Interventions for acute stroke management in Africa: a systematic review of the evidence

Abstract

BackgroundThe past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa.MethodsThis review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship.ResultsInitially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa.ConclusionEvidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients’ outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake.Systematic review registrationPROSPERO CRD42016051566 Electronic supplementary materialThe online version of this article (10.1186/s13643-017-0594-4) contains supplementary material, which is available to authorized users.

Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective

“…Stroke case-fatality rates in SSA are the highest in the world ranging from 21-47% in various studies [66,68,69], compared to 17-30% in high-income countries [70], and almost double for hemorrhagic stroke compared to ischemic stroke [67,68]. A few studies have demonstrated overall positive patient outcomes following acute stroke care interventions in Africa [71]. Given that hypertension is the single most important preventable risk factor for stroke in SSA [6,66], its optimal control should be the main focus to help reduce stroke occurrence.…”

Improving the quality of care for people who had a stroke in a low‐/middle‐income country: A qualitative analysis of health‐care professionals’ perspectives

“…Similar to other resource‐poor regions, recent research indicates access and delivery of quality and evidence‐based stroke care in Africa is limited and often poor . Studies in Ghana, Senegal and Congo further exemplify the limited nature of access to quality and evidence‐based stroke care in LMICs.…”

“…For example, it is estimated that up to 8.4 million deaths are recorded annually in LMICs as a result of compromised quality of care . Within the context of stroke care, a paradoxical situation exists where delivery of quality and evidence‐based care for optimal patient outcomes is relatively limited and poor in LMICs compared to high‐income countries (HICs), although about 80% of the entire global burden of stroke is reported from LMICs . This burden has been largely attributed to the poor quality of care delivered in those settings and the low uptake of evidence‐based practice .…”

“…2 Within the context of stroke care, a paradoxical situation exists where delivery of quality and evidence-based care for optimal patient outcomes is relatively limited and poor in LMICs compared to high-income countries (HICs), although about 80% of the entire global burden of stroke is reported from LMICs. 3 This burden has been largely attributed to the poor quality of care delivered in those settings and the low uptake of evidence-based practice. [4][5][6][7] Findings from the recent INTERSTROKE study further underscore the poor and limited access to optimal stroke care, leading to poor patient outcomes in LMICs.…”

“…8 Similar to other resource-poor regions, recent research indicates access and delivery of quality and evidence-based stroke care in Africa is limited and often poor. 3,4,[8][9][10] Studies in Ghana, 5 Senegal 6 and Congo 7 further exemplify the limited nature of access to quality and evidence-based stroke care in LMICs. Efforts to improve uptake of better stroke care interventions to ensure optimal patient outcomes in resource-poor settings have been persistently hampered by a range of barriers such as lack of skilled health personnel, patients' lack of funds to meet health-care costs and inadequate health infrastructure.…”