, and as such many hospitals worldwide have
developed a stroke fast tract; including Songklanagarind
Hospital. Although, the stroke fast tract can reduce the
time for diagnosis of stroke and increases the usage rate
of thrombolytic therapy in ischemic stroke
7
; only 14.9%
of acute stroke patients in ailand can arrived at the
hospital in time to receive thrombolytic therapy.
4
Lack
of knowledge of stroke risk factors, warning symptoms
and planned response when suspecting acute stroke
were found to be reasons of delayed prehospital time in
acute stroke.
8-12
Clinical practice guidelines recommend
patients who have warning symptoms of stroke should
go to the hospital immediately by calling emergency
medical services (EMS)
13
; however, a study in ailand
found that only 5.0-16.0% of stroke patient used EMS
as their transportation.
14
e National Stroke Association, American Heart
Association propagate the mnemonic abbreviation “FAST”,
which stands for facial palsy, arm drip (which means
weakness of upper and/or lower extremities), abnormal
speech and going to the hospital in time; to make people
easy to remember common warning symptoms of acute
stroke and emphasize people who have warning symptoms
of stroke should go to hospital without delay; or in time, as
per the ‘T’ in FAST.
15
Beyond the 3 most common warning
symptoms of stroke, included in the acronym FAST
16
,
there are also a number of other warning symptoms of
stroke.
17
A previous population-based study found that
63.0-75.1% of participants could not recognize any stroke
warning symptoms; however, 86.1% of them knew that
they should go to the hospital if they had stroke warning
symptoms.
4,5
Factors that related to good knowledge of stroke
risk factors, prevention methods, warning symptoms and
appropriate planned response when there is a suspicion
of acute stroke were younger age, female, married, higher
education, living in the city, being employed, sucient
income and underlying DM.
4,7,18-20
While hypertensive
patients may have more knowledge of stroke over a
normotensive population
19
, some studies found that
77.0% of hypertensive patients could not identify any
stroke risk factors or warning symptoms.
20
is study was developed with the primary objective
being to assess knowledge of stroke prevention methods
and warning symptoms among patients living with diabetes
and/or hypertension, who are in the high risk group of
stroke, as there are currently few studies concerning
this topic; especially in ailand and in this specic
group of patients. e secondary objectives were to
dene planned response when suspecting acute stroke,
and identify associated factors with stroke knowledge
scores and appropriateness of planned response when
suspecting acute stroke.
MATERIALS AND METHODS
Study design
A cross-sectional study was conducted from; 1
st
May – 31
st
August 2019, amongst patients living with
diabetes and/or hypertension who had continuous follow
up at the Primary Care Unit (PCU) of Songklanagarind
Hospital, Hat Yai, ailand; this being a tertiary care
hospital in Southern ailand.
Study sample and sampling
is study included patients living with diabetes
and/or hypertension who had continuous follow up at
the Primary Care Unit (PCU) of at least 1 year, came for
follow-up during the study period, had good consciousness
and consented to participate in our research. We excluded
patients who required emergency treatment, and whom
were already diagnosed with stroke or transient ischemic
attack. e sample size was calculated for the primary
objective, by using estimate of the mean in the population
formula; with standard deviation (S.D.) being calculated
from the pilot study (S.D. =3.3 and 4.5 for knowledge
of stroke prevention methods and warning symptoms,
respectively); and error (d) = 0.5. According to the maximum
calculated value, 312 participants were required. We
enrolled participants who were compatible with our
eligibility criteria by convenience sampling method.
Variables
e outcomes were assessed by a questionnaire,
which was divided into 3 parts: 1) knowledge of stroke,
consisting of prevention methods (yes-no questions 12
items) and warning symptoms of stroke (yes-no questions
10 items); 2) planned response when suspecting acute
stroke, assessed by an opened-end question: “If you have
symptoms suspected to be acute stroke, what is the rst
thing you will do?”; and 3) factors associated with stroke
knowledge scores and planned response, consisting of
participant characteristics, general knowledge and attitude
of stroke disease. e questions to explore knowledge of
stroke and associated factors were applied from previous
studies.
19–23
e questionnaire was veried for validity
by 3 family physicians, and calculated Item Objective
Congruence Index for each question. e results of all
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questions were more than 0.5; however, we adjusted
some questions according to the specialist’s suggestion.
en we conducted a pretest in thirty patients living
with diabetes mellitus and/or hypertension in another
PCU; which was close to our study setting. Test-retest
reliability was used to verify correlation coecient of stroke
knowledge scores in prevention methods and warning
symptoms; the results were 0.9 and 0.7, respectively.
