Community awareness of stroke in Accra, Ghana

Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries

Stroke is a leading cause of disability and mortality worldwide, and it disproportionately affects low- and middle-income countries (LMICs), which account for 88% of stroke fatalities. Prehospital stroke care delays are a crucial obstacle to successful treatment in these settings, especially given the limited therapeutic window for thrombolytic treatments, which may greatly improve recovery chances when initiated early after stroke onset. These delays are caused by a lack of public understanding of stroke symptoms, sociodemographic and cultural variables, and insufficient healthcare infrastructure. This review discusses these issues in detail, emphasizing the disparities in stroke awareness and reaction times between locations and socioeconomic classes. Innovative options for reducing these delays include the deployment of mobile stroke units and community-based educational campaigns. This review also discusses how technology improvements and personalized educational initiatives might improve stroke awareness and response in LMICs. The primary goal is to give a thorough assessment of the challenges and potential remedies that might serve as the foundation for policy reforms and healthcare improvements in LMICs, eventually improving stroke care and lowering disease-related mortality and disability.

Awareness of stroke, its signs, and risk factors: A cross-sectional population-based survey in Ghana

Background and Aims

The prevalence of stroke in sub-Saharan Africa is steadily rising, leading to a growing strain on the healthcare system in the region. In the context of Ghana, stroke ranks as the third most prevalent cause of mortality. The current body of scholarly research on stroke awareness in Ghana is quite limited. The aim of this study is to assess the level of awareness of stroke, as well as its signs and symptoms among the Ghanaian population.

Methods

The study employed a cross-sectional quantitative methodology, wherein 1000 participants completed self-administered structured questionnaires. Descriptive statistics were utilized to summarize the participants' socio-demographic characteristics and their responses. To assess the relationship between participants' sociodemographic traits and their awareness of stroke signs, symptoms, risk factors, and perception, the Chi-square test of independence was conducted using IBM SPSS version 26. A significance level of p < 0.05 was established.

Results

The study identified limited awareness regarding stroke symptoms, warning signs, and risk factors. The participants exhibited an overall knowledge range of 25.9% to 47.2% concerning stroke signs and symptoms, and a range of 24%-39% regarding its causes and risk factors. Notably, paralysis (70.8%) and diet (59.9%) were the most easily recognized warning signs and risk factors for stroke, respectively. Sociodemographic characteristics such as age, religion, educational status, exposure to stroke, employment status, and marital status were shown to be associated with participants knowledge of stroke (p < 0.05).

Conclusion

The study's results indicated a widespread lack of knowledge concerning the causes and risk factors of stroke among the Ghanaian population, highlighting the necessity for increased public education efforts to raise awareness about this condition.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study

Background and Objectives

Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda.

Methods

We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders.

Results

We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037).

Discussion

In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria

OBJECTIVES

To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk.

MATERIALS AND METHODS

A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk.

RESULTS

The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application.

CONCLUSIONS

Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.

Prevalence and knowledge of modifiable cardiovascular diseases risk factors among vulnerable population in Central Tanzania

BACKGROUND

Cardiovascular diseases (CVDs) are the global public health problem which has been associated with increasing prevalence of modifiable CVDs risk factors. This study aimed to describe the prevalence and knowledge of modifiable CVDs risk factors among vulnerable population of Central Tanzania.

METHODS

A community-based cross-sectional study design was employed. A total of 749 participants were interviewed. The socio-demographic information and modifiable CVDs risk factors (behavioral and biological) were measured using a modified World Health Organization (WHO) STEPwise approach for chronic disease risk factor surveillance. Knowledge of modifiable CVDs risk factors was measured by comprehensive heart disease knowledge questionnaire. Descriptive statistics were used to describe the knowledge and prevalence of modifiable CVDs risk factors. Logistic regression analysis was used to determine the factors associated with adequate knowledge of CVDs risk factors.

RESULTS

The prevalence of béhavioral risk factors were; current smokers and alcohol consumers were 4.4% and 18.0% respectively, use of raw salt was 43.7%, consumption of fruit/vegetables < 5 days per week was 56.9%. The prevalence of Biological CVDs risk factors was as follows: Overall, 63.5% (33.3% overweight and 29.9% obese) were overweight or obese, 4.5% were diabetic and 43.4% were hypertensive. Only 35.4% of participants had adequate knowledge of CVDs risk factors. Being a male (AOR = 1.44, 95%CI = 1.01-2.06, p < .05), having primary education (AOR = 6.43, 95%CI = 2.39-17.36, p < .0001), being employed (AOR = 1.59, 95%CI = 1.00-2.52, p < .05), ever checked blood pressure (AOR = 0.59, 95%CI = 0.42-0.84, p < .001), family history of hypertension (AOR = 0.38, 95%CI = 0.25-0.57, p < .0001) determined adequate knowledge of CVDs risk factors.

CONCLUSIONS

This study has revealed a high prevalence of modifiable CVDs risk factors and low knowledge of CVDs risk factors. Community health promotion interventions to increase population knowledge of CVDs risk factors are recommended for the efficacious reduction of CVDs in the country.

