Epidemiology of stroke in a rural community in Southeastern Nigeria

A systematic review of the epidemiology and the public health implications of stroke in Sub-Saharan Africa

BACKGROUND

With approximately 11 million strokes occurring annually worldwide, and over 6.5 million deaths annually, stroke has made its place as one of the major killers in the world. Although developing countries make up more than 4/5 of the global stroke burden, well-grounded information on stroke epidemiology remains lacking there.

AIMS

This systematic review study aimed to provide a synthesis of studies on the incidence and prevalence of stroke among adults in sub-Saharan Africa (SSA), subsequently deduce the associated risk factors and public health implications (mortality rates and economic costs) of the disease on the population of this region.

METHODS

A systematic review of studies carried out in the region and published on PUBMED. Eligibility criteria were established using the PEO (Population/Patient, Exposure, Outcome) format. Research articles investigating either (or all) of the following: ischemic or haemorrhagic stroke, incidence, prevalence, and risk factors of stroke in adults (≥ 18 years old), in at least one region of SSA were included. Exclusion criteria comprised studies involving populations younger than 18 years old, research conducted outside the designated research region, and articles inaccessible in full text. The PRISMA guidelines were used for the search strategy.

RESULTS

Fifty-two studies were included review. Among them, over 11 studies investigated the prevalence of the disease. Some older studies within the continent (Nigeria, 2011) showed a prevalence of 1.3 per 100 while more recent studies (Zambia, 2021) showed a prevalence of 4.3 per 1000. The highest prevalence noted in this region was in Madagascar (2017) with 48.17 per 100, while the lowest was recorded in (Zimbabwe, 2017) with 0.61 per 100. The study in Tanzania showed a crude incidence of 94·5 per 100 000 (76·0-115·0) while the study in Ghana in 2018 showed an incidence of 14.19 events per 1000 person-years [10.77-18.38]. The identified risk factors included hypertension, diabetes, smoking, alcohol consumption, physical inactivity, poor diets (more salt, less vegetables), dyslipidaemia, HIV/AIDS co-infection, heart disease (cardiomyopathies, cardiac arrhythmias), obesity, previous stroke and/or family history of stroke. Over 21 studies investigated the mortality rates due to stroke in SSA, with most of the studies being in West Africa. These studies revealed mortality rates as high as 43.3% in Ghana, and as low as 10.9% in Cameroon. Few studies reported on the economic costs of stroke in the region; two in Benin, two in Nigeria and one in Tanzania.

CONCLUSION

The increasing incidence/prevalence, lifestyle factors and interactions with other diseases, including major communicable diseases, stroke is becoming a pressing public health problem for SSA. Reducing the incidence of stroke in Africa will surely lower mortality, morbidity, disability, and the neurological as well as cognitive aftereffects of stroke, as is clear from the experience of higher-income nations. We recommend a collective intervention involving the governments of nations, international organizations, civil society, and the private sector for greater impact and sustainable outcomes reducing the epidemiology and implications of stroke in SSA.

Comparison of performances of SIREN or MFSRS in stroke risk prediction in an African environment

BACKGROUND

The Modified Framingham Stroke Risk Score (MFSRS) is a widely utilized stroke risk assessment algorithm usually applied in international comparison. The Stroke Investigative Research and Educational Network (SIREN) is the only known African-specific stroke risk assessment algorithm.

AIMS AND OBJECTIVES

To compare stroke risk estimates from the SIREN and the MFSRS in an African community.

METHODS

This was a population-based cross-sectional survey involving consecutively recruited 310 consenting adult residents (mean age = 37.21 ± 15.84 years) of a Nigerian community. Risk factors of stroke were assessed among the participants and were utilized in calculating stroke risk estimates on the MFSRS and the SIREN. The obtained data were analyzed using descriptive statistics and the Spearman-rank order correlation test at an alpha level of 0.05.