Data collection
ose patients who t into our eligibility criteria
were invited to participate in our research, and written
informed consent was obtained. e participants completed
the questionnaire by themselves; except for participants
who could not read the questionnaire, in such cases the
researcher helped by interviewing.
Data management and analysis
The data were entered in Epidata (version 3.1,
Denmark), with double entry basis, and analyzed using
the R program (R Core Team 2021, Vienna, Austria).
Descriptive statistical analysis was used to report the
sociodemographic characteristics of the participants, score
and detail of answer. For variables in age of participants,
we used the denition of age ≥ 60 years old to be cut-
o point of elderly; according to United Nations and
ailand’s Elderly Act. We presented categorical data in
terms of frequencies and percentage; while continuous
data were checked for normal distribution, and median
with interquartile range (IQR) was used when normal
distribution assumption was not met. We used multiple
linear regression and multiple logistic regression to assess
associated factors with stroke knowledge scores and
appropriateness of planned response when suspecting
acute stroke. Variables were eliminated in a stepwise
model, until a nal model resulted. Finally, signicant
factors were identied, based on adjusted coecient (β)
and adjusted Odds ratio, with 95% CI. A p-value < 0.05
was considered as signicant.
Ethics statement
e study protocol was approved by the Oce of
Human Research Ethics Committee (HREC), Prince of
Songkla University (REC 63-082-9-4). All participants
signed informed consent forms aer reading the participant
information sheet.
RESULTS
e baseline characteristic of 312 participants are
shown in Table 1; two thirds of them were elderly [age
range from 30.0 to 93.0 years; median (Q1, Q3) = 64.0
years (58.0, 71.0)] and more than half of them were
female. Median duration from time of diagnosis to
having diabetes and hypertension was ten years for both
diseases.
Table 2 shows general knowledge and attitude about
stroke disease in our participants; 20.5% of them had no
prior knowledge of “stroke”, and most of them thought
that a stroke was preventable. Only 5.0% of patients
living with diabetes and/or hypertension thought that
they had a high risk of developing stroke, and about one
third of the participants believed they had no risk of
developing stroke. e participants were tested for 2 parts
of stroke knowledge, consisting of: prevention methods
and warning symptoms of stroke. Table 3 shows the details
of the answers in each question concerning knowledge
of stroke prevention methods (full score = 12 points).
e median of score (Q1, Q3) was 9 points (8, 10), and
most of them had the correct knowledge concerning a
lifestyle that could prevent stroke. However, almost half
of the participants are of the opinion that using herbal
medication can prevent stroke. Table 4 shows the answers
of each question concerning warning symptoms of stroke
(full score = 10 points). e median score (Q1, Q3) was
7 points (6, 8), and more than half of them had correct
knowledge in stroke warning symptoms; especially the 3
symptoms in the acronym FAST, by the National Stroke
Association, American Heart Association.
15
More than a
third of participants did not know that sudden and severe
unexplained headaches, sudden confusion as well as
sudden trouble in seeing may be presenting symptoms of
acute stroke. Details of action that participants undertook
when having symptoms of suspected acute stroke are
shown in Table 5. More than half of them would go to
the hospital immediately by themselves or with family
members, only 22.5% of them would go to the hospital
immediately by calling EMS, and about 10.0% of them
would not go to the hospital immediately; instead they
rst rested or used alternative medicine.
Multivariate analysis of factors associated with
stroke knowledge scores and appropriateness of planned
response when suspecting acute stroke are shown in
Table 6. Participants who thought that they had a low
chance of having a stroke, and who had income were
signicantly associated with a higher score of stroke
prevention methods when compared with participants
who thought that they had no chance of having a stroke,
and whom did not have income (β = 0.40 and 0.57, p =
0.035 and 0.04; respectively). Additionally, adult patients
and those with a longer duration of being diagnosed with
DM were signicantly associated with an appropriate
planned response when suspecting acute stroke (adjusted
OR = 2.22 and 1.10; p = 0.01 and 0.02; respectively).
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TABLE 1. Sociodemographic characteristics of participants (n=312).
