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nte
rna
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l J
o
urna
l o
f
P
u
bli
c
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ea
lt
h Science
(
I
J
P
H
S)
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
,
p
p
.
1
5
1
5
~
1
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2
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SS
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s
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h
ttp
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ijp
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s
.
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co
m
Ass
o
cia
ted
factor
s
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curren
ce
stro
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a
mo
ng
stro
ke
pa
tient
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A
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ticle
his
to
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y:
R
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eiv
ed
Dec
13
,
2
0
2
3
R
ev
is
ed
Mar
24
,
2
0
2
4
Acc
ep
ted
Ap
r
24
,
2
0
2
4
S
tro
k
e
is
a
silen
t
k
il
ler.
P
re
v
e
n
t
in
g
th
e
re
c
u
rre
n
c
e
of
str
o
k
e
s
is
th
e
re
fo
re
e
ss
e
n
ti
a
l.
Th
is
stu
d
y
i
n
v
e
stig
a
ted
i
)
th
e
lev
e
l
of
h
e
a
lt
h
li
tera
c
y
to
p
r
e
v
e
n
t
th
e
re
c
u
rre
n
c
e
of
str
o
k
e
,
ii
)
fa
c
to
rs
a
ss
o
c
iate
d
with
n
o
t
h
a
v
in
g
a
stro
k
e
,
a
n
d
iii
)
As
so
c
iatio
n
s
b
e
twe
e
n
h
e
a
lt
h
l
it
e
ra
c
y
a
n
d
re
c
u
rre
n
c
e
of
str
o
k
e
.
T
h
is
c
ro
ss
-
se
c
ti
o
n
a
l
a
n
a
ly
ti
c
a
l
re
se
a
rc
h
wa
s
c
o
n
d
u
c
ted
with
2
4
0
sa
m
p
les
.
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u
lt
i
p
le
lo
g
isti
c
re
g
re
ss
io
n
wa
s
p
e
rfo
rm
e
d
to
d
e
sc
rib
e
th
e
fa
c
to
rs
a
n
d
a
ss
o
c
iatio
n
s
re
c
u
rre
n
c
e
stro
k
e
.
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h
e
re
su
lt
s
sh
o
we
d
th
a
t
t
h
e
m
a
jo
rit
y
of
th
e
sa
m
p
les
h
a
d
a
p
ro
b
lem
a
ti
c
lev
e
l
of
h
e
a
lt
h
li
tera
c
y
to
p
re
v
e
n
t
re
c
u
rre
n
c
e
stro
k
e
(
5
2
.
0
8
%
),
a
n
d
3
5
.
8
4
%
h
a
d
re
c
u
rre
n
c
e
stro
k
e
.
F
a
c
t
o
r:
N
o
t
d
ri
n
k
in
g
a
lco
h
o
l
wa
s
6
.
1
1
ti
m
e
s
m
o
re
th
a
n
d
ri
n
k
in
g
(a
d
j
.
O
R=
6
.
1
1
,
9
5
%
CI:
4
.
8
8
to
1
0
.
0
4
)
.
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e
re
wa
s
no
re
c
u
rre
n
c
e
of
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with
sta
t
isti
c
a
l
sig
n
ifi
c
a
n
c
e
at
th
e
0
.
0
5
le
v
e
l.
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h
u
n
d
e
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n
d
i
n
g
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il
l
4
.
4
3
ti
m
e
s
(a
d
j.
OR=
4
.
4
3
,
9
5
%
CI=
3
.
4
4
to
5
.
5
8
),
a
n
d
h
ig
h
a
p
p
ly
sk
il
l
3
.
6
7
ti
m
e
s
(a
d
j.
OR=
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.
6
7
,
9
5
%
CI=
2
.
4
4
to
8
.
1
8
)
th
a
n
lo
w
a
n
d
m
o
d
e
ra
te
lev
e
ls.
S
tatisti
c
a
ll
y
sig
n
ifi
c
a
n
t
at
th
e
0
.
0
5
lev
e
l.
P
e
r
fin
d
i
n
g
s
,
h
e
a
lt
h
li
tera
c
y
s
h
o
u
ld
be
a
c
ti
v
e
l
y
p
ro
m
o
te
d
to
p
re
v
e
n
t
str
o
k
e
re
c
u
rr
e
n
c
e
.
K
ey
w
o
r
d
s
:
Ass
o
ciate
d
f
ac
to
r
s
Hea
lth
liter
ac
y
No
n
-
r
ec
u
r
r
e
n
ce
s
tr
o
k
e
R
ec
u
r
r
en
ce
s
tr
o
k
e
Stro
k
e
p
atien
ts
T
h
is
is
an
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r
th
e
CC
BY
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
W
an
id
a
Srip
r
o
m
s
a
Facu
lty
of
Nu
r
s
in
g
,
Pra
b
o
r
o
m
ar
ajch
an
o
k
I
n
s
titu
te
No
n
th
ab
u
r
i,
T
h
ailan
d
E
-
m
ail
:
k
ao
g
r
an
d
@
h
o
tm
ail
.
co
m
1.
I
NT
RO
D
UCT
I
O
N
Stro
k
e
is
a
s
ilen
t
k
iller
an
d
is
th
e
lead
in
g
ca
u
s
e
of
d
is
ab
ilit
y
an
d
th
e
s
ec
o
n
d
lead
in
g
ca
u
s
e
of
d
ea
th
wo
r
ld
wid
e.
Fro
m
1
9
9
0
to
2
0
1
9
,
th
e
r
ate
of
s
tr
o
k
e
i
n
cr
ea
s
ed
by
7
0
%,
d
ea
th
s
attr
ib
u
tab
le
to
s
tr
o
k
e
in
cr
ea
s
ed
by
4
3
%,
th
e
p
r
ev
alen
ce
of
s
tr
o
k
e
in
cr
ea
s
ed
by
1
0
2
%,
an
d
d
is
ab
ilit
y
-
ad
ju
s
ted
life
y
ea
r
s
(
D
AL
Y)
in
cr
ea
s
ed
by
1
4
3
%.
T
h
e
2
0
2
2
Glo
b
al
Stro
k
e
Fact
Sh
ee
t
r
ev
ea
ls
th
at
th
e
life
tim
e
r
is
k
of
d
ev
el
o
p
in
g
a
s
t
r
o
k
e
h
as
in
cr
ea
s
ed
by
50%
o
v
er
th
e
p
ast
17
y
ea
r
s
,
an
d
1
in
4
p
eo
p
le
is
esti
m
a
ted
to
h
av
e
a
s
tr
o
k
e
in
th
eir
life
tim
e.
T
h
e
m
o
s
t
s
tr
ik
in
g
f
ea
tu
r
e
is
th
at
th
e
b
u
lk
of
th
e
g
lo
b
al
s
tr
o
k
e
b
u
r
d
en
(
8
6
%
of
d
ea
th
s
due
to
s
tr
o
k
e
a
n
d
89%
of
DAL
Ys)
o
cc
u
r
s
in
lo
wer
an
d
lo
wer
-
m
id
d
le
-
in
co
m
e
co
u
n
tr
ies.
T
h
is
d
is
p
r
o
p
o
r
tio
n
ate
b
u
r
d
en
is
b
o
r
n
e
by
lo
w
-
a
n
d
m
id
d
le
-
in
co
m
e
c
o
u
n
tr
ies,
cr
ea
tin
g
u
n
p
r
ec
e
d
en
ted
p
r
o
b
lem
s
f
o
r
lo
wer
-
in
c
o
m
e
f
am
ilies
.
Stro
k
e
E
p
id
em
io
l
o
g
y
in
T
h
ailan
d
R
ep
o
r
t
of
th
e
Div
is
io
n
of
No
n
c
o
m
m
u
n
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le
Dis
ea
s
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th
e
Min
i
s
tr
y
of
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b
lic
Hea
lth
in
2
0
2
1
[
1
]
f
o
u
n
d
th
e
r
ate
of
s
tr
o
k
e
p
er
1
0
0
,
0
0
0
p
o
p
u
latio
n
in
2
0
1
7
–
2
0
1
9
to
be
4
6
7
.
4
6
,
5
0
6
.
2
0
,
an
d
5
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.
5
4
,
r
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tiv
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d
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ate
f
r
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s
tr
o
k
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p
e
r
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0
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0
p
o
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u
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4
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8
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1
5
,
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d
5
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9
7
,
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esp
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tiv
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.
In
th
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No
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th
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th
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s
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k
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r
ate
p
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2017
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4
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8
9
,
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
5
1
5
-
1
5
2
0
1516
r
esp
ec
tiv
ely
,
an
d
t
h
e
d
ea
th
r
at
e
f
r
o
m
s
tr
o
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1
0
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0
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p
o
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latio
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was
3
9
.
0
6
,
3
9
.
9
4
,
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d
4
5
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3
2
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r
esp
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.
[
2
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.
Fro
m
th
e
d
ata,
it
is
f
o
u
n
d
th
at
th
e
m
o
r
b
id
ity
an
d
m
o
r
tality
r
ates
at
th
e
n
atio
n
al
lev
el
ar
e
h
ig
h
an
d
in
cr
ea
s
in
g
ev
er
y
y
ea
r
,
esp
ec
ially
in
th
e
No
r
th
ea
s
ter
n
r
eg
i
o
n
,
wh
ich
in
th
e
p
ast
h
ad
lo
wer
m
o
r
b
id
ity
an
d
m
o
r
tality
r
ates
f
r
o
m
s
tr
o
k
e
th
an
o
th
e
r
r
e
g
io
n
s
.
Ho
wev
e
r
,
at
p
r
esen
t,
it
is
f
o
u
n
d
th
at
th
e
m
o
r
b
id
ity
an
d
d
ea
t
h
r
ates
ar
e
h
ig
h
an
d
in
c
r
ea
s
in
g
ev
er
y
y
ea
r
.
Stro
k
e
is
a
lead
in
g
ca
u
s
e
of
d
ea
th
an
d
d
is
ab
ilit
y
in
T
h
ailan
d
.
It
is
esti
m
ated
th
at
th
er
e
ar
e
more
th
an
2
5
0
,
0
0
0
n
ew
ca
s
es
of
s
tr
o
k
e
each
y
ea
r
.
Stro
k
e
is
r
esp
o
n
s
ib
le
f
o
r
5
0
,
0
0
0
d
ea
th
s
p
er
y
ea
r
.
Alar
m
in
g
s
ta
tis
tics
f
r
o
m
T
h
ailan
d
'
s
Min
is
tr
y
of
Pu
b
lic
Hea
lth
r
a
n
k
s
tr
o
k
e
as
th
e
f
ir
s
t
m
o
s
t
co
m
m
o
n
ca
u
s
e
of
d
ea
th
f
o
r
b
o
th
wo
m
en
an
d
m
en
[
3
]
,
[
4
]
.
Stro
k
e
r
elate
d
m
o
r
tality
is
u
n
f
o
r
tu
n
ate,
but
f
o
r
th
e
s
u
r
v
iv
o
r
s
,
s
tr
o
k
e
p
lace
s
a
s
ig
n
if
ican
t
b
u
r
d
en
of
d
is
ab
ilit
y
on
p
atien
ts
an
d
th
eir
f
am
ilies
.
It
is
co
n
s
id
er
ed
to
h
av
e
th
e
h
i
g
h
est
d
is
ea
s
e
b
u
r
d
en
in
T
h
ailan
d
.
It
is
m
ea
s
u
r
ed
in
d
is
ab
ilit
y
-
ad
j
u
s
ted
life
y
ea
r
s
(
DAL
Ys)
in
f
em
ales
an
d
th
ir
d
in
m
ales
[
3
]
,
[
5
]
.
I
s
ch
em
ic
s
tr
o
k
e
T
h
er
e
a
r
e
r
is
k
f
ac
to
r
s
,
in
clu
d
in
g
:
ag
e
,
an
x
iety
,
d
ep
r
ess
io
n
,
an
d
h
ig
h
s
tr
ess
lev
els,
d
iab
etes
m
ellitu
s
,
h
y
p
e
r
ten
s
io
n
,
o
b
esit
y
h
y
p
er
lip
id
em
ia,
s
leep
ap
n
ea
,
an
d
h
y
p
er
li
p
id
em
ia
.
L
if
esty
le
ch
a
n
g
es
T
h
is
in
clu
d
es
q
u
itti
n
g
s
m
o
k
in
g
.
R
ed
u
ce
alco
h
o
l
u
s
e
an
d
in
cr
ea
s
e
ex
er
cise.
It
is
also
im
p
o
r
tan
t
in
m
a
n
ag
in
g
p
atien
ts
with
a
h
is
to
r
y
of
s
tr
o
k
e
d
is
ea
s
e
or
tr
an
s
ien
t
is
ch
em
ic
attac
k
[
6
]
–
[
9
]
.
A
r
ec
u
r
r
e
n
t
s
tr
o
k
e
is
wh
en
a
p
er
s
o
n
h
as
an
o
th
e
r
s
tr
o
k
e
af
te
r
th
e
f
ir
s
t
s
tr
o
k
e.
R
ec
u
r
r
en
ce
can
h
av
e
a
s
ig
n
if
ican
t
im
p
ac
t
on
a
p
er
s
o
n
'
s
q
u
ality
of
life
.
Var
io
u
s
s
tu
d
i
es
i
t
was
f
o
u
n
d
t
h
at
th
e
r
ec
u
r
r
en
ce
r
ate
of
s
tr
o
k
es
was
d
if
f
er
en
t.
Hav
in
g
h
ad
o
n
e
s
tr
o
k
e
is
a
r
is
k
f
ac
to
r
f
o
r
h
av
in
g
a
n
o
th
e
r
s
tr
o
k
e.
In
g
en
e
r
al,
th
e
ca
u
s
e
of
a
r
ec
u
r
r
en
t
s
tr
o
k
e
is
th
e
s
am
e
as
th
e
ca
u
s
e
of
th
e
f
ir
s
t
s
tr
o
k
e.
T
wo
ty
p
es
of
s
tr
o
k
es
can
o
cc
u
r
an
is
ch
em
ic
s
tr
o
k
e
an
d
a
h
em
o
r
r
h
ag
ic
s
tr
o
k
e
[
1
0
]
.
Stan
d
ar
d
tr
ea
tm
e
n
t
f
o
r
ac
u
te
is
ch
em
ic
s
tr
o
k
e
is
th
e
u
s
e
of
t
h
r
o
m
b
o
ly
s
is
with
in
4
.
5
h
o
u
r
s
of
s
y
m
p
to
m
o
n
s
et
[
1
1
]
.
Stro
k
e
tr
ea
tm
e
n
t
h
as
a
tr
ea
tm
en
t
ap
p
r
o
ac
h
f
o
cu
s
ed
p
r
im
ar
ily
on
r
esto
r
in
g
b
lo
o
d
f
l
o
w
to
th
e
b
r
ain
an
d
h
ea
lin
g
th
e
n
eu
r
o
lo
g
ical
d
am
a
g
e
ca
u
s
ed
by
t
h
e
s
tr
o
k
e
[
1
2
]
.
A
r
ev
iew
of
h
ea
lth
liter
ac
y
liter
atu
r
e
f
o
u
n
d
th
at
h
ea
lth
liter
ac
y
is
th
e
ab
ilit
y
to
o
b
tain
,
ac
ce
s
s
,
a
n
d
a
r
ev
ie
w
of
h
ea
lth
liter
ac
y
liter
atu
r
e
f
o
u
n
d
th
at
h
ea
lth
lit
er
ac
y
is
th
e
ab
ilit
y
to
o
b
tain
,
ac
ce
s
s
,
u
n
d
er
s
tan
d
,
ap
p
r
aise,
an
d
ap
p
ly
ess
en
tial
h
ea
lth
in
f
o
r
m
atio
n
f
o
r
p
r
o
m
o
tin
g
b
etter
h
ea
lth
m
ay
be
a
m
ajo
r
o
b
s
tacle
to
th
e
life
s
ty
le
of
s
tr
o
k
e
p
atien
ts
,
r
ed
u
cin
g
th
eir
r
is
k
of
s
tr
o
k
e
[
1
3
]
.
Patien
ts
with
in
s
u
f
f
icie
n
t
h
ea
lth
liter
ac
y
h
av
e
b
ee
n
s
h
o
wn
to
h
av
e
less
u
n
d
er
s
tan
d
i
n
g
of
th
eir
m
ed
ic
al
co
n
d
itio
n
s
.
T
h
er
ef
o
r
e,
lo
w
liter
ac
y
is
a
s
s
o
ciate
d
with
p
r
o
b
lem
s
p
r
ev
e
n
tin
g
d
is
ea
s
e
r
is
k
.
Dela
y
ed
d
iag
n
o
s
is
l
ow
s
elf
-
ca
r
e
s
k
ills
L
ac
k
of
u
n
d
er
s
tan
d
i
n
g
of
m
ed
ical
ad
v
ice
an
d
f
o
llo
win
g
p
h
y
s
ician
ad
v
ice.
Fo
r
th
is
r
e
aso
n
,
th
e
U.
S.
Su
r
g
eo
n
Gen
er
al
h
as
id
en
tifie
d
h
ea
lth
liter
ac
y
as
a
n
atio
n
al
p
r
io
r
ity
t
h
at
s
h
o
u
l
d
be
d
e
v
elo
p
ed
[
1
4
]
,
[
1
5
]
.
T
h
e
r
ef
o
r
e
,
t
h
e
r
esear
ch
er
wo
u
l
d
lik
e
to
s
tu
d
y
th
e
f
ac
to
r
s
ass
o
ciate
d
with
h
ea
lth
liter
ac
y
an
d
th
e
r
ec
u
r
r
en
ce
of
s
tr
o
k
e
a
m
o
n
g
s
tr
o
k
e
p
atien
ts
in
T
h
ailan
d
to
cr
ea
te
h
ea
lth
p
r
o
m
o
tio
n
g
u
id
elin
es
f
o
r
p
r
ev
en
tin
g
s
tr
o
k
e
r
ec
u
r
r
e
n
ce
.
2.
M
E
T
H
O
D
T
h
e
p
o
p
u
latio
n
in
th
is
s
tu
d
y
of
s
tr
o
k
e
p
atien
ts
in
n
o
r
t
h
ea
s
ter
n
,
T
h
ailan
d
,
by
s
im
p
l
e
r
an
d
o
m
s
am
p
lin
g
.
T
h
e
No
r
t
h
ea
s
ter
n
r
eg
io
n
c
o
n
s
is
ts
of
f
o
u
r
r
eg
i
o
n
s
.
R
ep
r
esen
tativ
es
f
r
o
m
4
r
e
g
io
n
s
co
n
s
is
tin
g
of
4
p
r
o
v
in
ce
s
wer
e
r
an
d
o
m
ly
s
elec
ted
,
an
d
th
e
p
r
o
v
in
cial
r
ep
r
esen
tativ
es
wer
e
r
an
d
o
m
l
y
s
elec
ted
as
4
s
u
b
-
d
is
tr
ict
h
ea
lth
p
r
o
m
o
tio
n
h
o
s
p
itals
.
T
h
en
th
e
s
am
p
le
was
s
elec
ted
ac
co
r
d
in
g
to
th
e
in
cl
u
s
io
n
cr
iter
i
a.
T
h
e
s
am
p
le
s
ize
ca
lcu
latio
n
is
b
ased
on
a
f
o
r
m
u
la
th
at
is
s
im
p
lifie
d
f
o
r
m
u
ltip
le
lo
g
is
tic
r
eg
r
ess
io
n
in
th
e
an
aly
s
is
[
1
6
]
.
T
h
e
f
o
r
m
u
la
is
ad
ju
s
ted
ac
co
r
d
in
g
to
th
e
in
f
lu
en
ce
of
th
e
r
elatio
n
s
h
ip
b
etwe
en
in
d
ep
en
d
en
t
v
ar
iab
les
with
th
e
v
ar
ian
ce
in
f
latio
n
f
ac
to
r
(
V
I
F).
R
esear
ch
to
o
ls
u
s
in
g
s
am
p
le
q
u
esti
o
n
n
air
es.
Acc
o
r
d
in
g
to
th
e
esti
m
atio
n
s
ca
le,
ap
p
lied
r
esear
ch
to
o
ls
h
av
e
f
o
u
r
lev
els:
in
s
u
f
f
icien
t,
p
r
o
b
lem
atic,
s
u
f
f
icien
t
an
d
ex
ce
llen
t
[
1
7
]
.
T
h
e
r
eliab
ilit
y
of
th
e
q
u
esti
o
n
n
air
e
was
v
alid
ated
th
r
o
u
g
h
a
q
u
esti
o
n
n
air
e
tr
y
-
o
u
t.
T
h
e
n
an
aly
ze
r
eliab
ilit
y
.
C
r
o
n
b
ac
h
'
s
co
ef
f
icien
t
m
eth
o
d
was
u
s
e
d
.
T
h
e
C
r
o
n
b
ac
h
'
s
alp
h
a
c
o
ef
f
icien
t
o
f
th
e
h
ea
lth
liter
ac
y
f
o
r
r
ec
u
r
r
e
n
ce
s
tr
o
k
e
s
ca
le
was 0
.
8
0
.
R
esear
ch
eth
ics
T
h
is
r
esear
ch
p
r
o
t
o
co
l
h
as
b
e
en
r
ev
iewe
d
by
th
e
Sirin
d
h
o
r
n
C
o
lleg
e
of
Pu
b
lic
Hea
lth
I
n
s
titu
tio
n
al
R
ev
iew
B
o
ar
d
(
SC
PHKKI
R
B
)
.
T
h
e
e
th
ical
n
u
m
b
er
was
HE
6
5
2
0
8
5
g
r
an
ted
on
Dec
em
b
er
2
6
t
h
,
2
0
2
2
.
3.
RE
SU
L
T
S
AND
D
I
SCU
SS
I
O
N
3
.
1
.
G
ener
a
l
info
rm
a
t
i
o
n
T
h
e
r
esu
lts
of
th
e
s
tu
d
y
co
n
s
is
ted
of
240
s
am
p
les,
m
o
s
tly
f
em
ale,
7
0
.
0
9
%,
ag
e
≥
60
y
ea
r
s
6
5
.
5
5
%,
body
m
ass
in
d
ex
o
v
e
r
weig
h
t
6
0
%,
d
u
al
f
am
ily
s
tatu
s
6
6
.
4
4
%,
ed
u
ca
tio
n
lev
el
s
ec
o
n
d
ar
y
s
ch
o
o
l8
1
.
0
1
%,
d
is
ea
s
e
d
iab
etes
m
ellitu
s
2
7
.
1
3
%,
d
is
ea
s
e
Hig
h
b
lo
o
d
p
r
ess
u
r
e
5
0
.
6
0
%,
d
u
r
atio
n
of
s
tr
o
k
e
with
in
3
–
5
y
ea
r
s
6
2
%,
n
o
n
-
s
m
o
k
in
g
9
4
.
9
6
%,
Do
n
o
t
d
r
in
k
alco
h
o
lic
b
e
v
er
ag
es
9
5
.
8
4
%,
do
n
o
t
u
s
e
n
o
n
s
ter
o
i
d
al
an
ti
-
in
f
lam
m
ato
r
y
d
r
u
g
s
8
5
.
6
6
%,
do
n
o
t
u
s
e
h
er
b
al
m
e
d
icin
e
6
5
.
8
9
%,
co
m
e
to
s
ee
t
h
e
d
o
cto
r
as
p
er
ap
p
o
in
tm
en
t
9
9
%,
an
d
ta
k
e
m
ed
icin
e
as
p
r
e
s
cr
ib
ed
by
t
h
e
d
o
ct
o
r
9
5
.
0
1
%.
an
d
3
5
.
8
4
%
h
a
d
r
ec
u
r
r
en
t
s
to
k
e.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
s
s
o
cia
ted
fa
cto
r
s
o
f n
o
n
-
r
ec
u
r
r
en
ce
s
tr
o
ke
a
mo
n
g
s
tr
o
ke
p
a
tien
ts
in
Th
a
ila
n
d
(
I
s
a
r
ee
P
a
d
p
h
a
i
)
1517
3
.
2
.
H
ea
lt
h
lite
ra
cy
lev
el
Acc
ess
s
k
ill
was
f
o
u
n
d
to
h
av
e
s
co
r
es
at
th
e
m
o
s
t
p
r
o
b
lem
atic
lev
el;
60
p
er
ce
n
t
h
a
d
an
av
e
r
ag
e
s
co
r
e
of
14
.
18
(
SD
=
3
.
22
)
;
u
n
d
e
r
s
tan
d
s
k
ill
h
ad
s
co
r
es
at
th
e
lo
w
lev
el;
54
.
20
p
e
r
ce
n
t
h
ad
an
a
v
er
ag
e
s
co
r
e
of
7
.
31
(
SD
=
1
.
99
).
A
p
p
r
aisal
s
k
ill
was
f
o
u
n
d
to
h
av
e
a
s
co
r
e
at
th
e
m
o
s
t
p
r
o
b
lem
atic
lev
el,
48
.
34
p
er
ce
n
t,
with
an
av
er
ag
e
s
co
r
e
of
15
.
55
(
SD
=
2
.
88
).
an
d
ap
p
ly
s
k
ill,
f
o
u
n
d
to
h
av
e
a
s
co
r
e
at
th
e
m
o
s
t
p
r
o
b
l
em
atic
lev
el,
47
.
92
p
er
ce
n
t,
with
an
av
er
a
g
e
s
co
r
e
of
32
.
94
(
SD
=
4
.
65
).
as
d
etail
ed
in
T
ab
le
1
.
T
ab
le
1
.
Hea
lth
liter
ac
y
le
v
el
(
n
=
240
)
H
e
a
l
t
h
l
i
t
e
r
a
c
y
l
e
v
e
l
s
N
u
mb
e
r
P
e
r
c
e
n
t
a
g
e
1
.
A
c
c
e
s
s
s
k
i
l
l
(
M
a
x
=
25
)
I
n
su
f
f
i
c
i
e
n
t
26
10
.
83
P
r
o
b
l
e
ma
t
i
c
1
4
4
60
S
u
f
f
i
c
i
e
n
t
56
23
.
33
Ex
c
e
l
l
e
n
t
14
5
.
84
M
e
a
n
(
S
t
a
n
d
a
r
d
d
e
v
i
a
t
i
o
n
)
(
14
.
18
)
±
3
.
22
M
e
d
i
a
n
(
M
i
n
:
M
a
x
)
15
(
9
:
24
)
2
.
U
n
d
e
r
st
a
n
d
s
k
i
l
l
(
M
a
x
=
10
)
Lo
w
1
3
0
54
.
20
H
i
g
h
1
1
0
45
.
80
M
e
a
n
(
S
t
a
n
d
a
r
d
d
e
v
i
a
t
i
o
n
)
(
7
.
31
)
±
1
.
99
M
e
d
i
a
n
(
M
i
n
:
M
a
x
)
7
(
3
:
10
)
3
.
A
p
p
r
a
i
s
e
s
k
i
l
l
(
M
a
x
=
25
)
I
n
su
f
f
i
c
i
e
n
t
16
6
.
66
P
r
o
b
l
e
ma
t
i
c
1
1
6
48
.
34
S
u
f
f
i
c
i
e
n
t
1
0
2
42
.
50
Ex
c
e
l
l
e
n
t
6
2
.
5
M
e
a
n
(
S
t
a
n
d
a
r
d
D
e
v
i
a
t
i
o
n
)
(
15
.
55
)
±
2
.
88
M
e
d
i
a
n
(
M
i
n
:
M
a
x
)
15
(
11
:
25
)
4
.
A
p
p
l
y
s
k
i
l
l
(
M
a
x
=
5
0
)
I
n
su
f
f
i
c
i
e
n
t
16
6
.
66
P
r
o
b
l
e
ma
t
i
c
1
1
5
47
.
92
S
u
f
f
i
c
i
e
n
t
97
40
.
42
Ex
c
e
l
l
e
n
t
12
5
.
00
M
e
a
n
(
S
t
a
n
d
a
r
d
d
e
v
i
a
t
i
o
n
)
(
32
.
94
)
±
4
.
65
M
e
d
i
a
n
(
M
i
n
:
M
a
x
)
32
(
19
:
47
)
3
.
3
.
Ana
ly
s
is
of
f
a
ct
o
rs
a
nd
re
la
t
i
o
ns
hip
s
bet
wee
n
hea
lt
h
lite
r
a
cy
a
nd
re
curr
ence
s
t
ro
k
e
.
Fro
m
th
e
a
n
aly
s
is
of
o
v
er
all
s
t
r
o
k
e
p
atien
ts
,
it
was
f
o
u
n
d
t
h
a
t,
Facto
r
:
No
t
d
r
in
k
in
g
alco
h
o
l
was
6
.
11
tim
es
more
th
a
n
d
r
in
k
i
n
g
(
ad
j
.
OR
=
6
.
11,
95
%
CI
:
4
.
88
to
10
.
04
).
T
h
e
r
e
was
no
r
ec
u
r
r
en
ce
of
s
tr
o
k
e
with
s
tatis
t
ical
s
ig
n
if
ican
ce
at
th
e
0
.
05
lev
el
.
Hig
h
u
n
d
er
s
tan
d
s
s
k
ill
4
.
43
tim
es
(
ad
j
.
OR
=
4
.
4
3
,
95
%
CI
=
3
.
44
to
5
.
58
)
,
a
n
d
h
ig
h
ap
p
ly
s
k
ill
3
.
67
tim
es
(
ad
j
.
OR
=
3
.
67,
95
%
CI
=
2
.
44
to
8
.
13
)
th
an
lo
w
a
n
d
m
o
d
er
ate
lev
els
.
Statis
t
ically
s
ig
n
if
ican
t
at
th
e
0
.
05
lev
el
.
(
L
o
w
–
m
o
d
er
ate
=
in
s
u
f
f
icien
t,
p
r
o
b
lem
atic,
Hig
h
=
s
u
f
f
icien
t,
ex
ce
llen
t
)
as
d
etailed
in
T
a
b
le
2
.
T
ab
le
2
.
T
he
GL
MM
lo
g
is
tic
r
eg
r
ess
io
n
an
aly
s
is
(
n
=
2
4
0
)
C
a
t
e
g
o
r
y
N
u
mb
e
r
s
%
non
r
e
c
u
r
r
e
n
c
e
of
st
r
o
k
e
C
r
u
d
e
OR
A
d
j
u
st
e
d
OR
95
%
CI
p
-
v
a
l
u
e
1
.
A
l
c
o
h
o
l
i
c
D
r
i
n
k
10
4
.
16
1
1
1
<
0
.
001
N
o
t
d
r
i
n
k
2
3
0
95
.
84
7
.
10
6
.
11
4
.
88
to
10
.
04
2
.
U
n
d
e
r
st
a
n
d
s
k
i
l
l
Lo
w
–
m
o
d
e
r
a
t
e
1
3
0
10
.
58
1
1
1
<
0
.
001
H
i
g
h
1
1
0
44
.
40
5
.
59
4
.
43
3
.
44
to
5
.
58
3
.
A
p
p
l
y
s
k
i
l
l
Lo
w
–
m
o
d
e
r
a
t
e
1
3
1
16
.
00
1
1
11
<
0
.
001
H
i
g
h
1
0
9
52
.
77
4
.
88
3
.
67
2
.
44
to
8
.
18
p
≤.
05
*
3
.
4
.
Dis
cu
s
s
io
n
Mo
s
t
of
th
e
s
am
p
le
g
r
o
u
p
h
ad
h
ea
lth
liter
ac
y
to
p
r
ev
e
n
t
r
ec
u
r
r
en
ce
at
th
e
p
r
o
b
le
m
atic
lev
el
(
51
.
28
%)
,
co
n
s
is
ten
t
with
r
ese
ar
ch
th
at
f
o
u
n
d
th
at
s
tr
o
k
e
d
is
ea
s
e
h
as
lo
w
h
ea
lth
liter
ac
y
lev
els
[
1
8
]
,
[
1
9
]
T
h
is
can
be
ex
p
lain
ed
as
:
Hea
lth
lit
er
ac
y
is
r
elate
d
to
u
n
d
er
s
tan
d
i
n
g
.
Fu
r
th
er
m
o
r
e,
I
h
av
e
ac
ce
s
s
to
ac
cu
r
ate
h
ea
lt
h
in
f
o
r
m
atio
n
to
tak
e
ap
p
r
o
p
r
i
ate
ac
tio
n
an
d
f
o
llo
w
tr
ea
tm
en
t
r
ec
o
m
m
en
d
atio
n
s
.
Patien
ts
with
in
ad
eq
u
ate
h
ea
lth
liter
ac
y
r
ep
o
r
te
d
a
p
o
o
r
er
u
n
d
er
s
tan
d
i
n
g
of
th
eir
m
e
d
ical
co
n
d
itio
n
s
an
d
p
o
o
r
s
elf
-
m
an
ag
em
en
t
s
k
ills
.
L
ac
k
of
u
n
d
er
s
tan
d
in
g
of
m
e
d
ical
ad
v
ice
an
d
lo
w
a
d
h
er
e
n
ce
to
tr
ea
tm
en
t
r
ec
o
m
m
e
n
d
ati
o
n
s
in
f
lu
en
ce
h
ea
lth
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2252
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
3
,
No
.
4
,
Dec
em
b
er
20
24
:
1
5
1
5
-
1
5
2
0
1518
liter
ac
y
lev
els,
in
f
lu
en
ce
d
by
v
ar
io
u
s
d
eter
m
i
n
an
ts
.
T
h
e
m
o
s
t
f
r
eq
u
en
tly
m
e
n
tio
n
e
d
f
ac
to
r
s
wer
e
ed
u
ca
tio
n
,
ag
e,
an
d
s
o
cio
ec
o
n
o
m
ic
f
ac
to
r
s
[
2
0
]
–
[
2
3
]
.
T
h
is
m
a
y
be
due
to
th
e
lack
of
d
e
v
elo
p
m
e
n
t
in
h
ea
lth
liter
ac
y
,
lim
itatio
n
s
in
ac
ce
s
s
in
g
r
eli
ab
le
h
ea
lth
i
n
f
o
r
m
atio
n
,
an
d
lim
itatio
n
s
in
h
a
v
in
g
m
o
d
e
r
n
co
m
m
u
n
icatio
n
eq
u
ip
m
en
t
with
a
co
m
p
r
e
h
en
s
iv
e
in
ter
n
et
s
ig
n
al
n
etwo
r
k
d
if
f
er
en
t
f
r
o
m
r
esear
ch
.
It
wa
s
f
o
u
n
d
th
at
s
tr
o
k
e
p
atien
ts
ex
h
ib
ited
ap
p
r
o
p
r
iate
s
tr
o
k
e
k
n
o
wled
g
e
an
d
p
er
f
o
r
m
ed
m
o
d
e
r
ate
to
h
ig
h
lev
els
of
h
ea
lth
-
p
r
o
m
o
tin
g
b
eh
av
io
r
s
[
2
4
]
.
It
was
f
o
u
n
d
to
be
d
if
f
er
e
n
t
f
r
o
m
s
tu
d
ies
th
at
f
o
u
n
d
th
at
m
o
s
t
of
th
e
s
am
p
le
h
ad
h
ea
lth
liter
ac
y
at
a
s
u
f
f
icien
t
lev
el
b
ec
au
s
e
h
ea
lth
liter
ac
y
is
an
im
p
o
r
tan
t
f
ac
to
r
to
c
o
n
s
id
er
in
p
o
s
t
-
s
tr
o
k
e
r
eh
ab
ilit
atio
n
[
2
5
]
.
B
ec
au
s
e
h
e
alth
liter
ac
y
h
as
alr
ea
d
y
b
ee
n
d
ev
elo
p
e
d
.
Facto
r
s
f
o
r
not
d
r
in
k
i
n
g
alc
o
h
o
l
:
6
.
11
tim
es
more
th
an
d
r
i
n
k
in
g
,
wh
ich
is
co
n
s
is
ten
t
with
r
esear
ch
th
at
f
o
u
n
d
d
r
in
k
in
g
alco
h
o
l
is
a
f
ac
to
r
af
f
ec
tin
g
r
ec
u
r
r
en
ce
r
ates
b
ec
au
s
e
d
r
in
k
in
g
alco
h
o
l
will
r
esu
lt
in
h
ig
h
er
b
lo
o
d
p
r
ess
u
r
e
an
d
d
r
i
n
k
in
g
l
ar
g
e
am
o
u
n
ts
of
alco
h
o
l
will
wea
k
en
th
e
b
lo
o
d
an
d
m
a
k
e
it
d
if
f
icu
lt
to
s
to
p
.
W
h
en
th
e
r
u
p
tu
r
e
of
a
b
lo
o
d
v
ess
el
in
th
e
b
r
ain
is
co
m
b
in
ed
with
h
ig
h
b
lo
o
d
p
r
ess
u
r
e,
it
in
cr
ea
s
es
b
r
ain
tis
s
u
e
d
am
ag
e
an
d
in
cr
ea
s
es
b
r
ain
t
is
s
u
e
d
am
ag
e
.
It
will
h
av
e
th
e
ef
f
ec
t
of
not
s
tim
u
latin
g
th
e
r
ec
u
r
r
en
ce
of
th
e
d
is
ea
s
e
an
d
p
r
o
m
o
tin
g
th
e
r
e
co
v
er
y
of
s
tr
o
k
e
[
2
6
]
,
[
2
7
]
,
wh
ich
was
f
o
u
n
d
to
be
co
n
s
i
s
ten
t
with
r
esear
ch
ass
o
ciate
d
to
a
less
er
ex
ten
t
with
h
ea
lth
an
d
b
eh
a
v
io
r
al
f
ac
to
r
s
s
u
ch
as
h
ig
h
alco
h
o
l
co
n
s
u
m
p
tio
n
[
2
8
]
.
Hig
h
-
lev
el
u
n
d
er
s
tan
d
in
g
s
k
il
ls
ar
e
more
th
a
n
lo
w
-
lev
el
an
d
m
o
d
e
r
ate
4
.
43
tim
es,
b
ec
a
u
s
e
a
h
ig
h
lev
el
of
u
n
d
er
s
tan
d
i
n
g
will
r
e
s
u
lt
in
s
tr
o
k
e
p
atien
ts
h
a
v
in
g
an
u
n
d
er
s
tan
d
in
g
of
th
e
g
u
id
e
lin
es
f
o
r
p
r
ev
en
tin
g
r
ec
u
r
r
en
ce
s
tr
o
k
e
an
d
h
a
v
in
g
th
e
in
tellectu
al
ab
ilit
y
to
th
in
k
an
aly
tically
,
r
ef
lect,
an
d
ch
ec
k
r
eliab
ilit
y
with
ca
u
s
e
an
d
ef
f
ec
t
.
To
put
in
to
p
r
ac
tice
to
p
r
ev
e
n
t
r
ec
u
r
r
e
n
ce
s
tr
o
k
es
an
d
h
i
g
h
a
p
p
ly
s
k
ill
is
3
.
67
tim
es
g
r
ea
ter
th
an
lo
w
an
d
m
o
d
er
ate
b
ec
a
u
s
e
h
ig
h
-
ap
p
l
y
s
k
ills
wi
ll
r
es
u
lt
in
s
tr
o
k
e
p
atien
ts
h
av
in
g
th
e
ab
ilit
y
to
m
ak
e
d
ec
is
io
n
s
.
Ag
r
ee
in
g
to
ac
h
iev
e
an
i
n
ten
tio
n
or
ch
o
ice
f
o
r
wh
ich
o
n
e
can
be
r
esp
o
n
s
ib
le
lead
s
to
d
ec
is
io
n
-
m
ak
in
g
a
n
d
s
elec
tio
n
to
p
r
ev
en
t
a
r
ec
u
r
r
en
ce
of
s
tr
o
k
e
,
c
o
n
s
is
ten
t
with
r
esear
ch
as
:
Stro
k
e
p
atie
n
ts
with
in
s
u
f
f
icien
t
h
ea
lth
liter
ac
y
h
ad
s
ig
n
if
ican
tly
lo
wer
m
ea
n
h
ea
l
th
liter
ac
y
s
co
r
es
th
an
th
o
s
e
w
ith
ad
eq
u
ate
h
ea
lth
liter
ac
y
[
2
9
]
.
A
nd
f
o
u
n
d
th
at
l
o
w
h
ea
lth
liter
ac
y
in
cr
ea
s
es
th
e
r
is
k
of
a
d
v
er
s
e
s
tr
o
k
e
-
r
elate
d
h
ea
lth
o
u
tco
m
es
[
2
1
]
.
A
nd
r
elate
d
to
h
ea
lth
liter
ac
y
,
is
r
elate
d
to
h
ea
lth
s
tat
u
s
an
d
h
ea
lth
b
eh
av
io
r
in
p
ati
en
ts
with
co
r
o
n
ar
y
ar
ter
y
d
is
ea
s
e
.
an
d
p
r
e
v
en
tio
n
of
ca
r
d
io
v
ascu
lar
d
is
ea
s
e
[
3
0
]
.
A
nd
is
co
n
s
is
ten
t
with
s
tu
d
ies
th
at
h
av
e
f
o
u
n
d
h
ig
h
er
h
ea
lth
liter
ac
y
m
ay
co
n
tr
ib
u
te
to
p
ar
ticip
atio
n
in
ce
r
tain
s
elf
-
m
an
ag
e
m
en
t
ac
tiv
iti
es
.
T
h
is
m
ad
e
t
h
e
s
elf
-
ca
r
e
of
th
e
s
u
b
jects
at
th
e
h
ig
h
lev
el
b
etter
th
an
at
t
h
e
lo
w
an
d
m
o
d
er
ate
lev
els
[
3
1
]
.
4.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
s
h
o
ws
th
at
a
s
s
o
cia
ted
f
ac
to
r
s
of
non
-
r
ec
u
r
r
e
n
ce
s
tr
o
k
e
am
o
n
g
s
tr
o
k
e
p
atien
ts
,
in
clu
d
in
g
not
d
r
in
k
in
g
alco
h
o
l,
h
ea
lth
li
ter
ac
y
,
in
clu
d
i
n
g
u
n
d
er
s
tan
d
i
n
g
an
d
a
p
p
ly
in
g
s
k
ills
,
can
be
u
s
ed
as
g
u
id
elin
es
f
o
r
p
r
e
v
en
tin
g
r
ec
u
r
r
e
n
t
s
tr
o
k
e
am
o
n
g
s
tr
o
k
e
p
atien
ts
.
To
r
ed
u
ce
th
e
r
ec
u
r
r
e
n
ce
of
s
tr
o
k
es
in
p
atien
ts
.
T
h
er
ef
o
r
e,
ac
tiv
ities
to
d
ev
elo
p
h
ea
lth
liter
ac
y
to
p
r
ev
en
t
r
e
cu
r
r
en
ce
of
s
tr
o
k
e
s
h
o
u
ld
be
o
r
g
an
ized
f
o
r
s
tr
o
k
e
p
atien
ts
.
C
o
n
d
u
ct
a
r
esear
ch
s
tu
d
y
to
s
tu
d
y
t
h
e
ef
f
ec
tiv
e
n
ess
of
th
e
h
ea
lth
liter
ac
y
d
e
v
elo
p
m
en
t
p
r
o
g
r
am
to
p
r
ev
en
t
r
ec
u
r
r
e
n
ce
of
s
tr
o
k
e.
ACK
NO
WL
E
DG
E
M
E
NT
S
T
h
e
au
th
o
r
s
wo
u
ld
lik
e
to
th
an
k
th
e
p
atien
ts
with
s
tr
o
k
e
in
n
o
r
t
h
ea
s
ter
n
wh
o
p
ar
ticip
at
ed
in
th
is
s
tu
d
y
.
An
d
th
is
s
tu
d
y
was
f
u
n
d
ed
by
th
e
Fu
n
d
am
en
tal
Fu
n
d
Scien
ce
,
r
esear
ch
an
d
in
n
o
v
atio
n
.
f
is
ca
l
y
ea
r
2023
.
R
esear
ch
g
r
an
t
n
u
m
b
er
is
NO
4
3
6
7
9
3
4
.
RE
F
E
R
E
NC
E
S
[
1
]
W
o
r
l
d
H
e
a
l
t
h
O
r
g
a
n
i
z
a
t
i
o
n
,
“
W
o
r
l
d
S
t
r
o
k
e
D
a
y
2
0
2
2
.
”
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
w
w
w
.
w
h
o
.
i
n
t
/
sr
i
l
a
n
k
a
/
n
e
w
s/
d
e
t
a
i
l
/
2
9
-
10
-
2
0
2
2
-
w
o
r
l
d
-
st
r
o
k
e
-
d
a
y
-
2
0
2
2
(
a
c
c
e
sse
d
N
o
v
1
,
2
0
2
3
)
.
[
2
]
M
i
n
i
s
t
r
y
of
P
u
b
l
i
c
H
e
a
l
t
h
,
“
2
0
2
1
r
a
t
e
of
s
t
r
o
k
e
p
a
t
i
e
n
t
s
p
e
r
1
0
0
,
0
0
0
p
e
o
p
l
e
,
”
2
0
2
0
.
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
:
/
/
w
w
w
.
t
h
a
i
n
c
d
.
c
o
m/
2
0
1
6
/
mi
ss
i
o
n
/
d
o
c
u
me
n
t
s
-
d
e
t
a
i
l
.
p
h
p
?
i
d
=
1
3
8
9
3
&t
i
d
=
3
2
&g
i
d
=
1
-
0
2
0
(
a
c
c
e
sse
d
N
o
v
1
,
2
0
2
3
)
.
[
3
]
N.
C.
S
u
w
a
n
w
e
l
a
,
“
S
t
r
o
k
e
e
p
i
d
e
m
i
o
l
o
g
y
in
T
h
a
i
l
a
n
d
,
”
J
o
u
r
n
a
l
of
S
t
ro
k
e
,
v
o
l
.
1
6
,
n
o
.
1,
p.
1,
2
0
1
4
,
d
o
i
:
1
0
.
5
8
5
3
/
j
o
s.
2
0
1
4
.
1
6
.
1
.
1
.
[
4
]
N.
Ji
t
n
a
r
i
n
,
V.
K
o
s
u
l
w
a
t
,
N.
R
o
j
r
o
o
n
g
w
a
s
i
n
k
u
l
,
A.
B
o
o
n
p
r
a
d
e
r
m,
C.
K.
H
a
d
d
o
c
k
,
a
n
d
W.
S.
C.
P
o
st
o
n
,
“
R
i
s
k
f
a
c
t
o
r
s
f
o
r
o
v
e
r
w
e
i
g
h
t
a
n
d
o
b
e
si
t
y
a
m
o
n
g
T
h
a
i
a
d
u
l
t
s:
R
e
s
u
l
t
s
of
t
h
e
n
a
t
i
o
n
a
l
Th
a
i
f
o
o
d
c
o
n
su
m
p
t
i
o
n
su
r
v
e
y
,
”
N
u
t
r
i
e
n
t
s
,
v
o
l
.
2,
n
o
.
1,
p
p
.
60
–
7
4
,
Ja
n
.
2
0
1
0
,
d
o
i
:
1
0
.
3
3
9
0
/
n
u
2
0
1
0
0
6
0
.
[
5
]
K.
B
u
n
d
h
a
m
c
h
a
r
o
e
n
,
P.
O
d
t
o
n
,
S.
P
h
u
l
k
e
r
d
,
a
n
d
V.
Ta
n
g
c
h
a
r
o
e
n
sat
h
i
e
n
,
“
B
u
r
d
e
n
of
d
i
s
e
a
s
e
in
T
h
a
i
l
a
n
d
:
C
h
a
n
g
e
s
in
h
e
a
l
t
h
g
a
p
b
e
t
w
e
e
n
1
9
9
9
a
n
d
2
0
0
4
,
”
B
MC
P
u
b
l
i
c
H
e
a
l
t
h
,
v
o
l
.
1
1
,
p.
5
3
,
2
0
1
1
,
d
o
i
:
1
0
.
1
1
8
6
/
1
4
7
1
-
2
4
5
8
-
11
-
5
3
.
[
6
]
R.
O
z
a
,
K.
R
u
n
d
e
l
l
,
a
n
d
M.
G
a
r
c
e
l
l
a
n
o
,
“
R
e
c
u
r
r
e
n
t
i
sc
h
e
mi
c
s
t
r
o
k
e
:
s
t
r
a
t
e
g
i
e
s
f
o
r
p
r
e
v
e
n
t
i
o
n
,
”
Am
e
r
i
c
a
n
f
a
m
i
l
y
p
h
y
s
i
c
i
a
n
,
v
o
l
.
9
6
,
n
o
.
7,
p
p
.
436
–
4
4
0
,
2
0
1
7
.
[
7
]
W
o
r
l
d
H
e
a
l
t
h
O
r
g
a
n
i
z
a
t
i
o
n
,
“
W
o
r
l
d
-
S
t
r
o
k
e
-
D
a
y
.
”
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s:
/
/
w
w
w
.
w
o
r
l
d
-
st
r
o
k
e
.
o
r
g
/
w
o
r
l
d
-
s
t
r
o
k
e
-
d
a
y
-
c
a
m
p
a
i
g
n
/
w
o
r
l
d
-
st
r
o
k
e
-
d
a
y
-
2
0
2
3
(
a
c
c
e
sse
d
N
o
v
2
,
2
0
2
3
)
.
[
8
]
Jo
h
n
H
o
p
k
i
n
s
M
e
d
i
c
i
n
e
,
“
S
t
r
o
k
e
.
”
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
w
w
w
.
h
o
p
k
i
n
sme
d
i
c
i
n
e
.
o
r
g
/
h
e
a
l
t
h
/
c
o
n
d
i
t
i
o
n
s
-
a
n
d
-
d
i
s
e
a
s
e
s/
s
t
r
o
k
e
(
a
c
c
e
s
se
d
N
o
v
2
,
2
0
2
3
)
.
[
9
]
N
a
t
i
o
n
a
l
I
n
st
i
t
u
t
e
of
H
e
a
l
t
h
,
“
S
t
r
o
k
e
c
a
u
s
e
s
a
n
d
r
i
s
k
f
a
c
t
o
r
s,”
N
a
t
i
o
n
a
l
H
e
a
r
t
,
L
u
n
g
a
n
d
B
l
o
o
d
I
n
st
i
t
u
t
e
.
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
w
w
w
.
n
h
l
b
i
.
n
i
h
.
g
o
v
/
h
e
a
l
t
h
/
s
t
r
o
k
e
/
c
a
u
se
s
(
a
c
c
e
ss
e
d
N
o
v
2
,
2
0
2
3
)
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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t J Pu
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Hea
lth
Sci
I
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N:
2252
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8
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6
A
s
s
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ted
fa
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f n
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ec
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Th
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(
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1519
[
1
0
]
V
i
l
l
i
n
e
s
a
n
d
Z
a
w
n
,
“
R
e
c
u
r
r
e
n
t
s
t
r
o
k
e
s:
W
h
a
t
to
k
n
o
w
,
”
2
0
2
3
,
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
w
w
w
.
me
d
i
c
a
l
n
e
w
st
o
d
a
y
.
c
o
m
/
a
r
t
i
c
l
e
s
/
r
e
c
u
r
r
e
n
t
-
st
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o
k
e
s
(
a
c
c
e
sse
d
N
o
v
3
,
2
0
2
3
)
[
1
1
]
S.
T
i
a
m
k
a
o
,
“
C
a
n
st
r
o
k
e
n
e
t
w
o
r
k
i
m
p
r
o
v
e
a
c
c
e
ssi
b
i
l
i
t
y
of
s
t
r
o
k
e
f
a
s
t
t
r
a
c
k
in
N
o
r
t
h
-
e
a
s
t
e
r
n
of
Th
a
i
l
a
n
d
?
,
”
J
o
u
r
n
a
l
of
t
h
e
M
e
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y
of
P
u
b
li
c
He
a
lt
h
,
Th
a
il
a
n
d
.
S
h
e
got
M
a
ste
r
of
S
c
ien
c
e
in
E
n
v
ir
o
n
m
e
n
tal
Tec
h
n
o
lo
g
y
,
Ki
n
g
M
o
n
g
k
u
t'
s
Un
i
v
e
rsi
ty
of
Tec
h
n
o
lo
g
y
T
h
o
n
b
u
ri
,
Th
a
il
a
n
d
in
2
0
0
1
.
S
h
e
i
n
tere
ste
s
in
P
u
b
li
c
He
a
lt
h
S
c
ien
c
e
,
En
v
iro
n
m
e
n
tal
He
a
lt
h
,
Oc
c
u
p
a
ti
o
n
a
l
He
a
lt
h
a
n
d
Was
te
M
a
n
a
g
e
m
e
n
t
.
S
h
e
can
be
c
o
n
tac
ted
at
e
m
a
il
:
d
u
a
n
g
ru
d
e
e
@s
c
p
h
k
k
.
ac
.
th
,
d
_
c
h
o
tk
lan
g
@
h
o
tma
il
.
c
o
m
.
Wip
h
a
d
a
Wij
a
k
k
a
n
a
la
n
is
th
e
lec
tu
re
r
at
F
a
c
u
lt
y
of
P
u
b
li
c
He
a
lt
h
&
Alli
e
d
He
a
lt
h
S
c
ien
c
e
s
,
P
ra
b
o
ro
m
a
ra
jch
a
n
o
k
I
n
stit
u
te
,
M
i
n
istr
y
of
P
u
b
li
c
He
a
lt
h
,
Th
a
il
a
n
d
.
S
h
e
got
M
a
ste
r
of
Nu
rsin
g
S
c
ien
c
e
,
F
a
c
u
lt
y
of
Nu
rs
in
g
in
1
9
9
6
a
n
d
D
o
c
to
ra
l
d
e
g
re
e
of
Cu
rricu
l
u
m
a
n
d
In
str
u
c
to
n
,
F
a
c
u
lt
y
of
E
d
u
c
a
ti
o
n
in
2
0
0
1
,
Kh
o
n
Ka
e
n
U
n
iv
e
rsit
y
,
T
h
a
il
a
n
d
.
S
h
e
in
tere
ste
s
in
fa
st
-
trac
k
p
a
ti
e
n
ts,
n
o
n
-
c
o
m
m
u
n
ica
b
le
d
is
e
a
se
s,
h
e
a
lt
h
li
tera
c
y
,
a
n
d
p
re
-
h
o
sp
i
tal
c
a
re
.
S
h
e
can
be
c
o
n
tac
ted
at
e
m
a
il
:
wip
wij@
g
m
a
il
.
c
o
m
.
Nitc
h
a
k
a
r
n
Mee
lu
n
is
th
e
Lec
tu
re
r
at
Co
m
m
u
n
it
y
P
u
b
l
ic
He
a
lt
h
De
p
a
rtme
n
t
,
S
iri
n
d
h
o
rn
Co
ll
e
g
e
of
P
u
b
li
c
He
a
lt
h
K
h
o
n
Ka
e
n
.
F
a
c
u
lt
y
of
P
u
b
li
c
He
a
lt
h
&
a
m
p
;
Alli
e
d
He
a
lt
h
S
c
ien
c
e
s
.
P
ra
b
o
ro
m
a
ra
jch
a
n
o
k
I
n
stit
u
te
.
M
i
n
istr
y
of
P
u
b
li
c
He
a
lt
h
,
Th
a
il
a
n
d
.
S
h
e
got
M
a
ste
r
of
P
u
b
l
ic
He
a
lt
h
(
En
v
iro
n
m
e
n
tal
)
,
F
a
c
u
lt
y
of
P
u
b
li
c
He
a
lt
h
,
K
h
o
n
Ka
e
n
Un
iv
e
rsity
,
Th
a
il
a
n
d
in
2
0
1
1
.
S
h
e
in
tere
ste
s
in
P
u
b
li
c
He
a
lt
h
S
c
ien
c
e
,
En
v
iro
n
m
e
n
ta
l
He
a
lt
h
,
n
o
n
-
c
o
m
m
u
n
ica
b
le
d
ise
a
se
s,
He
a
lt
h
li
tera
c
y
a
n
d
He
a
lt
h
b
e
h
a
v
i
o
r
.
S
h
e
can
be
c
o
n
tac
ted
at
e
m
a
il
:
lad
y
n
id
rich
e
r@
g
m
a
il
.
c
o
m
.
Ar
in
r
a
d
a
La
d
la
is
th
e
Lec
tu
re
r
at
Co
m
m
u
n
it
y
P
u
b
l
ic
He
a
lt
h
De
p
a
rtme
n
t,
S
iri
n
d
h
o
rn
Co
ll
e
g
e
of
P
u
b
l
ic
He
a
lt
h
Kh
o
n
Ka
e
n
.
F
a
c
u
l
ty
of
P
u
b
li
c
He
a
lt
h
&
Alli
e
d
He
a
lt
h
S
c
ien
c
e
s
.
P
ra
b
o
ro
m
a
ra
jch
a
n
o
k
I
n
stit
u
te
.
M
i
n
istr
y
of
P
u
b
li
c
He
a
lt
h
,
Th
a
il
a
n
d
.
S
h
e
g
o
t
Do
c
to
ra
l
d
e
g
re
e
of
P
h
il
o
so
p
h
y
P
ro
g
ra
m
in
He
a
lt
h
S
c
ien
c
e
,
F
a
c
u
lt
y
of
F
a
c
u
lt
y
of
M
e
d
ici
n
e
,
M
a
h
a
sa
ra
k
h
a
m
Un
iv
e
rsit
y
,
Th
a
il
a
n
d
in
2
0
1
9
.
S
h
e
in
tere
ste
s
in
Co
m
m
u
n
it
y
d
ise
a
se
s,
En
v
ir
o
n
m
e
n
tal
He
a
lt
h
,
He
a
lt
h
of
El
d
e
rl
y
a
n
d
S
y
ste
m
a
ti
c
Re
v
iew
s
a
n
d
M
e
ta
-
An
a
l
y
sis
.
S
h
e
c
a
n
be
c
o
n
tac
ted
at
e
m
a
il
:
Ari
n
ra
d
a
.
la
d
la@
m
a
il
.
c
o
m
.
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