Awareness of Stroke Risk Factors, Warning Signs, and Preventive Behaviour Among Diabetic Patients in Al-Ahsa, Saudi Arabia

Objectives This study aims to measure the level of awareness about stroke symptoms, risk factors, and preventive health practices that could be taken to reduce the risk of stroke among diabetic patients in Al-Ahsa, Saudi Arabia. Methods A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia in 2020. The sample included a total of 202 male and female Saudi adults aged 18-65 years, with either type 1 or type 2 diabetes mellitus, and living in Al Ahsa, Saudi Arabia. The information was collected randomly through an online questionnaire distributed among patients after getting their contact information from relevant governmental and private diabetes clinics and after signing the informed consent. For awareness and knowledge items, each correct answer was scored one point and the total summation of the discrete scores of the different items was calculated. A diabetic patient with a score less than 60% of the total score was considered to have poor awareness while a score of 60% or more of the total score was considered a good level of awareness. Results A total of 87 (43.1%) participants had an overall good awareness level, while 115 (56.9%) had poor awareness levels. Around 40.6% of the study patients had heard about stroke, 61.9% knew that stroke affects the brain, and 24.3% reported that stroke is higher among males. As for factors associated with stroke, the most reported was high blood pressure (71.8%), followed by diabetes mellitus (69.3%). Exactly 65.8% of participants knew about the mechanism of ischemic stroke and 42.6% reported hemorrhagic stroke. A high percentage of patients (73.1%) realize that they could reduce their risk of stroke. Conclusion The findings of the current study showed that less than half (43.1%) of the Saudi patients with DM had a good awareness level regarding stroke and its related risk factors and warning signs. Older patients (aged 50-65 years) with high social levels (high education and income) and those with a family history of stroke had significantly higher awareness levels. Hypertension, DM, and smoking are the highest reported known risk factors of stroke, and speech disorders are the highest known stroke presentation to the respondents.

The structure, processes, and outcomes of stroke rehabilitation in Ghana: A study protocol

Background

Conventional and complementary treatments are often used in rehabilitation for persons with stroke. The conventional treatment makes use of medications, physiotherapy, occupational, speech, and diet therapies, while the complementary treatment makes use of homeopathy, naturopathy, massage, and acupuncture. The structure, process, and outcomes of stroke rehabilitation using conventional or complementary treatments have not been empirically investigated in Ghana.

Aims

This study aims to investigate the structure, process, and outcomes of stroke rehabilitation at the Korle Bu Teaching Hospital (KBTH) in Accra and Kwayisi Christian Herbal Clinic (KCHC) in Nankese-Ayisaa, Ghana, and to explore the experiences of persons with stroke.

Methods

This study involves a mixed methods approach. This study will utilize three study designs, namely, cross-sectional, hospital-based cohort, and qualitative exploratory study designs. The objectives of the study will be achieved using three phases, namely, phase one will recruit health professionals and gather information on the structure and process of stroke rehabilitation at a conventional and complementary hospital using adapted questionnaires; phase two will determine the outcomes of stroke patients attending a conventional and complementary hospital facility at baseline, 2-, 3-, and 6-month follow-up using outcome measures based on the International Classification of Functioning, Disability and Health (ICF) model; and phase three will explore the experiences of stroke patients who use complementary or conventional treatment using an interview guide.

Data analysis

IBM SPSS Statistics Version 27 will be used to analyze the data using descriptive and inferential statistics. Repeated measures of ANOVA will be used to determine the differences between variables at baseline, 2-, 3-, and 6-month post-stroke. The qualitative data will be transcribed and entered into Atlas Ti version 9.0. The data will be coded and analyzed using thematic areas that will be generated from the codes.

Conclusion

The study protocol will provide a comprehensive overview of the structure, process, and outcomes of stroke rehabilitation in Ghana, incorporating both conventional and complementary treatment and rehabilitation into the stroke recovery journey. It will also inform clinical practice, with new insights on the experiences of stroke patients based on their choice of rehabilitation pathway.

Perceptions of community members on contextual factors driving cardiovascular disease behavioural risk in Ghana: a qualitative study

Background

There is clear evidence that lifestyle interventions are effective towards reducing cardiovascular risk. However, implementing these interventions in real-world setting has been suboptimal, especially in sub-Saharan Africa, thus creating ‘evidence to practice gap.’ We explore perceptions of community members on contextual factors driving cardiovascular disease (CVD) behavioural risk (alcohol consumption, smoking, physical (in)activity and fruits and vegetables consumption) in Ghana.

Methods

This was a cross-sectional study. Thirty (30) focus group discussions (FGDs) were carried out in five communities in Ghana (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) between October and November 2017, and these were analysed using a thematic approach.

Results

Five main factors were raised by participants as contextual factors driving alcohol consumption and smoking and these include economic (poverty, unemployment, loss of jobs), psycho-social (worries, hardships, anxieties), medical (pain suppression, illness management), sexual (sexual performance boost), and socio-cultural (curse invocation, quest for supernatural powers) factors. Personal/social factors (time constraints, personal dislike, lack of knowledge of the benefits of exercise), economic factors (poverty, economic hardship), and negative health effects (getting tired easily, medical conditions) were cited as reasons why community members did not engage in physical activity. Consumption of fruits and vegetables in the five communities were determined by availability, cost, personal (dis)like, lack of knowledge about benefits, and cultural taboo. Participants’ narratives revealed that the symbolic functions of some of these behavioural risk factors and the built environment were important determining factors that have sustained these behaviours in these communities over the years.