Characteristics
Age (years)
< 60 106 (34.0)
≥60 206(66.0)
Gender
Male 126(40.4)
Female 186 (59.6)
Occupation
Unemployed 79(25.3)
Employed 160 (51.3)
Retirement 73(23.4)
Income
No income 46 (14.7)
Havingincomes 266(85.3)
Highest level of education
Primary education level 150 (48.1)
Secondaryeducationlevel 76(24.4)
Tertiaryeducationlevel 86(27.5)
Marital status
Single 25(8.0)
Married 271(86.9)
Divorced/widow 16 (5.1)
Smoking status
a
Never 231(74.0)
Ex-smoker 63(20.2)
Current 18 (5.8)
Subgroup of participants
DM alone 34 (10.9)
HT alone 170 (54.5)
DM with HT 108 (34.6)
DurationofdiagnosedDM(year)[median(Q1,Q3)](n=142) 10.0(4.0,15.0)
DurationofdiagnosedHT(year)[median(Q1,Q3)](n=278) 10.0(5.0,15.0)
Data are presented as n (%) unless indicated otherwise.
Abbreviations: DM : diabetes mellitus; HT : hypertension
a
Smoking status
24
;
- never = participant who has never smoked, or smoked less than 100 cigarettes in their lifetime
- ex-smoker = participant who has smoked at least 100 cigarettes in their lifetime, but quit smoking at the time of interview
- current = participant who has smoked at least 100 cigarettes in their lifetime and is currently smoking
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TABLE 2. General knowledge and attitude about stroke disease (n=312).
TABLE 3. Knowledge on methods to prevent stroke (n=312).
General knowledge and attitude n (%)
Knowing about stroke before participating in the research
No 64(20.5)
Yes 248(79.5)
Aware that stroke is a preventable disease
No 11 (3.5)
Yes 301 (96.5)
The chance you could have a stroke
No 91(29.2)
Low 158 (50.6)
Moderate 50 (16.0)
High 13(4.2)
Methods Correct answer
n (%)
Regular exercise at least 3-5 times/week 304 (97.4)
Well control of blood pressure, plasma glucose and serum lipid 303 (97.1)
Knowingriskfactorsofstrokeandpreventingthem 300(96.2)
Smokingcessation 282(90.4)
Weightreductioninoverweightorobesepatients 281(90.1)
Decreaseconsumptionofsaltyfoods 265(84.9)
Increaseconsumptionofunsweetvegetablesandfruits 261(83.7)
Decreaseconsumptionofsweetenedbeverages 255(81.7)
Decreaseamountofalcoholdrinkinginalcoholicconsumers 246(78.8)
Using herbal medication
a
179 (57.4)
Be careful of head trauma
a
90(28.8)
Drinking pure water
a
58 (18.6)
a
lifestyles that cannot prevent stroke.
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TABLE 4. Knowledge of the warning symptoms of stroke (n=312).
Question Correct answer
n (%)
Sudden numbness of unilateral face, arm or leg
a
289(92.6)
Sudden weakness of unilateral face, arm or leg
a
287(92.0)
Suddentroubleinwalking/dizziness,lossofbalanceorcoordination 280(89.7)
Sudden trouble in speaking
a
279(89.4)
Sudden,severeheadachewithunknowncause 231(74.0)
Sudden muscle strain of arm or leg
b
195(62.5)
Sudden chest pain
b
190 (60.9)
Sudden confusion or misunderstanding 189 (60.6)
Sudden trouble in seeing (one or both eyes) 186 (59.6)
Sudden numbness or weakness of bilateral face, arm or leg
b
53 (17.0)
a
3 symptoms in the acronym FAST, by the National Stroke Association, American Heart Association
15
b
symptoms that are not warning symptoms of stroke
TABLE 5. Planned response when suspecting acute stroke.
Planned response n (%)
Gotohospitalimmediatelybythemselvesorfamilymembers 210(67.3)
Go to hospital immediately by calling emergency medical services
a
71(22.8)
Restathome 20(6.4)
Usingalternativemedicine 7(2.2)
Go to hospital next day 4 (1.3)
a
appropriated planned response when suspecting acute stroke
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TABLE 6. Factors associated with stroke knowledge scores and appropriateness of planned response when suspecting
acute stroke.
Stroke knowledge score Appropriate planned
Prevention methods
a
Warning symptoms
a
response when
suspecting acute stroke
by calling EMS
b
β(95%CI) p-value β(95%CI) p-value adjustedOR p-value
(95%CI)
General knowledge and attitude of stroke disease
Knowledge of stroke before
participating in the research
No Ref. Ref. Ref.
Yes 0.36(-0.04,0.76) 0.076 0.29(-0.14,0.73) 0.189 1.57(0.75,3.31) 0.235
Aware that stroke is a
preventable disease
No Ref. Ref. Ref.
