Krassimira Stoeva 1, Klara Dokova 1, Philip Kirov 2, Nevijana Feschieva 1, Stefka Petrova 3 John Powles 4 (1) Dept of Social Medicine, Medical University, Varna, Bulgaria, (2) Clinic of Neurology, Acute Stroke Unit, University Hospital, Varna, Bulgaria (3) National Centre for Hygiene, Medical Ecology and Nutrition, Sofia (4) Dept of Public Health and Primary Care, University of Cambridge More women than men were able to nominate an accepted risk factor (45% compared to 33% for first mentions) and more urban dwellers than rural dwellers (44% compared to 33% for first mentions). There was thus an overall gradient in knowledge from urban females to rural males (23% compared to 11% for ‘acceptable’ first mentions). 382 Public understanding of the causes of high stroke risk in north-east Bulgaria Subjects eligible for inclusion in the study were residents of the village of Grozdovo, and the Primorski district of the city of Varna with stated ages of 45 to 74. They were quota sampled from the lists of cooperating general practitioners with the aim of achieving approximately equal numbers in each 10 year age stratum for each sex location group. The 91 rural and 97 urban subjects who completed the winter cycle of the parent study form the basis of this report. Comparison with census data from 1992 showed that persons with less schooling were under-represented in our samples, especially in the rural areas. During interviews conducted in January – March 2000 covering many aspects of lifestyle and family circumstances respondents were asked: “Why do you think stroke is so common in this region? ”. Interviewers were instructed not to prompt responses and to record first and other reasons offered in summary verbatim form. All answers were post- coded – first into 33 categories, which were then combined into 10 more inclusive groups. Descriptive statistical analysis was performed using SPSS version 11.0  Knowledge of those established causes of stroke likely to be incurring the greatest population attributable risk – namely high blood pressure and cigarette smoking – is very low in these high risk populations.  The roles of overweight and obesity (widespread in these populations) and heavy drinking (present in a proportion of the adult male population) were also largely overlooked.  The gradient in knowledge between urban female and rural male participants, corresponds (inversely) to the gradient in stroke incidence.  Ignorance of the modifiable causes of stroke should be investigated as a contributing cause to their current high rates in Bulgaria. The addition of open ended (unprompted) knowledge questions to risk factor surveys could help document the extent of this phenomenon in large representative populations.  A high percentage nominated stress and poverty as causes of stroke. The study was performed in a transition period which is imposing enormous economic burdens on the population. The popular belief that poverty causes stroke is consistent with considerable epidemiological evidence identifying it as a (distal) cause 2,3,4. However the relief of poverty through the life cycle 2 is a long term objective lying mostly outside public health responsibilities.  Our findings point to the ineffectiveness of the efforts so far made within Bulgaria to deal with the public health challenge posed by stroke. This needs to be addressed immediately by concerted national programmes of public education about the established modifiable causes of stroke. Wellcome Trust, London 1. Introduction 178 (94,6 %) of the respondents offered at least one reason for the high risk of stroke and 57 people (30 %) gave more than 3 reasons. Neither high blood pressure nor hypertension were mentioned by any of the study participants. Only 5,6% of the respondents suggested smoking (not as a first answer) as a cause for stroke. Salty food or low consumption of fresh fruits and vegetables were not included among the first mentions. Stress (101) and poverty (20) accounted for 68% of the first mentions. Dietary factors other than high salt and low fruit and vegetable consumption accounted for 40% of other mentions. 2. Methods 4. Conclusions Funding source 3. Results References [1] Powles J, Kirov P, Feschieva N, Stanoev M, Atanasova V. Stroke in urban and rural populations in north-east Bulgaria: incidence and case fatality findings from a 'hot pursuit' study. BMC-Public Health 2002;2(1):24. [2] Davey Smith G,Hart C, Blane D et al. Adverse socioeconomic conditions in childhood and cause specific adult mortality: Prospecitve observation. BMJ 1998;316: [3] Jakovljevi D, Sarti C, Sivenius J, et al. Socioeconomic status and ischemic stroke: The FINMONICA Stroke Register. Stroke 2001;32: [4] Hart C, Hole D, Davey Smith G. The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: The Renfrew/Paisley Study. Am J Public Health 2000; 90 (11) : * Question addressing population risk ** Question addressing individual risk Data from associated stroke incidence study 3. Results (cont) Stroke incidence in North - Eastern Bulgaria is amongst the highest yet reported for European populations 1. The extent to which Bulgarian publics are aware of scientific knowledge about the main modifiable causes of stroke appears to be undocumented. We assessed public knowledge of stroke risk factors among well defined urban and rural populations in North Eastern Bulgaria as a part of “Varna Diet and Stroke Study" (a preliminary investigation of risk factors for stroke combined with a diet validation study). Web address: