This nationwide cross-sectional study was conducted between January 5 and May 10, 2025, among undergraduate students (n = 484) enrolled at public and private universities across Saudi Arabia (Figure 1). Participating institutions represented the four major geographic regions of the country: Central, Eastern, Western, and Southern region. This wide institutional distribution ensured adequate national representation.

Ethical approval was obtained from the Institutional Review Board of King Faisal University (Approval No. KFU-REC-2025-JAN-ETHICS3006). All participants provided informed consent electronically or in person before participation. Confidentiality and anonymity were maintained throughout the study.

The study population included undergraduate students enrolled in Saudi universities during the 2024–2025 academic year. Eligible participants were students from any level or discipline who met the following inclusion criteria:

Aged 18 years or older.

Students who did not meet the inclusion criteria provided incomplete responses, or submitted duplicate entries were excluded from the analysis.

The required sample size was calculated using a single population proportion formula, assuming a 95% confidence interval, 50% expected proportion (as no prior national data were available), and a 5% margin of error. The minimum required sample size was 385 participants. To account for potential non-responses and exclusions, an additional 25% was added, yielding a target sample of approximately 480 students. A total of 484 valid responses were ultimately included in the final analysis, exceeding the calculated requirement and ensuring adequate statistical power.

A convenience sampling strategy was used to recruit participants from universities across different regions of Saudi Arabia. Recruitment was conducted through three complementary channels to ensure broad coverage and diversity of disciplines.

In-person recruitment was carried out by members of the research team, who approached students on university campuses in shared areas such as libraries, cafeterias, and student activity centers, inviting them to participate voluntarily. Online dissemination was also conducted through social media platforms, including WhatsApp and X (formerly Twitter), accompanied by a brief description of the study purpose and eligibility criteria. In addition, collaborating faculty members and student affairs offices at participating universities distributed the official invitation and questionnaire link via university email systems to reach a wider audience. The invitation letter provided information about the study objectives, confidentiality assurances, and estimated completion time. Participation was entirely voluntary, and informed consent was obtained electronically before respondents could proceed to the questionnaire. To maintain data integrity, each participant was allowed to submit the survey only once.

To assess the representativeness of the study sample, the distribution of key demographic characteristics (including sex, region, and type of university [public vs. private]) was compared descriptively with publicly available national statistics on undergraduate enrollment in Saudi Arabia. Overall, the sample demonstrated a distribution broadly comparable to national university enrollment patterns, although some differences are expected due to the use of convenience sampling.

Data were collected using a self-administered questionnaire distributed through multiple channels, including online distribution via Google Forms, in-person invitations on university campuses, and official university-wide email circulation coordinated through the Deanships of Information Technology and Scientific Research. The authors of the study represent a collaborative research team from universities across different regions of the country, including the Eastern, Western, Central, and Southern regions, to ensure broad geographic coverage.

We assessed student knowledge, attitudes, and practices toward stroke. The questionnaire was developed based on previously published tools assessing stroke awareness (13–17), with most items adapted from previously published Arabic-language questionnaires to ensure cultural and contextual relevance. Additional items were adapted from a validated survey conducted among university students in Jazan, Saudi Arabia (18). The adaptation process involved reviewing all candidate items for relevance to the study objectives, clarity, and appropriateness for undergraduate students, with minor wording modifications made where necessary without altering the original meaning of the items.

Content validity was assessed by a panel of experts consisting of public health specialists and clinical researchers with experience in stroke research, who evaluated the questionnaire for relevance, clarity, and completeness. Feedback from the panel was incorporated into the final version of the instrument. As most items were derived from previously validated Arabic instruments, the questionnaire was administered in Arabic. No forward–backward translation was required. The final Arabic version was reviewed to ensure linguistic clarity and consistency across items.

The instrument included 14 knowledge-based questions covering stroke warning signs, risk factors, affected organs, and appropriate response behaviors. Each correct response received one point, while incorrect answers received zero points. The total stroke knowledge score thus ranged from 0 to 14, with higher scores indicating greater knowledge. To assess reliability, a pilot test was conducted with 50 university students, and internal consistency of the knowledge domain was evaluated using Cronbach’s alpha, which yielded a value of 0.87, indicating good reliability.

Data were analyzed using IBM SPSS Statistics version 26 (IBM Corp, Armonk, NY). Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize demographic data and knowledge scores. For inferential analysis, univariate linear regression was performed to explore associations between demographic variables and stroke knowledge scores. Variables that showed significant associations in the univariate model (p < 0.05) were entered into a multivariate linear regression model to identify independent predictors of stroke knowledge. Regression results were reported using β coefficients, p-values, and 95% CIs. Prior to model interpretation, assumptions of linear regression were evaluated. Normality of residuals was assessed using visual inspection of histograms and normal probability (Q–Q) plots, while homoscedasticity was examined through residual-versus-fitted value plots. No substantial deviations from model assumptions were observed. A p-value of < 0.05 was considered statistically significant.

The final sample consisted of 484 university students from across Saudi Arabia. Of these, 52.7% (n = 255) were female and 47.3% (n = 229) were male, with a mean age of 21.89 years (SD = 4.1). Most participants were single (95.2%, n = 461), while 4.8% (n = 23) were married. Regarding academic specialization, 41.7% (n = 202) were enrolled in health-related disciplines, and 58.3% (n = 282) were in non-health fields. The majority of respondents (87.4%, n = 423) reported no chronic illnesses, whereas 12.6% (n = 61) reported having at least one chronic condition. In terms of academic level, 28.1% (n = 136) were fourth-year students, followed by 20.2% (n = 98) in the third year, 19.0% (n = 92) in the second year, 12.6% (n = 61) in the fifth year, 10.3% (n = 50) in the sixth year, and 9.7% (n = 47) in the first year. Regarding the geographical distribution of university enrollment, the majority of participants were registered in Universites located in the central area (36.4%, n = 176), followed by the western region (26.4%, n = 128) and the eastern region (25.2%, n = 122). The remaining participants were registered at universities in the southern region (12.0%, n = 58; Figure 2).

Prior knowledge of cerebrovascular accidents (strokes) was reported by 77.9% (n = 377) of participants. Regarding exposure, 16.5% (n = 80) indicated having relatives who had suffered a stroke, while 27.9% (n = 135) personally knew someone who had experienced a stroke.

Sources of prior stroke knowledge varied: schools (34.1%, n = 165) and the internet (32.9%, n = 159) were the most common, followed by healthcare professionals (10.3%, n = 50), while the remainder cited friends, social media, or other sources (Table 1).

The effect of stroke most recognized by participants was its impact on the neurological system, identified correctly by 73.8% of respondents (mean = 0.74, SD = 0.44; Figure 3). In contrast, only 54.1% (mean = 0.54, SD = 0.49) were aware that stroke is a treatable condition. Among the listed risk factors, high blood pressure was the most frequently recognized (85.1%, mean = 0.85, SD = 0.35), whereas diabetes was the least identified (47.5%, mean = 0.48, SD = 0.50). Regarding warning signs, difficulty in speaking and sudden body weakness were the most commonly known, with correct responses from 72.9 and 62.8% of participants, respectively. The mean overall knowledge score was 9.17 (SD = 2.8) out of 14, reflecting a moderate level of awareness about stroke risk factors, symptoms, and outcomes (Table 2).

Mean stroke knowledge scores showed a graded increase with advancing year of study. Lower scores were observed among first- and second-year students (8.06 ± 2.34 and 7.76 ± 2.37, respectively), while progressively higher scores were noted among students in the fourth to sixth years of study (9.60 ± 2.84, 10.26 ± 2.76, and 11.50 ± 2.51, respectively), indicating a positive association between academic level and stroke knowledge (Table 3).

In the univariate analysis, male participants demonstrated significantly lower knowledge scores (β = −1.194, p < 0.001), whereas students enrolled in health-related disciplines scored higher (β = 2.922, p < 0.001). Having a relative or acquaintance who had experienced a stroke was also associated with higher knowledge levels (β = 2.113, p < 0.001 and β = 1.612, p < 0.001, respectively). Educational level showed a positive effect, with students in their fourth to sixth years of study demonstrating higher awareness (β = 2.003, p < 0.001).

In the multivariate model, these associations remained largely consistent. Male sex continued to be associated with lower scores (β = −0.601, p = 0.006), while being in a health-related specialty predicted higher knowledge (β = 2.06, p < 0.001). Having relatives who had suffered a stroke also remained a significant predictor (β = 1.096, p = 0.002), whereas the effect of personally knowing someone with a stroke became less pronounced (β = 0.642, p = 0.03). These results indicate that academic background, personal exposure, and gender differences play key roles in determining stroke awareness among university students (Table 4).

Most respondents (90.9%) believed that stroke is a preventable condition. When asked about the importance of maintaining a healthy lifestyle, 82.6% considered it “very important,” and 13.8% regarded it as “important.” A strong majority (88.8%) agreed that individuals experiencing stroke symptoms should seek immediate medical care. Regular health checkups were perceived as “very important” by 68.2% of participants, although 6.4% felt they could be ignored if a person appeared healthy. Nearly half of the respondents (49.8%) reported that they had never advised others on stroke prevention, and 33.3% stated that they lacked adequate knowledge to do so. Only 14.3% reported monitoring their own health indicators, such as blood pressure or cholesterol, on a regular basis, whereas 49.6% did so occasionally. When presented with a stroke scenario, 87.2% of students indicated that they would seek immediate medical assistance, reflecting generally positive attitudes toward emergency response (Table 5).

The main strength of this study is its extensive, multi-regional sample, which provides a broad national overview of stroke awareness among Saudi university students. Using a validated questionnaire with good internal consistency (Cronbach’s alpha = 0.87) enhances the reliability and comparability of the results. Nevertheless, this study’s convenience sampling and online distribution may over-represent digitally engaged or health-interested students, limiting generalizability across regions, institution types, and non-university youth. Its cross-sectional design precludes causal inference, and self-reported knowledge/practices are vulnerable to recall and social-desirability biases. Although internal consistency was good, item content may overweight “visible” signs over subtler symptoms, risking misclassification. Unmeasured confounding (e.g., prior coursework, family health literacy), unmodeled clustering by college/university, potential nonresponse bias, and timing effects (e.g., proximity to exams or campaigns) may further influence estimates. Heavy reliance on rapidly changing digital information environments and unassessed accessibility needs (e.g., rural campuses, sensory impairments) could also mask equity gaps in stroke literacy. Also, as this study sampled the general university population, the availability of detailed subgroup-specific documentation was limited; however, the findings offer a useful baseline to inform future targeted studies in more narrowly defined student cohorts.

Universities should integrate brief, competency-based stroke awareness modules into student orientation and general health courses, reinforced through periodic refreshers and practical FAST/BE-FAST simulations to strengthen early recognition and emergency response (20). Preventive initiatives should prioritize under-recognized vascular risk factors (e.g., diabetes, dyslipidemia, tobacco and e-cigarette use) and target non-health disciplines, early-year students, and males through peer-led programs and clinician-guided digital content. These interventions should be grounded in behavior-change frameworks such as the Health Belief Model and aligned with national noncommunicable disease prevention priorities under Saudi Vision 2030 to ensure scalability and sustainability.