Conclusions

This study showed that successful implementation of CVD interventions in Ghana needs to address the perceptions of community members on factors driving CVD behavioural risk factors. Future policies and interventions should be developed based on these contextual factors taking into consideration the age, sex and ethnic variations especially with interventions seeking to address CVD risk factors at the primary health care level. These findings should urge local policy makers and health managers to incorporate the roles of these contextual factors in new programs targeting cardiovascular health. Closing the ‘evidence to practice’ gap as far as CVD interventions are concerned may be impossible without this.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13646-3.

Determinants of Stroke Mortality through Survival Models: The Case of Mettu Karl Referral Hospital, Mettu, Ethiopia

Introduction

Every year worldwide, between five to six million deaths are associated with stroke; on average, one stroke-related death occurs every four minutes. In Ethiopia, stroke is a frequent cause of mortality and morbidity from noncommunicable diseases. Therefore, this study was aimed at determining factors associated to stroke mortality through survival models in Mettu Karl Referral Hospital.

Methods

This study was conducted from September 1, 2014, to April 1, 2017, and encompassed 202 stroke patients at Mettu Karl Referral Hospital. The Cox semiparametric regression was used for analyzing survival analysis of stroke patients using R software.

Results

A total of 202 stroke patients were included in the study, and among those patients, 72.8% and 27.2% were censored and died, respectively. According to the result of Cox semiparametric regression model, sex of patients, hypertension, baseline complication, and stroke type had significant effect on survival of the stroke patient at 5% significance level.

Conclusion

The results from Cox semiparametric regression model indicated that sex of patients, hypertension, baseline complication, and stroke type were major factors related to the survival time of stroke patients. The researcher recommends that the people should be aware on the burden of those risk factors and well informed about the disease.

Awareness, Recognition, and Response to Stroke among the General Public-An Observational Study

Objective  To evaluate awareness and response to stroke among the general public.

Materials and Methods  In this prospective, observational study, self-reported stroke awareness questionnaire was administered in 2000 consecutive participants who visited outpatient clinic of a tertiary care hospital. For data analysis, comparison included for awareness of stroke and response in case of stroke.

Results  The average age of the study participants was 39.64 ± 15.55 (17–85), with 651(32.6%) women. Among the respondents, 786(39.3%) participants mentioned stroke as blood clot in the brain; 268(13.4%) stated it as brain hemorrhage. Awareness of stroke was higher in people in cities (71.0 vs. 8.5%; p  < 0.001) and graduates (75.3 vs. 60.9%; p  < 0.001) or knew a family member or friend who had stroke (42.7 vs. 30.4%; p  < 0.001). Most commonly recognized risk factors included stress (1,152; 57.6%) and hypertension (1,148; 57.4%). Most identified warning sign was weakness of one side of body (807; 40.4%) and speech impairment (658; 32.9%). Participants who were aware of stroke knew a greater number of risk factors (3.75 ± 2.88 vs. 2.45 ± 2.66; p  < 0.001) and warning signs (2.85 ± 2.25 vs. 1.49 ± 1.41; p <0.001). Among 1,138 participants who were aware of stroke, 166 (14.6%) participants knew one correct response in case of a stroke, either call a doctor (49.3 vs. 35.0%; p <0.001) or call an ambulance (41.1 vs. 34.9%; p  = 0.055). Participants who knew one correct response to stroke had at least a family member/friend who had stroke (44.1 vs. 34.3%; p  < 0.022).

Conclusion  We report that among 56.9% of the participants who were aware of stroke most could not name more than four risk factors or three warning signs of stroke. Only 14.6% of those aware of stroke knew appropriate response to stroke.

Explanatory models of stroke in Ghana: perspectives of stroke survivors and their caregivers

Objective: This study examines explanatory models (EMs) of stroke and its complications among people living with stroke, and their caregivers, in two urban poor communities in Accra (Ga Mashie) and Korle Bu Teaching Hospital (KBTH), Accra.Methods: Twenty-two stroke survivors and 29 caregivers were recruited from 2 urban poor communities in Accra and KBTH. Qualitative data were obtained using semi-structured interviews that lasted between 45 minutes and 2 hours. The interviews were audiotaped, transcribed and analysed thematically, informed by the concept of EMs of illness.Results: Participants referred to stroke as a sudden event and they expressed different emotional responses after the stroke onset. Stroke survivors and their caregivers attributed stroke with poor lifestyle practices, high blood pressure, unhealthy diet and dietary practices, supernatural causes, stress, family history, other chronic diseases, and delay in treatment of symptoms. While the stroke survivors associated stroke complications with physical disability and stigmatisation, the caregivers associated these with physical disability, behavioural and psychological changes, cognitive disability and death. These associations were mostly influenced by the biomedical model of stroke.Conclusion: The biomedical model of stroke is important for developing interventions that will be accepted by the stroke survivors and the caregivers. Nevertheless, sociocultural explanations of stroke need to be taken into consideration during delivery of medical information to the participants. This study proposes an integrated biopsychosociocultural approach for stroke intervention among the study participants.