RESULTS

The percentage stroke risk scores estimated by the SIREN and the MFSRS were 34.5% and 6.79% respectively. The most prevalent risk factors among the participants were hypertriglyceridemia (100.0%), raised waist-hip ratio (50.6%), hypercholesterolemia (45.5), physical inactivity (43.2%), psychological stress (41.3%), and hypertension (37.7%). Only two (hypertriglyceridemia and high blood pressure) out of the six factors considered in the MFSRS were rated among the first 10 most impactful risks by the SIREN. There was a weak correlation between the total scores on the MFSRS and the SIREN (rho = 0.39; p < 0.01) suggesting that the two ratings were discordant.

CONCLUSION

There were disagreements between the risk estimates on the SIREN and MFSRS with SIREN having a higher estimate that corresponded with the literature; this may be suggesting a poorer estimation of stroke risks by the MFSRS in an African environment. There is a need for large African-based quality control studies to determine and address these lapses.

The Burden and Quality of life of Caregivers of Stroke Survivors with Cognitive Impairment in Selected Healthcare Facilities in Anambra State, Nigeria

Objective:

To determine the burden and quality of life of caregivers of stroke survivors with cognitive impairment in selected healthcare facilities in Anambra State, Nigeria.

Methods:

This was a cross-sectional survey using the World Health Organization QOL-BREF and Caregiver Strain Index (CSI) as instruments. Descriptive statistics of frequency, percentage counts, mean and standard deviation were used to summarize the socio-demographics. Spearman’s ranked order correlation; Mann–Whitney U test assessed the correlation and gender and age difference in QoL and caregiver’s burden. Alpha level was set at 0.05.

Results:

Physical health domain of QOL was slightly moderate (53.29 ± 15.19), psychological health was low (46.33 ± 16.96), social relationship was slightly moderate (51.16 ± 0.31), environmental health was slightly moderate (51.22 ± 15.88), the burden of caregivers was high (6.35 ± 1.29).

Conclusion:

The quality of life of the caregivers of stroke survivors with cognitive impairment was moderate, and the caregivers’ stress was high in the sample of the population studied.

Prevalence of stroke survival in rural communities living in northern Peru

BACKGROUND AND PURPOSE

Stroke is the leading cause of neurological impairment in the South American Andean region. However, the epidemiology of stroke in the region has been poorly characterized.

METHODS

We conducted a staged three-phase population-based study applying a validated eight-question neurological survey in 80 rural villages in Tumbes, northern Peru, then confirmed presence or absence of stroke through a neurologist's examination to estimate the prevalence of stroke.

RESULTS

Our survey covered 90% of the population (22,278/24,854 individuals, mean age 30±21.28, 48.45% females), and prevalence of stroke was 7.05/1,000 inhabitants. After direct standardization to WHO's world standard population, adjusted prevalence of stroke was 6.94/1,000 inhabitants. Participants aged ≥85 years had higher stroke prevalence (>50/1000 inhabitants) compared to other stratified ages, and some unusual cases of stroke were found among individuals aged 25-34 years. The lowest age reported for a first stroke event was 16.8 years. High blood pressure (aPR 4.2 [2.7-6.4], p>0.001), and sedentary lifestyle (aPR 1.6 [1.0-2.6], p = 0.045) were more prevalent in people with stroke.

CONCLUSIONS

The age-standardized prevalence of stroke in this rural coastal Peruvian population was slightly higher than previously reported in studies from surrounding rural South American settings, but lower than in rural African and Asian regions. The death rate from stroke was much higher than in industrialized and middle-income countries.

Structural validity and reliability of the return to work assessment scale among post stroke survivors

BACKGROUND

Return to work (RTW) after injury or illness is a behavior influenced by physical, psychological and social factors. This study aims to determine the structural validity and reliability of a return to work assessment scale using internal consistency and factor analysis.

METHOD

A cross sectional survey research design was adopted for this study involving 101 Post stroke survivors. The return to work assessment scale, which was developed by Ibikunle et al. in 2019, was subjected to structural validity and reliability.

RESULT

The results reveal that 58 (57.4%) were males and 43 (42.2%) females with mean ages of 53.88±10.68 years. Internal consistency was high with a Cronbach's alpha coefficient of 0.81 for Domain 1, 0.93 for Domain 2 and 0.76 for Domain 3.Test-retest reliability analysis gave an ICC of 0.85(p = 0.001) for Domain 1, Domain 2 an ICC of 0.91 (p = 0.001) and Domain 3 an ICC of 0.99 (p = 0.001). The Kaiser-Meyer-Olkin measure of sampling adequacy (KMO) value for Domain 1 was X2  = 0.63 and that of Bartlett's test of sphericity value was significant (P = 0.000), Kaiser-Meyer-Olkin measure of sampling adequacy for Domain 2 was 0.84 and the Bartlett's test of sphericity value was significant (P = 0.000), the Kaiser-Meyer-Olkin measure of sampling adequacy for Domain 3 was 0.66 while the Barlett's test of sphericity was significant (p = 0.001). Therefore the factor analysis was appropriate.

CONCLUSION

The return to work assessment scale is a good, internally consistent and reliable tool that has demonstrated good group and structural validity.

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.

Stroke in Africa: profile, progress, prospects and priorities

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.

Estimating morbidity due to stroke in Nigeria: a systematic review and meta-analysis

BACKGROUND

The response to stroke in Nigeria is impaired by inadequate epidemiologic information. We sought to collate available evidence and estimate the incidence of stroke and prevalence of stroke survivors in Nigeria.

METHODS

Using random effects meta-analysis, we pooled nationwide and regional incidence and prevalence of stroke from the estimates reported in each study.

RESULTS

Eleven studies met our selection criteria. The pooled crude incidence of stroke in Nigeria was 26.0 (12.8-39.0) /100,000 person-years, with this higher among men at 34.1 (9.7-58.4) /100,000, compared to women at 21.2 (7.4-35.0) /100,000. The pooled crude prevalence of stroke survivors in Nigeria was 6.7 (5.8-7.7) /1000 population, with this also higher among men at 6.4 (5.1-7.6) /1000, compared to women at 4.4 (3.4-5.5) /1000. In the period 2000-2009, the incidence of stroke in Nigeria was 24.3 (95% CI: 11.9-36.8) per 100,000, with this increasing to 27.4 (95% CI: 2.2-52.7) per 100,000 from 2010 upwards. The prevalence of stroke survivors increased minimally from 6.0 (95% CI: 4.6-7.5) per 1000 to 7.5 (95% CI: 5.8-9.1) per 1000 over the same period. The prevalence of stroke survivors was highest in the South-south region at 13.4 (9.1-17.8) /100,000 and among rural dwellers at 10.8 (7.5-14.1) /100,000.

CONCLUSION

Although study period does not appear to contribute substantially to variations in stroke morbidity in Nigeria, an increasing number of new cases compared to survivors may be due in part to limited door-door surveys, or possibly reflects an increasing mortality from stroke in the country.

Pattern of stroke in a rural Kenyan hospital

Background

The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital.

Patients and Methods

The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts.

Results

Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32–96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%).

Conclusion

Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.

Carotid Intima-Media Thickness and Carotid Plaque: A Pilot Study of Risk Factors in an Indigenous Nigerian Population

BACKGROUND

Risk factors for carotid intima-media thickness (cIMT) and carotid plaque (CP) differ by ethnicity; however, this is not well understood in some ethnic populations. This work examines the risk factors for cIMT and CP in an indigenous Nigerian population.

METHODS

We assessed cIMT and CP in 122 participants and then performed biochemical analysis: fasting blood glucose (FBG), hemoglobin A1c, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), and total cholesterol (TC). The clinical history and anthropometric characteristics of participants were recorded. Linear models were used to assess the factors associated with cIMT and CP, and stepwise multivariate regression analyses were conducted to assess the predictors of cIMT and CP.

