Stroke literacy in a sample of Italian adults: an iceberg model revealing domain-specific gaps beyond apparent emergency awareness.
Bagnato M, Di Donna M, et al. • Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology • 2026
Findings support an iceberg model of stroke literacy, with surface awareness masking deeper, phase-specific gaps; education should target stroke severity misconceptions and symptom recognition, particularly in older adults.
Key Findings
Results
Only 25% of participants correctly identified 'cerebral stroke' and 'cerebral ischemia' as synonyms, indicating widespread conceptual knowledge gaps.
52% rated stroke as severe but ischemia as milder, demonstrating a fundamental misunderstanding of disease terminology
Accuracy was significantly higher in healthcare workers compared to non-healthcare workers (45% vs 23%, p < 0.001)
Higher education was associated with better accuracy (29% vs 22%, p = 0.002)
Survey conducted among 1,769 participants nationwide in Italy
Results
One quarter of participants failed to identify unilateral paralysis as the cardinal symptom of stroke.
Recognition of unilateral paralysis was lower in those aged ≥41 years (70-73%) compared to younger respondents (~77-79%), p = 0.019
This symptom recognition gap was statistically significant across age groups
The finding highlights a domain-specific deficit in symptom recognition despite general awareness of stroke as an emergency
Results
Treatment awareness was high among participants, with 84% demonstrating awareness of time-dependent stroke treatment.
Treatment awareness was associated with higher education and healthcare-related exposure (p = 0.007)
This represented one of the stronger domains of stroke literacy in the sample
Higher treatment awareness contrasted with lower conceptual knowledge, supporting the iceberg model described by the authors
Results
Intended emergency medical services (EMS/112) call was reported by 85% of participants as their intended response to a suspected stroke.
Intended EMS call was associated with younger age (p = 0.004)
Indirect stroke-care exposure was also associated with intended EMS call (p = 0.001)
Despite the high rate of intended emergency action, pre-hospital delays remain a documented public health problem, suggesting a gap between stated intention and actual behavior
Results
65% of participants achieved a high composite stroke literacy score (≥3 correct domains), with healthcare employment as the sole independent predictor.
Healthcare employment independently predicted a high composite score (OR 2.02, 95% CI 1.28-3.19)
Age and educational level were not independently associated with achieving a high composite score in multivariable logistic regression
The composite score required ≥3 correct answers across four domains: conceptual knowledge, symptom recognition, awareness of time-dependent treatment, and intended emergency action
The sample was 71% female, 60% university-educated, 35% were >40 years, 9% worked in healthcare, and 47% reported a family history of stroke
Discussion
The study identified a domain-specific 'iceberg model' of stroke literacy where surface-level emergency awareness masks deeper phase-specific knowledge gaps.
High rates of intended EMS use (85%) and treatment awareness (84%) contrast sharply with low rates of conceptual knowledge (25% synonym recognition)
The authors describe this pattern as an 'iceberg model' where apparent emergency awareness conceals deficits in conceptual understanding and symptom recognition
The model suggests that public campaigns have successfully conveyed the emergency nature of stroke but have not addressed underlying conceptual misunderstandings
The authors recommend that education should specifically target stroke severity misconceptions and symptom recognition, particularly in older adults
Methods
The study was a nationwide cross-sectional survey with a sample skewed toward female and higher-educated participants.
Total sample size was 1,769 participants
71% were female and 60% were university-educated, which the authors note as a sample limitation
9% of participants worked in healthcare and 47% reported a family history of stroke
35% of participants were >40 years of age
A composite score of ≥3 correct across four domains was used as the primary outcome, analysed using contingency tests and multivariable logistic regression
What This Means
This research suggests that public knowledge about stroke in Italy follows an 'iceberg' pattern: most people know to call emergency services if they suspect a stroke, but much deeper misunderstandings lie beneath the surface. In a survey of nearly 1,800 Italian adults, 85% said they would call emergency services and 84% were aware that stroke requires urgent treatment — yet only 25% understood that 'cerebral stroke' and 'cerebral ischemia' refer to the same condition. Alarmingly, more than half of respondents rated stroke as serious but ischemia as less serious, revealing a fundamental confusion about terminology that could delay help-seeking in real emergencies. Additionally, one in four participants failed to recognize unilateral (one-sided) paralysis as a key warning sign of stroke, with older adults performing worse on this question.
The study found that working in healthcare was the strongest predictor of overall stroke knowledge, making someone about twice as likely to score well across all four knowledge domains. Interestingly, age and education level alone were not independently linked to better overall scores once other factors were accounted for, suggesting that simply having more education does not guarantee well-rounded stroke literacy. Older adults and people without healthcare exposure appeared particularly vulnerable to specific knowledge gaps.
This research suggests that current public health campaigns have successfully spread the message that stroke is an emergency requiring an immediate call to emergency services, but have not adequately addressed what stroke actually is, what it is called, or how to recognize all of its symptoms. Future education efforts may need to go beyond awareness slogans to correct specific misconceptions — especially the dangerous assumption that 'ischemia' is a milder condition than 'stroke' — and to focus on symptom recognition in older populations who may be at greatest risk.
Bagnato M, Di Donna M, Bernocchi F, Borrello L, Bracaglia M, Di Mauro G, et al.. (2026). Stroke literacy in a sample of Italian adults: an iceberg model revealing domain-specific gaps beyond apparent emergency awareness.. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. https://doi.org/10.1007/s10072-026-09134-w