Sex, Knowledge, and Attitude of Stroke Survivors Attending Bebe Herbal Center on Risk Factors before and after Stroke

Objective

The objective of this study was to investigate the extent stroke survivors who attended an herbal center knew of stroke risk factors and whether significant sex differences existed. Study Design. This was a cross-sectional study conducted from January to June 2018 at Bebe Herbal Center, and it involved two well-trained assistants who interviewed 149 first-time stroke survivors after consent and ethical approval were obtained. The survivors self-reported their knowledge, attitude, and beliefs on risk factors before and after stroke. Statistical Analyses. Means of continuous variables were compared using Student's unpaired t-test, while categorical variables between males and the females were analyzed using Pearson's chi-square test. P < 0.05 was taken as significant.

Results

Mean age of men (64.81 ± 1.24 yrs) was significantly higher than that of women (61.39 ± 1.42 yrs) (F = 0.096, t = 1.79, df = 147; P < 0.05). More men than women were 60 years and above while more women than men were below 60 years. Pearson's chi-square test showed significant association of sex with education (χ² = 12.31; df = 3, P < 0.006), occupation (χ² = 23.65; df = 4, P < 0.001), alcohol intake (χ² = 24.23; df = 1; P < 0.001), and smoking (χ² = 9.823; df = 1; P < 0.001). The commonest risk factor suffered was hypertension (73.1%), followed by alcohol intake (59.1%), smoking (31.5%), and diabetes mellitus (26.7%); these affected men more than women. Male survivors unaware of their hypertensive status were more likely to have stroke than females, and age had a significant effect on the likelihood of developing a stroke; the same was occupation.

Conclusions

These survivors suffered mainly from hypertension, triggered by psychosocial problems and diabetes mellitus; their stroke seemed fueled by unrecognized hypertension, unrecognized diabetes mellitus, ignorance of hyperlipidemia, and wide-scale belief in witchcraft as risk factor. Awareness programs in the third world should take these observations into consideration.

Knowledge of Stroke Risk Factors and Signs in Parakou, a Northern City of Benin in West Africa

INTRODUCTION

We aimed to determine knowledge of stroke risk factors and signs in an urban population of northern Benin.

METHODS

A door-to-door purposeful sampling survey was conducted in resident population (age ≥15 years) of the district of Titirou in the city of Parakou (N = 255,478) in Benin between March 15 and July 15, 2016. In-person interviews were conducted with data collection on structured questionnaires with close and open questions, according to standard definitions. Multivariable logistic regression was used to assess predictors of good knowledge, defined by provision of a correct response in pre-defined set of questions on stroke risk factors and warning signs.

RESULTS

Of 4,671 participants (mean age 27.7 ± 12.9 years; females 50.6%), only 404 (8.6%) knew at least 1 stroke risk factor. Knowledge level of stroke risk factors (odds ratio, 95% confidence interval) was related to age (1.37, 1.27-1.48), level of education (2.54, 1.73-3.72), and family history of stroke (3.01, 2.08-4.26). Only 230 (4.9%) were able to cite at least 1 stroke symptom, and this knowledge was great with increasing age (1.04, 1.02-1.06), family (3.63, 2.41-5.49) and personal history of stroke (3.71, 1.86-7.42), and high level of education (4.35, 2.68-7.07).

CONCLUSION

Knowledge of stroke risk factors and signs is low in northern Benin. Greater public education and awareness campaigns are required to address the burden of stroke.

Public knowledge of risk factors and warning signs for cardiovascular disease among young and middle-aged adults in rural Tanzania

Background

Improving cardiovascular health requires public knowledge and reduction of modifiable cardiovascular disease (CVD) risk factors. This study assessed knowledge of risk factors and warning signs for CVDs among young and middle-aged adults in Morogoro, Tanzania.

Methods

We conducted a community-based survey as part of cluster randomized controlled study of community health workers (CHWs) intervention for reduction of blood pressure among young and middle-aged adults in rural Morogoro. Information on socio-demographic characteristics, knowledge of risk factors and warning signs for CVDs was collected using an interviewer administered questionaire. Knowledge was assessed using open-ended questions followed by closed-ended questions. Descriptive statistics were used to describe knowledge of risk factors and warning signs. Logistic regression analysis was used to investigate factors associated with adequate knowledge of risk factors and warning signs for CVDs.

Results

Two-thirds (65.7%) of the participants had heard about CVDs. The main sources of information were mainly relatives/ neighbors (64.8%) and radio (53.0%). Only 28.3% of the participants reported health care providers as source of information about CVDs. More than half of the participants (52.4%) did not mention even one risk factor spontaneously while 55.2% were unable to mention any warning sign. When asked to select from a list, 6.9% were unable to correctly identify any risk factor whereas 11.8% could not correctly identify even a single warning sign. Quarter of participants (25.4%) had good knowledge score of risk factors, 17.5% had good knowledge score of warning signs and 16.3% had overall good knowledge of both risk factors and warning signs. Residing in Ulanga, having higher education level, having ever checked blood pressure and being overweight/obese predicted adequacy of knowledge score for both risk factors and warning signs.