RESULTS

The cIMT thickness varied from .5 mm to 1.3 mm. Family history of heart disease (FHHDx), physical activity, FBG, HDL-C, TG, TC, body mass index (BMI), systolic pressure, and waist circumference were significantly associated with cIMT (P ≤ .01). High systolic (β = .008) and diastolic (β = .17) pressure, FHHDx (β = .24), age (β = .004), physical activity (β = -.09), and waist circumference (β = -.017) significantly predicted 85% of the variation in cIMT (P < .001 for all). Family history of hypertension (FHH), LDL-C, and high blood pressure were significantly associated with CP (P ≤ .05). The significant predictors of CP were FHH (β = .145, P = .03), smoking (β = .167, P = .01), HDL-C (β = .283, P < .001), weight (β = .150, P = .04), and BMI (β = .183, P = .01), explaining most of the 43.2% variation in CP.

CONCLUSIONS

Some of the risk factors differ from those of other ethnicities, suggesting a need for population-specific approach to risk assessment and early detection of subclinical disease.

Obstructive sleep apnea and stroke

Obstructive Sleep Apnea (OSA) is a common co-morbid condition in stroke patients. It represents a very important risk factor for stroke in addition to the other established ones such as hypertension, cardiovascular disease (CVD), hyperlipidemia, atrial fibrillation (AF), type 2 diabetes mellitus (T2DM), stress, smoking, and heavy drinking. Although in the United States the prevalence of OSA has somewhat decreased from the previous years, globally its prevalence remains constant, or in some cases, is on the rise. In this review we present the epidemiology for OSA in stroke populations and discuss the risk factors for stroke as well as the underlying pathogenetic mechanisms linking OSA, stroke and CVD. We also emphasize the more thorough evaluation and control of OSA in order to prevent the disabling side effects of a stroke, which not only compromises the physical and mental health of a person and increases the burden on families, but also adds a severe burden to national health economics. OSA should always be considered when assessing a patient with transient ischemic attacks (TIA). Work up and treatment for OSA will not only help prevent stroke with its devastating consequences, but will also help prevent CVD, and ameliorate co-morbid conditions such as diabetes and hypertension in these vulnerable populations.

Stroke incidence, prevalence and mortality in women worldwide

BACKGROUND

The study of sex differences on stroke incidence, prevalence and mortality is an emerging field of stroke epidemiology and care.

AIMS

This study sought to determine the information available on stroke epidemiology in women worldwide and possible sex differences in stroke epidemiology, and, if so, describe the nature of these differences and whether they are consistent across countries/groups of countries.

SUMMARY

We searched the available literature in English published between 1 January 2008 and 5 May 2015. Out of 17.789 papers only 56 peer-reviewed papers (29 community-based studies, 17 retrospective studies, 6 reviews, and 4 cross-sectional studies) have been included in the study. This review adopted the epidemiologic transition theory, which classifies countries into four stages according to their levels of industrialization and economy. For the first and second stages, reliable registries and health certification are lacking, and therefore our sought after data were very limited.In the third stage, specifically for Eastern Europe (post-socialist countries), the burden from stroke in women was on the rise, while in the fourth stage, despite an aging population, decreases in stroke incidence, prevalence and mortality have been observed, even in subjects older than 80 years for both sexes. However, regarding studies of US populations, these trends for women were less pronounced for African Americans, and Hispanics as well as Indians. This suggests a "gender-gap" regarding access to treatment and care.In conclusion, identifying the presence of differing global burden between the sexes will allow us to better understand how to prevent, treat, and manage both men and women.

