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Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20:207-221. [PMID: 38228908 DOI: 10.1038/s41582-023-00921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.
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Affiliation(s)
- Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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2
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Lindley RI. Providing Stroke Expertise across India. J Neurosci Rural Pract 2021; 12:226-227. [PMID: 33927514 PMCID: PMC8064846 DOI: 10.1055/s-0041-1726664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Richard I. Lindley
- Sydney Medical School, Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
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Prvu Bettger J, Liu C, Gandhi DB, Sylaja P, Jayaram N, Pandian JD. Emerging Areas of Stroke Rehabilitation Research in Low- and Middle-Income Countries. Stroke 2019; 50:3307-3313. [DOI: 10.1161/strokeaha.119.023565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Janet Prvu Bettger
- From the Duke Global Health Institute, Duke University, Durham, NC (J.P.B.)
| | - Chelsea Liu
- Department of Epidemiology, Bloombesrg School of Public Health, Johns Hopkins University, Baltimore, MD (C.L.)
| | - Dorcas B.C. Gandhi
- College of Physiotherapy and Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (D.B.C.G.)
| | - P.N. Sylaja
- Comprehensive Stroke Care Program (P.N.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Nitha Jayaram
- Department of Physical Medicine and Rehabilitation (N.J.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jeyaraj Durai Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.)
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Liu H, Mohammed A, Shanthosh J, News M, Laba TL, Hackett ML, Peiris D, Jan S. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ Open 2019; 9:e025127. [PMID: 31391188 PMCID: PMC6687007 DOI: 10.1136/bmjopen-2018-025127] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators. DESIGN Systematic review using the UK Medical Research Council guidance for PE as a guide. DATA SOURCES Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018. ELIGIBILITY CRITERIA We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance. RESULTS 69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention's mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context-factors such as governance, financing structures and workforce-if unanticipated could adversely impact implementation. CONCLUSION Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers. PROSPERO REGISTRATION NUMBER CRD42016035572.
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Affiliation(s)
- Hueiming Liu
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Alim Mohammed
- The George Institute for Global Health, Hyderabad, India
| | - Janani Shanthosh
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Madeline News
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Tracey-Lea Laba
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
| | - Maree L Hackett
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
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Melifonwu R. Clinical stroke research in resource limited settings: tips and hints. Int J Stroke 2019; 14:NP13-NP14. [PMID: 31226921 DOI: 10.1177/1747493019858773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rita Melifonwu
- Stroke Action Nigeria, Ime Obi Ogbeosa, Onitsha, Nigeria
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Walker R, Gray WK, Jusabani A. RE: Clinical stroke research in resource limited settings: Tips and hints. Int J Stroke 2019; 14:NP11-NP12. [PMID: 30816055 DOI: 10.1177/1747493019833011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Richard Walker
- 1 Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - William K Gray
- 1 Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - Ahmed Jusabani
- 2 Kilimanjaro Christian Medical Centre Moshi, United Republic of Tanzania
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Anderson CS, Chaturvedi S. Stroke in China and India: Big populations, big challenges. Neurology 2018; 91:643-644. [PMID: 30158162 DOI: 10.1212/wnl.0000000000006270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Craig S Anderson
- From The George Institute for Global Health (C.S.A.), Faculty of Medicine, University of New South Wales, Sydney, Australia; The George Institute for Global Health China at Peking University Health Sciences Center (C.S.A.), Beijing; and Department of Neurology & Stroke Program (S.C.), University of Miami Miller School of Medicine, FL.
| | - Seemant Chaturvedi
- From The George Institute for Global Health (C.S.A.), Faculty of Medicine, University of New South Wales, Sydney, Australia; The George Institute for Global Health China at Peking University Health Sciences Center (C.S.A.), Beijing; and Department of Neurology & Stroke Program (S.C.), University of Miami Miller School of Medicine, FL
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Liu H, Lindley R, Alim M, Felix C, Gandhi DB, Verma SJ, Tugnawat DK, Syrigapu A, Ramamurthy RK, Pandian JD, Walker M, Forster A, Hackett ML, Anderson CS, Langhorne P, Murthy GV, Maulik PK, Harvey LA, Jan S. Family-led rehabilitation in India (ATTEND)-Findings from the process evaluation of a randomized controlled trial. Int J Stroke 2018; 14:53-60. [PMID: 30044209 DOI: 10.1177/1747493018790076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Training family carers to provide evidence-based rehabilitation to stroke patients could address the recognized deficiency of access to stroke rehabilitation in low-resource settings. However, our randomized controlled trial in India (ATTEND) found that this model of care was not superior to usual care alone. AIMS This process evaluation aimed to better understand trial outcomes through assessing trial implementation and exploring patients', carers', and providers' perspectives. METHODS Our mixed methods study included process, healthcare use data and patient demographics from all sites; observations and semi-structured interviews with participants (22 patients, 22 carers, and 28 health providers) from six sampled sites. RESULTS Intervention fidelity and adherence to the trial protocol was high across the 14 sites; however, early supported discharge (an intervention component) was not implemented. Within both randomized groups, some form of rehabilitation was widely accessed. ATTEND stroke coordinators provided counseling and perceived that sustaining patients' motivation to continue with rehabilitation in the face of significant emotional and financial stress as a key challenge. The intervention was perceived as an acceptable community-based package with education as an important component in raising the poor awareness of stroke. Many participants viewed family-led rehabilitation as a necessary model of care for poor and rural populations who could not access rehabilitation. CONCLUSION Difficulty in sustaining patient and carer motivation for rehabilitation without ongoing support, and greater than anticipated access to routine rehabilitation may explain the lack of benefit in the trial. Nonetheless, family-led rehabilitation was seen as a concept worthy of further development.
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Affiliation(s)
- Hueiming Liu
- 1 The George Institute for Global Health, Sydney, Australia.,2 University of Sydney, Sydney, Australia.,3 University of New South Wales, Sydney, Australia
| | - Richard Lindley
- 1 The George Institute for Global Health, Sydney, Australia.,2 University of Sydney, Sydney, Australia
| | - Mohammed Alim
- 4 George Institute for Global Health, Hyderabad, India
| | - Cynthia Felix
- 4 George Institute for Global Health, Hyderabad, India
| | | | | | | | | | | | | | | | | | - Maree L Hackett
- 1 The George Institute for Global Health, Sydney, Australia.,2 University of Sydney, Sydney, Australia.,3 University of New South Wales, Sydney, Australia.,10 University of Central Lancashire, Preston, UK
| | - Craig S Anderson
- 1 The George Institute for Global Health, Sydney, Australia.,2 University of Sydney, Sydney, Australia.,3 University of New South Wales, Sydney, Australia.,11 The George Institute China at Peking University Health Science Centre, China
| | | | | | - Pallab K Maulik
- 3 University of New South Wales, Sydney, Australia.,4 George Institute for Global Health, Hyderabad, India.,13 The George Institute for Global Health, Oxford University, Oxford, UK
| | | | - Stephen Jan
- 1 The George Institute for Global Health, Sydney, Australia.,2 University of Sydney, Sydney, Australia.,3 University of New South Wales, Sydney, Australia
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