Conclusion

Knowledge of risk factors and warning signs in this rural population of young and middle-aged adults was generally low. Health care providers were less likely to provide health education regarding risk factors and warning signs for CVDs. Health promotion interventions to increase population knowledge of risk factors and warning signs should be implemented for successful reduction of CVDs in Tanzania.

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

BACKGROUND AND OBJECTIVE

Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC.

METHODS

A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data.

RESULTS

A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers.

CONCLUSION

Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

'I think one of the ways they will help is to create awareness': primary school teachers' perceptions of cardiovascular diseases in Nigeria

The increasing incidence and prevalence of non-communicable diseases is a major global health concern. Cardiovascular diseases (CVDs) account for the highest percentage of deaths related to non-communicable diseases, and low and middle-income countries (LMIC) face the highest burden of CVDs. Understanding the knowledge and perception of CVDs and their risk factors in an LMIC such as Nigeria may play an important role in cardiovascular health promotion and improvement plans to reduce CVD-related deaths. A qualitative study was conducted using semi-structured interviews to gain an in-depth understanding of some personal and sociocultural views on CVDs and their risk factors. The participants were purposively sampled primary school teachers in South-Eastern Nigeria. Thematic analysis approach was used for data analysis. The study findings include knowledge of heart disease, perceived causes and risk factors of CVDs, spirituality, and the way forward. Overall, the knowledge of CVDs in the setting was found to be related to the psychosocial nature of the participants; the effectiveness of any intervention needs to take these factors into consideration. For example, health policies for CVD health education and awareness should be tailored to address some of the issues of belief, values, and religion, as mentioned in the study.

Assessment of Knowledge on Risk Factors, Warning Signs, and Early Treatment Approaches of Stroke among Community Adults in North India: A Telephone Interview Survey

Background As stroke is a catastrophic illness, knowing its risk factors, early signs and symptoms, and management strategies could potentially prevent morbidity and mortality among the people.

Objectives The aim of this study is to determine the public cognizance of risk factors, signs and symptoms, and early treatment options available for stroke with particular emphases on thrombolysis, and its window period.

Materials and Methods A cross-sectional telephonic interview-based survey was conducted in the states of Punjab, Haryana, and Himachal Pradesh of North India from August 2017 to December 2017.

Results Of 350 respondents those participated in the survey with a mean age ± standard deviation of 39.93 ± 13.41  years, hypertension was found to be the most common risk factor among the study participants ( n = 205, 58.57%) and 28.85% of the study participants were not aware of the risk factors, whereas 46% of the participants were not aware of warning signs of stroke. The window period of thrombolysis was compared with gender, and it was found that the higher number of male participants ( n = 49) adduced the right window of thrombolysis (0–4.5  hours) as compared with the female participants ( n = 26).

Conclusions Survey results suggested that there exists scant information about risk factors, alarming signs, and early treatment approaches among community adults toward stroke. In this regard, there is an immense need to conduct awareness camps related to stroke to educate the vulnerable public.

Knowledge, attitudes, and preventative practices regarding ischemic heart disease among emergency department patients in northern Tanzania

OBJECTIVES

The objective of this study is to increase understanding of knowledge, attitudes, and preventative practices regarding ischemic heart disease (IHD) in sub-Saharan Africa in order to develop patient-centered interventions to improve care and outcomes.

STUDY DESIGN

This is a prospective observational study.

METHODS

Adult patients presenting with chest pain or shortness of breath to an emergency department in northern Tanzania were enrolled. A questionnaire was adapted from existing knowledge attitude and practice surveys regarding cardiovascular disease and the WHO STEPS instrument. Individual five-year risk of cardiovascular event was determined by validated models based on age, sex, systolic blood pressure, body mass index, diabetes, and smoking status. An IHD knowledge score was calculated by giving one point for each correct response to the knowledge-related items, with a maximum score of 10. Associations between IHD knowledge and patient characteristics were assessed by Welch's t-test.

RESULTS

A total of 349 patients were enrolled, with median interquartile range (IQR) age 60 (45, 72) years. Of participants, 259 (74.2%) had hypertension, and 228 (65.3%) had greater than 10% five-year risk of cardiovascular event. The mean (SD) knowledge score was 4.8 (3.3). The majority of respondents (224, 64.2%) recognized obesity as a risk factor for heart attack, while a minority (34, 9.7%) knew that a daily aspirin could reduce the risk of cardiovascular event. Greater IHD knowledge was associated with younger age (P = 0.045) and higher levels of education (P < 0.001) but not higher risk of cardiovascular disease (P = 0.123). Most respondents expressed a willingness to diet to improve their health (322, 92.3%) and a preference for treatment from a physician rather than a traditional healer for a heart attack (321, 92.0%). A minority of patients reported exercising regularly (88, 25.2%) or seeing a doctor routinely for checkups (100, 28.7%).

CONCLUSIONS

High-risk emergency department patients in northern Tanzania have moderate knowledge regarding IHD but do not consistently engage in healthy preventive practices. Patient-centered interventions are needed to improve IHD knowledge and practices in high-risk populations.