Yes -0.09(-0.94,0.77) 0.845 -0.21(-1.14,0.73) 0.664 1.03(0.20,5.23) 0.970
The chance you
could have a stroke
No chance Ref. Ref. Ref.
lowchance 0.40(0.03,0.77) 0.035* 0.19(-0.21,0.59) 0.359 0.7(0.36,1.35) 0.289
Mediumchance 0.46(-0.03,0.96) 0.068 -0.17(-0.71,0.38) 0.543 0.550.22,1.38) 0.202
Highchance 0.55(-0.3,1.39) 0.206 0.32(-0.61,1.25) 0.497 0.840.21,3.36) 0.806
Sociodemographic characteristics of participant
Age (years)
≥60 Ref. Ref. Ref.
<60 0.13(-0.24,0.50) 0.493 0.31(-0.09,0.72) 0.127 2.221.18,4.17) 0.014*
Occupation
Unemployed Ref. Ref. Ref.
Employed -0.30(-0.77,0.17)0.205 0.10(-0.41,0.61) 0.691 2.310.87,6.18) 0.095
Retirement -0.06(-0.58,0.47) 0.831 0.26(-0.31,0.83) 0.369 2.400.82,7.04) 0.111
Income
No income Ref. Ref. Ref.
Havingincomes 0.57(0.02,1.12) 0.041* 0.40(-0.19,1.00)0.184 0.920.29,2.93) 0.888
Marital status
Single Ref. Ref. Ref.
Married 0.15(-0.74,0.45) 0.626 0.15(-0.50,0.80)0.647 0.440.17,1.12) 0.085
Divorced/widow -0.06(-0.97,0.85) 0.897 0.03(-0.97,1.02) 0.958 0.200.03,1.22) 0.081
Subgroup of participants
DM alone Ref. Ref. Ref.
HTalone 0.31(-0.41,1.03) 0.401 0.08(-0.71,0.87) 0.84 3.32(0.89,12.41) 0.074
DMwithHT 0.02(-0.61,0.65) 0.956 0.10(-0.59,0.80)0.768 0.76(0.24,2.40)0.645
DurationofdiagnosedDM 0.04(0,0.08) 0.076 0.02(-0.02,0.07) 0.324 1.10(1.01,1.19)0.021*
(years)
DurationofdiagnosedHT -0.02(-0.05,0.01) 0.138 0.01(-0.02,0.04) 0.475 0.96(0.91,1.02) 0.173
(years)
Abbreviations: EMS : emergency medical services; DM : diabetes mellitus; HT : hypertension
* statistical signicant,
a
multiple linear regression,
b
multiple binary logistic regression
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DISCUSSION
Most patients living with diabetes and/or hypertension,
which are a high risk group for cardiovascular disease
(CVD), could identify more than half of the stroke
prevention methods and warning symptoms; especially
in the income group. However, they still did not show
enough awareness with regards to their attitude of
concern in having a stroke. Additionally, they had an
inappropriate planned response when suspecting acute
stroke; especially the elderly and those with a short
duration of being diagnosed with DM.
Our study was conducted in patients living with
diabetes and/or hypertension, and most of our participants
were elderly. is is in contrast with previous studies
25–27
,
in which they were population-based survey’s; therefore,
reporting on younger aged participants. Women outweighed
the proportion of men in this study, which is the same
as in the previous studies.
18,28
Almost half of the study
participants graduated to the level of primary school; this
is close to a previous study that reported their participants
were of a low education level.
25
Most of the participants claimed that they knew
of the disease, namely “stroke”, before participating in
our research, similar to a previous study in hypertensive
patients
29
; and knew that a stroke is preventable. However,
we were surprised that our participants, who were in
a high risk group for CVD, had little awareness about
developing a stroke; this result was lower than that observed
amongst hypertensive patients in Pakistan.
29
It may be
due to our participants having a higher proportion of
elder patients, and lower education levels.
Most of our study participants had appropriate
knowledge with regards to the lifestyle measures to adopt
for stroke prevention. is nding corresponds with a
previous study.
30
is could be due to ailand having
emphasized the prevention of CVD for many years; such
as, the campaign in reduction of CVD risk via various
advertising media. However, more than half of our
participants misunderstood that herbal medication can
help to prevent stroke; it may be due to herbal usage being
common in ailand; including among the elderly who
were the majority of participants in our research.
31
Use of
herbal medication may make people feel self-reliant
30
; so
it is common in patients with chronic diseases.