Stroke survivors in Nigeria: A door-to-door prevalence survey from the Niger Delta region

The burden of stroke has been projected to increase in low-and middle-income countries due to the ongoing epidemiological transition. However, community-based stroke prevalence studies are sparse in sub-Saharan Africa particularly in Nigeria. This study aimed to provide a comparative estimate of the prevalence of stroke survivors in the rural Niger Delta region. A three-phased door-to-door survey was conducted using WHO modified instruments. In the first-phase, 2028 adults (≥18years) participants randomly selected from two rural communities were screened by trained health research assistants for probable stroke. In the second phase, suspected cases were screened with stroke-specific tool. Positive cases were made to undergo complete neurological evaluation by two study neurologist in phase-three. Stroke diagnosis was based on clinical evaluation using WHO criteria. Overall, 27 (8 first-ever and 19 recurrent cases) stroke survivors with crude prevalence of 13.31/1000 (95% CI, 8.32-18.31) and a non-significant difference in prevalence between the two study communities were found, (P=0.393I). In addition, age-adjusted prevalence of stroke survivors was 14.6/1000 person, about 7-folds higher than previous estimates outside the Niger Delta region. The prevalence increases significantly with advancing in age, P<0·001. Among others, hypertension (92.59%) was the commonest risk factor and comorbidity found. Improved stroke surveillance and care, as well as better management of the underlying risk factors, primarily undetected or uncontrolled high blood pressure, remains a public health priority.

The Use of Qualitative Methods in Developing Implementation Strategies in Prevention Research for Stroke Survivors in Nigeria

Implementing complex clinical interventions is a key challenge in many global regions. Local communities play a necessary role in enhancing feasibility and strengthening adaptive issues in the design and implementation of stroke interventions in developing countries. Drawing on the knowledge of physicians, patients, and caregivers, the authors employed qualitative methods as a phase 1 strategy to explore the challenges of stroke management and improve the adaptability and efficient delivery of a multimodal preventive intervention for secondary stroke disease in Nigeria. A total of 22 individual interviews were conducted with healthcare professionals, as well as 12 focus groups with patients and caregivers. Findings revealed four operational domains to improve strategies for phase 2 implementation and intervention: (1) barriers influencing optimal adherence in stroke survivors, (2) patient health beliefs and perceptions of patient health beliefs by others, (3) adoption of the "patient report card," and (4) "medical action plan" and family management strategies.

Atrial fibrillation in Sub-Saharan Africa: epidemiology, unmet needs, and treatment options

Health care in Sub-Saharan Africa is being challenged by a double burden of disease as lifestyle diseases common in the developed world, such as stroke and atrial fibrillation (AF), increase, while, simultaneously, health issues of the developing world in terms of communicable disease persist. The prevalence of AF is lower in Africa than in the developed world but is expected to increase significantly over the next few decades. Patients with AF in Africa tend to be younger and have a higher prevalence of rheumatic valvular heart disease than patients with AF in other regions. Permanent AF is the most prevalent type of AF in Africa, possibly due to the lower use of rhythm control strategies than in the developed world. Mortality rates of patients with AF in Africa are high, due largely to poor health care access and suboptimal therapy. The risk of stroke in AF, which is moderate to high in Africans as in the developed world, contributes to the high mortality rate. Patients with AF in Africa are often undertreated with antithrombotics, as cost and access to monitoring are major barriers. Vitamin K antagonists, including warfarin, are the most commonly available oral anticoagulants, but regular monitoring can be challenging, especially for patients in remote areas. Several non-vitamin K antagonist oral anticoagulants (NOACs) have been approved for use in countries across Sub-Saharan Africa and have the potential to reduce stroke burden. The higher cost of newer agents may be offset by the reduced need for regular monitoring, fixed dosing, and lower risk of intracranial bleeding; NOACs could provide a treatment option for patients in remote areas with limited access to regular monitoring. However, NOACs are not indicated in valvular AF. More work is needed to increase understanding of the epidemiology of AF and stroke, as well as to improve management strategies to reduce the burden of cardiovascular disease predicted for Africa.