Community-Level Knowledge and Perceptions of Stroke in Rural Malawi

Background and Purpose- The incidence of stroke in Malawi is unknown but major risk factors, including hypertension, obesity, and diabetes mellitus, are highly prevalent. We sought to understand community-level knowledge about stroke. Methods- A population-based cross-sectional study was conducted in rural Malawi (2016-2017). Adults aged ≥15 years were randomly selected and interviewed about their knowledge and perceptions of stroke symptoms, risk factors, and prevention. Logistic regression was used to investigate sociodemographic factors associated with stroke knowledge. Results- Of 812 selected, 739 (91% response rate) were seen and consented; 57% were female, and the median age was 52.0 years. Knowledge of stroke was poor: 71% knew no (correct) risk factors. Witchcraft (20.6%) was mentioned as frequently as hypertension (19.8%) as a cause. Knowledge of stroke was greatest in the most educated and wealthy and lowest in men, the never married, and the youngest age group. HIV-positive individuals had higher knowledge of prevention (odds ratio, 2.91; 95% CI, 1.21-7.03) than HIV negative individuals. Conclusions- Knowledge about stroke is very low in this community, particularly among the least educated and poor. Programs to support prevention, early recognition, and timely hospital presentation after a stroke are needed.

Perceptions of Stroke and Associated Health-Care-Seeking Behavior in Northern Tanzania: A Community-Based Study

BACKGROUND

Little is known about knowledge of stroke symptoms, perceptions of self-risk, and health-care-seeking behavior for stroke in East Africa.

METHODS

A 2-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household health-care decision makers were asked to list all symptoms of a stroke. They were further asked if they thought they had a chance of having a stroke and where they would present for care for stroke-like symptoms. A socioeconomic status score was derived via principal component analysis from 9 variables related to wealth.

RESULTS

Of 670 respondents, 184 (27.4%) knew a conventional stroke symptom and 51 (7.6%) thought they had a chance of having a stroke. Females were less likely to perceive themselves to be at risk than males (OR 0.49, 95% CI 0.28-0.89, p = 0.014). Of respondents, 558 (88.3%) stated they would present to a hospital for stroke-like symptoms. Preference for a hospital was not associated with knowledge of stroke symptoms or perception of self-risk but was associated with a higher socioeconomic status score (p < 0.001).

CONCLUSIONS

Knowledge of stroke symptoms and perception of self-risk are low in northern Tanzania, but most residents would present to a hospital for stroke-like symptoms.

Prevalence and correlates of stroke among older adults in Ghana: Evidence from the Study on Global AGEing and adult health (SAGE)

This study examines the prevalence and correlates of stroke among older adults in Ghana. This cross-sectional study retrieved data from Wave 1 of the World Health Organization (WHO) Survey on Global Ageing and Adult Health (SAGE) conducted between 2007 and 2008. The sample, comprising 4,279 respondents aged 50 years and above, was analysed using descriptive statistics, cross tabulations and Chi-Square tests, and a multivariable binary logistic regression. Respondents ranged in age from 50 to 114 years, with a median age of 62 years. Stroke prevalence was 2.6%, with the correlates being marital status, level of education, employment status, and living with hypertension or diabetes. The results showed that being separated/divorced, having primary and secondary education, being unemployed and living with hypertension and diabetes, significantly increased the odds of stroke prevalence in this population. The results suggest that interventions to reduce stroke prevalence and impact must be developed alongside interventions for hypertension, diabetes and sociodemographic/economic factors such as marital status, level of education, and employment status.

Knowledge, attitudes and practices of West Africans on genetic studies of stroke: Evidence from the SIREN Study

BACKGROUND

It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa.

OBJECTIVE

To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies.

METHODS

A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed.

RESULTS

Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25-1.81) and a family history of stroke (OR 1.20, 1.03-1.39) while Islamic religion (OR=0.82, CI: 0.72-0.94), being currently unmarried (OR = 0.81, CI: 0.70-0.92), and alcohol use (OR = 0.78, CI: 0.67-0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03-1.74) but inversely associated with a medical history of high blood pressure (OR = 0.79, 0.65-0.96).

CONCLUSION

To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.

A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.

Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life

Stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high mortality but the high morbidity also results in up to 50% of survivors being chronically disabled. Thus stroke is a disease of immense public health importance with serious economic and social consequences. The public health burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries. This paper provides an overview of stroke in the 21^st century from a public health perspective.

Incidence and Outcomes after Out-of-Hospital Medical Emergencies in Gambia: A Case for the Integration of Prehospital Care and Emergency Medical Services in Primary Health Care

BACKGROUND

The Gambia is going through a rapid epidemiologic transition with a dual disease burden of infections and non-communicable diseases occurring at the same time. Acute, time-sensitive, medical emergencies such as trauma, obstetric emergencies, respiratory failure, and stroke are leading causes of morbidity and mortality among adults in the country.ProblemData on medical emergency care and outcomes are lacking in The Gambia. Data on self-reported medical emergencies among adults in a selection of Gambian communities are presented in this report.

METHODS

A total of 320 individuals were surveyed from 34 communities in the greater Banjul area of The Gambia using a survey instrument estimating the incidence of acute medical emergencies in an adult population. Self-reported travel time to a health facility during medical emergencies and patterns of health-seeking behavior with regard to type of facility visited and barriers to accessing emergency care, including cost and medical insurance coverage, are presented in this report.