32,33
With
regards to knowledge of stroke warning symptoms; most
of the participants had the correct knowledge concerning
symptoms that may be a presentation of acute stroke. e
results are in accordance with previous studies
12,18,27–29,34,35
,
and may be due to three out of four of them being an
element in the acronym FAST, by the National Stroke
Association, American Heart Association.
15
Additionally,
this is well known worldwide in medical advertising
for mnemonics in acute stroke symptom detection and
early management by immediately going to the hospital.
“FAST” is one of the more successful public campaigns
in promoting knowledge of common stroke warning
symptoms; as we found that most of our participants
knew all 3 symptoms in “FAST”, similar to a previous
study.
16
However FAST still has aws, in that is does not
include the less common stroke warning symptoms; as
nearly half of our participants did not know that sudden
trouble in seeing can be a warning symptom of stroke;
this was similar to previous studies.
18,20,30,36
Although,
the ‘T’ in FAST makes mention that when a patient
suspects an acute stroke they should go to the hospital
immediately, it does not mention this should be done
via EMS, according to guideline recommendations.
13
e most common planned response when acute stroke
was suspected, was to go to the hospital immediately
by themselves, or with family members; while only a
quarter of them have an appropriate planned response
by calling EMS; this is in line with a previous study.
19
Previous studies have shown that most people believed
in the benet of EMS; however, the low rate of EMS
usage may be caused from a concern in the diculty
in its process and longer ambulance waiting times.
37,38
Alternative medicine was still a choice of planned response
when suspecting acute stroke, as was the case in previous
studies.
12,19,34
is may be due to ai traditions and faith
in alternative medicines.
is study shows that participants who have income
had a statistically signicant association with increasing of
scores of stroke prevention methods; which is the same as
a previous study.
28
However, the increasing score of 0.57
points may not have any clinical benet. Adult participants
and those with a prolonged diagnosed of DM have an
appropriate planned response when having symptoms
suspected of being an acute stroke when compared with
elderly patients, and those with a shorter diagnoses of
DM; these results correspond with previous studies.
21,39
It may be due to cognitive impairment problems in the
elderly, resulting in not retaining knowledge from their
physicians or public advertising, or that they cannot call
EMS by themselves.
38
For patients with longer diagnoses
of DM, it may increase the patient’s awareness and chance
of receiving knowledge over time.
The strengths of this study consist of: firstly,
our research is one of the few studies that evaluated
knowledge of stroke in a high risk population. Secondly,
we assessed participant’s awareness of the chance of
developing a stroke, which was a topic of little interest
in previous studies. irdly, we asked for information
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on planned responses when suspecting acute stroke;
instead of assessing knowledge in early management.
is was because knowledge is only just one factor that
aects behavior, and dierent contexts of each person
inuences action; such as, ease of accessibility to a nearby
hospital or ability to call EMS. In addition, this study is
one of the few study’s that explored planned responses
by an opened-end question, instead of multiple-choice
questions
12,19,34
; in order to decrease a chance of bias from
choosing the ‘good answers’ from choices. However,
there were some limitations. Firstly, we did not explore
the reason of planned response answers, for which the
results could be used for developing a method to the
solution of problems. For example; if their inappropriate
planned response came from a lack of knowledge, the
proper intervention would be education on the benets
of EMS usage. Secondly, this study was conducted in
a primary care unit of a tertiary care hospital, so the
results cannot be generalized to other hospital settings.
Lastly, the sample size was calculated for the primary
objective, so the number of the sample size may not be
large enough to show signicance in factors associated with
stroke knowledge scores, and appropriateness of planned
response. For future research, we suggest extending this
to other health care settings, increasing the sample size
for increasing statistical power of results, and adding
another helpful topic for solving some problems directly;
such as, reason of planned response as well as ability and
barrier in using EMS.
CONCLUSION
Patients living with diabetes and/or hypertension still
do not have enough knowledge of stroke. Additionally, they
have a less than acceptable level of awareness in concerns
to the risks of developing a stroke. e participants in
this study had an inappropriate planned response when
suspecting acute stroke. FAST is a successful public
campaign for promoting knowledge of the most common
warning symptoms of stroke.
ACKNOWLEDGEMENTS
We greatly appreciate the assistance of Pitchayanont
Ngamchaliew, Supakorn Sripaew, and Rattanaporn
Chootong for creating the Item Objective Congruence
index for our data collection form. We also thank Kittisakdi
Choomalee for the data analysis, and the International
Aairs Department for their assistance in editing the
English of this paper.
Conict of interest statement: none
Funding sources: none
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