BY MRIDULA BHARATHI
Every year, 12 million people experience an interruption in blood flow to their brain, with little warning, stealing them of their speech, mobility, and even life within minutes. Yet, while the biological mechanisms of stroke are universal, the chances of surviving one are not. In the United States, those living in rural communities experience a 30% increase in stroke mortality compared to urban populations, not because treatment is unavailable, but because awareness is.1 Globally, stroke awareness campaigns have been implemented and evaluated in urban areas, and fail to reach rural populations due to technological and educational gaps.2 Consequently, a lack of timely recognition of stroke symptoms coupled with a delayed activation of emergency medical services persists in rural areas, continuing to widen the mortality divide. This educational gap is a violation of the right to health literacy, an essential component of the right to health recognized by the World Health Organization. Efforts must be made to bring stroke educational campaigns to rural areas and understand the shortcomings of current stroke educational models, such as FAST (Face, arm, speech, time), to address this broader human-rights inequity and improve stroke outcomes in rural communities.
Primarily, the disproportionate impact of stroke mortality on rural communities is not driven by differences in fatality. While mortality is a measure of the frequency of deaths in a population, fatality refers to the proportion of deaths among those who experience stroke. Rates of stroke fatality remain consistent between urban and rural areas—patients in both regions are transported to primary stroke centers at similar rates, and the expansion of telestroke programs has helped standardize the quality of acute stroke treatment. Instead, the elevated mortality reflects the higher incidence of stroke in rural areas.
Multiple factors contribute to this increased burden.Rural populations have a higher prevalence of major stroke risk factors, including diabetes mellitus and hypertension.1 Moreover, lower socioeconomic status limits access to consistent primary care, which has shown to elevate stroke risk by limiting primordial stroke prevention.1 Equally critical is the prolonged delay between symptom onset and emergency service activation. Due to the time-sensitive nature of stroke and the narrow window for interventions, such as intravenous tPA (Tissue Plasminogen Activator), which offers greatest benefit within 3-4.5 hours of symptom onset, it is necessary to promptly recognize stroke warning signs and alert EMS.1 This delay in EMS activation is tied closely to the limited awareness of stroke symptoms in rural populations, highlighting the urgency for public-health efforts in rural areas to increase stroke education.4
Existing public health efforts, including the FAST campaign, legislative initiatives, community screenings, and high-intensity media campaigns, have attempted to address these gaps. Yet, each faces limitations that reduce its effectiveness in rural settings. High-intensity media and public education campaigns—such as the two 10-week media markets in Montana that included four paid television advertisements, three paid radio advertisements, and paid newspaper advertisements—highlighted stroke warning signs and the necessity to call 911.5 This intervention showed significant increases in stroke warning sign recognition and awareness of the need to alert emergency responders when these conditions were present.5 However, due to the expense of these interventions, they often overlook rural communities in favor of urban areas where such initiatives can reach larger audiences. Moreover, paid television and social media advertising limit its reach to those connected to the platforms, often excluding rural populations. In an effort to address rural needs more directly, community-based stroke screening programs have been introduced. But, these initiatives tend to attract only the “worried sick” or “worried well”(people who worried that they were sick and actually were or not), which is a minor proportion of those in rural areas who could benefit from a stroke screening. Even among the “worried sick,” behavioral change is minimal. Individuals frequently fail to implement recommended lifestyle modifications or follow up with their physicians, limiting the program’s long-term impact despite its high cost.6 These limitations underscore the need for low-cost, high-reach interventions.
Options such as newsletter announcements, radio public service announcements, and informational health packets offer more scalable alternatives. In a study where all three were deployed, only the monthly newsletter consistently produced meaningful increases in stroke awareness.6 While these low-cost strategies show promise, the most widely recognized inexpensive intervention remains the Stroke Awareness FAST campaign. Launched by the Department of Health in England in 2009 and soon adapted by the USA and Australia, this initiative aimed to raise public awareness of stroke symptoms and decrease the time taken from symptom onset to receival of care. Its affordability and broad dissemination have made it a staple of stroke awareness, with regional modifications (BE-FAST: Balance and Eyes) supplementing knowledge about symptoms. However, there is conflicting evidence regarding the impact of this campaign on the general population in understanding stroke symptoms.7
Studies have shown that even individuals who can correctly recite the FAST acronym often fail to apply it when witnessing real-time stroke symptoms.8 Symptoms often do not present as cleanly as the acronym suggests, and adults in rural areas could misattribute stroke symptoms to hypoglycemia, migraines, fatigue from manual labor, and age-related changes.8 Thus, this gap between knowledge and action undermines the core purpose of the campaign and raises the question: how can stroke symptoms be easily recognized and why does recognition not translate into response?