RESULTS

Of the 320 individuals surveyed, 262 agreed to participate resulting in a response rate of 82%. Fifty-two percent of respondents reported an acute medical emergency in the preceding year that required urgent evaluation at a health facility. The most common facility visited during such emergencies was a health center. Eighty-seven percent of respondents reported a travel time of less than one hour during medical emergencies. Out-of-pocket cost of medications accounted for the highest expenditure during emergencies. There was a low awareness and willingness to subscribe to health insurance among individuals surveyed.

CONCLUSION

There is a high incidence of acute medical emergencies among adults in The Gambia which are associated with adverse outcomes due to a combination of poor health literacy, high out-of-pocket expenditures on medications, and poor access to timely prehospital emergency care. There is an urgent need to develop prehospital acute care and Emergency Medical Services (EMS) in the primary health sector as part of a strategy to reduce mortality and morbidity in the country. TourayS, SanyangB, ZandrowG, TourayI. Incidence and outcomes after out-of-hospital medical emergencies in Gambia: a case for the integration of prehospital care and Emergency Medical Services in primary health care. Prehosp Disaster Med. 2018;33(6):650-657.

Factors predicting community participation in patients living with stroke, in the Western Cape, South Africa

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa. Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews. Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors. Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients' participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors. Implications for Rehabilitation Community participation in the general population of stroke survivors' is largely determined by their mobility function. Determinants of community participation among stroke survivors essentially vary according to age and gender. Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients' demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

Knowledge about Stroke in Belo Horizonte, Brazil: A Community-Based Study Using an Innovative Video Approach

BACKGROUND AND PURPOSE

Stroke is a leading cause of death in Brazil. Knowledge about the clinical manifestations of stroke as well as its risk factors and its management is still poor in the country. We intended to assess the stroke knowledge of an urban population in Belo Ho-rizonte, Brazil.

METHODS

Individuals assisted by a basic health unit were interviewed between February and August 2014. After demographic data collection, the participants were asked to watch a video that consisted of a person presenting stroke signals and they were asked to answer questions about the condition shown on the video. Afterwards, they answered a semi-structured questionnaire to evaluate their stroke knowledge.

RESULTS

A total of 703 people were interviewed (62.1% female, mean age 46.7 years). Recognition of a person having a stroke on the presented video was achieved by 56.1% of the subjects. Female sex (p = 0.029) and contact with someone who had had a stroke (family member [p < 0.01], neighbor [p < 0.05]) increased the odds of correctly identifying the condition showed on the video. The most commonly mentioned clinical manifestations of stroke were weakness (34.7%) and speech disturbance (31.6%). Stroke risk factors that were most named were "unbalanced diet" (42.3%) and hypertension (33.7%). Most participants (66.8%) said they would call the emergency medical services, while 17.8% would go directly to a hospital. Only 17 subjects knew thrombolytic therapy for acute stroke.

CONCLUSION

Female sex and a family history of stroke increased the odds of recognizing the signs of stroke. Knowledge about the clinical manifestations, risk factors, and management of stroke was low in the studied population.

Stroke care in Africa: A systematic review of the literature

Background

Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited.

Aim

To describe the status of stroke care in Africa.

Summary of review

We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa.

Conclusions

This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice.

Knowledge and practices related to stroke prevention among hypertensive and diabetic patients attending Specialist Hospital, Sokoto, Nigeria

INTRODUCTION

Stroke has become a problem of public health importance worldwide. Knowledge and practices related to stroke prevention among hypertensive and diabetic patients are important in the control of the disease. In Nigeria, recent reports indicate an emerging epidemic of stroke. This study aimed to determine the knowledge and practices related to stroke prevention among hypertensive and diabetic patients in Sokoto, Nigeria.

METHODS

This was a cross-sectional study among 248 patients attending hypertension and diabetes clinic of Specialist Hospital, Sokoto, Nigeria, selected by systematic sampling technique. A semi-structured questionnaire was used to collect data on the research variables. Data were analyzed using IBM SPSS version 20 statistical package.

RESULTS

The mean age of respondents was 48.21 ± 15.07 years and they were predominantly females (65.7%). The respondents had good knowledge of stroke (70.3%), organs or parts of body affected by stroke (89.1%), signs or symptoms of stroke (87.0%), stroke risk factors (86.6%) and stroke prevention (90.8%). Formal education was the sole predictor of good knowledge of signs or symptoms of stroke (aOR = 3.99, 95% CI = 1.58-10.13, p = 0.004), stroke risk factors (aOR = 4.24, 95% CI = 1.68-10.67, p = 0.002) and stroke prevention (aOR = 3.45, 95% CI = 1.09-10.93, p = 0.035). Stroke prevention practices were sub-optimal and significantly associated with formal education and being employed.

CONCLUSION

These findings suggest the need for all stakeholders to focus on both patients' education and empowerment in halting the rising burden of stroke across the globe.

Knowledge and awareness of and perception towards cardiovascular disease risk in sub-Saharan Africa: A systematic review

INTRODUCTION

Cardiovascular diseases (CVDs) are the most common cause of non-communicable disease mortality in sub-Saharan African (SSA) countries. Gaps in knowledge of CVD conditions and their risk factors are important barriers in effective prevention and treatment. Yet, evidence on the awareness and knowledge level of CVD and associated risk factors among populations of SSA is scarce. This review aimed to synthesize available evidence of the level of knowledge of and perceptions towards CVDs and risk factors in the SSA region.

