Stroke systems of care in low-income and middle-income countries: challenges and opportunities

Pandian, Jeyaraj Durai; Kalkonde, Yogeshwar; Sebastian, Ivy; Felix, Cynthia; Urimubenshi, Gerard; Bosch, Jackie

doi:10.1016/s0140-6736(20)31374-x

Cited by 76 publications

(87 citation statements)

References 65 publications

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“…The introduction of stroke unit-based care has been the most effective method to improve mortality and morbidity in HICs ( 37 ). However, there are significant barriers to developing stroke unit-based care, in low-income countries (LICs) such as Sierra Leone ( 38 ). For example, how can multi-disciplinary stroke care be introduced if there are limited numbers of physiotherapists and an absence of other allied health professionals.…”

Section: Discussionmentioning

confidence: 99%

A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes

et al. 2021

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Introduction: Stroke is the second most common cause of adult death in Africa. This study reports the demographics, stroke types, stroke care and hospital outcomes for stroke in Freetown, Sierra Leone.Methods: A prospective observational register recorded all patients 18 years and over with stroke between May 2019 and April 2020. Stroke was defined according to the WHO criteria. Pearson's chi-squared test was used to examine associations between categorical variables and unpaired t-tests for continuous variables. Multivariable logistic regression, to explain in-hospital death, was reported as odds ratios (ORs) and 95% confidence intervals.Results: Three hundred eighty-five strokes were registered, and 315 (81.8%) were first-in-a-lifetime events. Mean age was 59.2 (SD 13.8), and 187 (48.6%) were male. Of the strokes, 327 (84.9%) were confirmed by CT scan. Two hundred thirty-one (60.0%) were ischaemic, 85 (22.1%) intracerebral haemorrhage, 11 (2.9%) subarachnoid haemorrhage and 58 (15.1%) undetermined stroke type. The median National Institutes of Health Stroke Scale on presentation was 17 [interquartile range (IQR) 9–25]. Haemorrhagic strokes compared with ischaemic strokes were more severe, 20 (IQR 12–26) vs. 13 (IQR 7–22) (p < 0.001), and occurred in a younger population, mean age 52.3 (SD 12.0) vs. 61.6 (SD 13.8) (p < 0.001), with a lower level of educational attainment of 28.2 vs. 40.7% (p = 0.04). The median time from stroke onset to arrival at the principal referral hospital was 25 hours (IQR 6–73). Half of the patients (50.4%) sought care at another health provider prior to arrival. One hundred fifty-one patients died in the hospital (39.5%). Forty-three deaths occurred within 48 hours of arriving at the hospital, with median time to death of 4 days (IQR 0–7 days). Of the patients, 49.6% had ≥1 complication, 98 (25.5%) pneumonia and 33 (8.6%) urinary tract infection. Male gender (OR 3.33, 1.65–6.75), pneumonia (OR 3.75, 1.82–7.76), subarachnoid haemorrhage (OR 43.1, 6.70–277.4) and undetermined stroke types (OR 6.35, 2.17–18.60) were associated with higher risk of in-hospital death.Discussion: We observed severe strokes occurring in a young population with high in-hospital mortality. Further work to deliver evidence-based stroke care is essential to reduce stroke mortality in Sierra Leone.

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Section: Discussionmentioning

confidence: 99%

A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes

et al. 2021

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“…These therapies are now available in Morocco, Tunisia, Algeria, Egypt, Central African Republic and South Africa 88 , 269 , 273 – 276 . Barriers to access include all causes of late hospital presentation, diagnostic delays, the high cost of thrombolytic agents and insufficient numbers of clinicians with the appropriate skills 88 , 275 , 277 , 278 . Early reports from the countries listed above have consistently shown that intravenous thrombolysis is associated with improved patient outcomes 269 , 273 , 274 , 276 .…”

Section: Stroke Services In Africamentioning

confidence: 99%

“…Task shifting and tele-health approaches have been suggested as strategies to mitigate the current scarcity of rehabilitation personnel and improve access to stroke rehabilitation in Africa 281 – 283 . A study of family-led rehabilitation after stroke (the ATTEND trial) was performed in India and this option could also be explored in Africa 277 , 284 . In a prospective, single-arm, pre–post study, 20 survivors of stroke recruited from a tertiary medical centre in Ghana received a smartphone with the 9zest Stroke Rehabilitation Therapy app (9zest) to deliver an individualized, goal-targeted exercise programme 5 days a week.…”

Section: Stroke Services In Africamentioning

confidence: 99%

Stroke in Africa: profile, progress, prospects and priorities

et al. 2021

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Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2–3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

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“…Providing care in low resource areas . An important element of reducing recurrent stroke is ensuring accessibility to care, even in lower resource settings [ 68 , 69 , 70 ]. PINGS looked at providing post-stroke care in Ghana and provided patients with pillboxes, BP monitors, and loaned cell phones, where they recorded their health data and received automated text message reminders [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

“Lessons Learned” Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

Lambert

Olulana

Bailey‐Davis

et al. 2021

JCM

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Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.

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Stroke systems of care in low-income and middle-income countries: challenges and opportunities

Cited by 76 publications

References 65 publications

A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes

A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes

Stroke in Africa: profile, progress, prospects and priorities

“Lessons Learned” Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

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