Part of the challenge lies in representation. The campaign features imagery of older adults, leading younger people to perceive stroke as an issue that does not pertain to them, diminishing engagement with and retention of the message.8 Even among older adults, who are at greatest risk for stroke, symptoms observed in real life are often dismissed as benign or attributed to less serious conditions, resulting in delays in contacting emergency service. Thus, this concerning evidence indicates that passive recall of an acronym and limited graphics are insufficient to support rapid recognition, interpretation, and intervention during a stressful and ambiguous medical event.
To be effective, stroke education must focus on active understanding and application in realistic scenarios. Educational tools should therefore incorporate live demonstrations of stroke symptoms, model bystander intervention, and include visuals of individuals from diverse backgrounds to reinforce the universal risk of stroke. Ideally, the sessions would conclude with interactive applications. For example, participants would be asked to evaluate a mock scenario and determine whether EMS should be alerted. This active learning offers a more comprehensive, behavior-oriented approach than an acronym alone. However, this intervention could be time consuming and expensive, and the ability to reach rural populations is still difficult.
To address these concerns, organizations like Stamp Out Stroke at Yale’s School of Medicine offer a model that delivers interactive presentations at senior centers and libraries, reaching individuals in rural communities. This low-cost approach not only intentionally reaches those of underserved and rural populations, but also prioritizes active learning over passive awareness. In addition, participants could be handed a follow-up pamphlet to reinforce key concepts of the session. This approach should be adapted nationally, allowing medical schools and health institutions to reach underserved rural communities more effectively, and disseminate knowledge in accessible, interactive methods. At the same time, one must recognize that improving stroke education alone will not eliminate the rural-urban disparity. It is essential to continue addressing broader systemic inequities to healthcare, such as increasing rural communities access to primary care, health insurance, and medications. Additionally, the average cost for an advanced life support ambulance is $1613 in America, posing a barrier for access to individuals in rural areas who often have a lower socioeconomic status or lack of health insurance.9 While these challenges require long-term policy solutions, students and community organizations can simultaneously help bridge the stroke education gap and teach individuals to recognize stroke symptoms rapidly to alert EMS. In doing so, students can play a necessary part in standardizing access to the right to health and supporting improved stroke outcomes across urban and rural communities.
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References
1.Howard, G. et al. Contributors to the excess stroke mortality in rural areas in the United States. Stroke 48, 1773–1778 (2017).
2.Howard, G. et al. Contributors to the excess stroke mortality in rural areas in the United States. Stroke 48, 1773–1778 (2017).
3.Lansberg, M. G., Bluhmki, E. & Thijs, V. N. Efficacy and safety of tissue plasminogen activator 3 to 4.5 hours after acute ischemic stroke. Stroke 40, 2438–2441 (2009).
4.Wein, T. H. et al. Activation of emergency medical services for acute stroke in a nonurban population. Stroke 31, 1925–1928 (2000).
5.Fogle, C. C. et al. Impact of media on community awareness of stroke warning signs: A comparison study. Journal of Stroke and Cerebrovascular Diseases 19, 370–375 (2010).
6.DeLemos, C. D., Atkinson, R. P., Croopnick, S. L., Wentworth, D. A. & Akins, P. T. How effective are “community” stroke screening programs at improving stroke knowledge and prevention practices? Stroke 34, (2003).
7.Bietzk, E. et al. Fast enough? the UK general public’s understanding of stroke. Clinical Medicine 12, 410–415 (2012).
8.Morrow, A., Miller, C. B. & Dombrowski, S. U. Can people apply ‘fast’ when it really matters? A qualitative study guided by the common sense self-regulation model. BMC Public Health 19, (2019). 9.Santos-Longhurst, A. How Much Does an Ambulance Ride Cost? Well U (2025). Available at: https://www.carecredit.com/well-u/health-wellness/ambulance-ride-cost/. (Accessed: 8th November 2025)
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