METHODS

Five databases were searched for publications up to December 2016. Narrative synthesis was conducted for knowledge level of CVDs, knowledge of risk factors and clinical signs, factors influencing knowledge of CVDs and source of health information on CVDs. The review was registered with Prospero (CRD42016049165).

RESULTS

Of 2212 titles and abstracts screened, 45 full-text papers were retrieved and reviewed and 20 were included: eighteen quantitative and two qualitative studies. Levels of knowledge and awareness for CVD and risk factors were generally low, coupled with poor perception. Most studies reported less than half of their study participants having good knowledge of CVDs and/or risk factors. Proportion of participants who were unable to identify a single risk factor and clinical symptom for CVDs ranged from 1.8% in a study among hospital staff in Nigeria to a high of 73% in a population-based survey in Uganda and 7% among University staff in Nigeria to 75.1% in a general population in Uganda respectively. High educational attainment and place of residence had a significant influence on the levels of knowledge for CVDs among SSA populations.

CONCLUSION

Low knowledge of CVDs, risk factors and clinical symptoms is strongly associated with the low levels of educational attainment and rural residency in the region. These findings provide useful information for implementers of interventions targeted at the prevention and control of CVDs, and encourages them to incorporate health promotion and awareness campaigns in order to enhance knowledge and awareness of CVDs in the region.

Exploring barriers to accessing physiotherapy services for stroke patients at Tema general hospital, Ghana

Background

Physiotherapy has been shown to reduce the risk of disability among stroke patients. Poor adherence to physiotherapy can negatively affect outcomes and healthcare cost. However, very little is known about barriers especially to physiotherapy services in Ghana. The objective of this study was to assess the barriers to physiotherapy services for stroke patients at Tema General Hospital (TGH). The individual/personal and health system barriers to physiotherapy services at TGH were determined.

Method

A cross-sectional study design was employed. A simple random sampling technique was used to recruit 207 respondents for a face-to-face interview. Interviewer-administered questionnaires were used to collect data on individual/personal barriers of respondents to physiotherapy services and were described using the Likert’s scale. Health system barriers were assessed using a self-structured questionnaire which had section under the following heading: human factors, physiotherapy modalities, physical barriers and material/equipment factors. The time spent waiting for physiotherapy and attitude of physiotherapist towards patients; physiotherapy modality such as electrotherapy, exercise therapy and massage therapy among others were some of the indices measured. Respondents’ adherence to Medication was assessed with the Morisky 8-item medication adherence questionnaire. Data were entered and analysed using Epi info 7 and STATA 12.0. Associations between the variables were determined using a chi-square test and logistic regression model was used to test the strength of associations between the independent and the dependent variables. The level of statistical significance was set at p < 0.05.

Results

The results showed that majority (76.3%) of the respondents had economic barrier as their main individual/personal barrier to physiotherapy services. For medication adherence level, patients with low medication adherence level were about 21 times the odds of defaulting on accessing physiotherapy services five times or more as compared to those with medium adherence level (OR 20.63, 95% CI 8.96, 42.97). It was concluded in the study that individual/personal barriers of stroke patients were the significant barriers to accessing physiotherapy services at Tema General Hospital.

Electronic supplementary material

The online version of this article (doi:10.1186/s40945-017-0037-5) contains supplementary material, which is available to authorized users.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

BACKGROUND

Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.

METHODOLOGY

A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used.

RESULTS

Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers.

CONCLUSIONS

Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.

TRIAL REGISTRATION

The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

The burden of stroke in Africa: a glance at the present and a glimpse into the future

Objective

Information on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa.

Methods

We systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures.

Results

Community-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.

Conclusions

While the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.

Chronic Diseases in North-West Tanzania and Southern Uganda. Public Perceptions of Terminologies, Aetiologies, Symptoms and Preferred Management

Background

Research has shown that health system utilization is low for chronic diseases (CDs) other than HIV. We describe the knowledge and perceptions of CDs identified from rural and urban communities in north-west Tanzania and southern Uganda.

Methods

Data were collected through a quantitative population survey, a quantitative health facility survey and focus group discussions (FGDs) and in-depth interviews (IDIs) in subgroups of population survey participants. The main focus of this paper is the findings from the FGDs and IDIs.

Results

We conducted 24 FGDs, involving approximately 180 adult participants and IDIs with 116 participants (≥18 years). CDs studied included: asthma/chronic obstructive lung disease (COPD), diabetes, epilepsy, hypertension, cardiac failure and HIV- related disease. The understanding of most chronic conditions involved a combination of biomedical information, gleaned from health facility visits, local people who had suffered from a complaint or knew others who had and beliefs drawn from information shared in the community. The biomedical contribution shows some understanding of the aetiology of a condition and the management of that condition. However, local beliefs for certain conditions (such as epilepsy) suggest that biomedical treatment may be futile and therefore work counter to biomedical prescriptions for management.

Conclusion

Current perceptions of selected CDs may represent a barrier that prevents people from adopting efficacious health and treatment seeking behaviours. Interventions to improve this situation must include efforts to improve the quality of existing health services, so that people can access relevant, reliable and trustworthy services.