Towards better prevention and care for stroke in LMICs
Death or disability from stroke is a growing concern around the world, with low- and middle-income countries more affected due to lack of awareness and treatment facilities. From early identification of risk factors to dedicated rehabilitation services, progress is being made in some of our most vulnerable regions.
Stroke is a growing threat to high-, middle- and low-income countries alike. In addition to its high fatality rate, it causes long-term disabilities and often affects people in the prime of their working lives, adding to the impact on health systems and economies.
Like other non-communicable diseases (NCDs), it is also frequently preventable. Early identification and management of risk factors, such as hypertension or diabetes, can help reduce the likelihood of stroke. Greater awareness of the symptoms and adequate facilities for rapid diagnosis and intervention can save lives and improve outcomes. With better management and rehabilitation patients are more likely to regain a higher quality of life.
Stroke was the second leading cause of mortality globally in 2019, accounting for 12% of all deaths, according to the Global Burden of Disease Study 2019. Because time is of the essence in treating stroke, countries with fragmented and rudimentary health infrastructure tend to experience higher fatality rates and greater disability. A report by the World Stroke Organisation (WSO) found that acute stroke treatments were offered in around 60% of high-income countries (HICs), compared with 26% in low- and middle-income countries (LMICs).
As the cases in China, Sierra Leone and the Middle East and North Africa indicate, addressing individual elements of stroke—from prevention to intervention to rehabilitation—can help improve outcomes. The most effective way of reducing the burden, however, is to create public health programmes that focus on prevention and screening for risk factors and promote best practices that ensure timely treatment.
China: Strengthening care across a fragmented health system
As elsewhere in the world, in China, too, the risk factors for stroke include hypertension, high rates of smoking and a decline in physical activity, as well as dietary factors—especially high sodium consumption in the northern and southwestern regions of the country.
Stroke is the number one killer and largest cause of disability in China, according to Lijing Yan, a professor at Duke Kunshan University and Peking University’s Institute for Global Health and Development, and the head of non-communicable chronic diseases research at the Global Health Research Centre of Duke Kunshan University.
"There is generally a lack of incentive for primary care to do this kind of work, which is a major obstacle in the prevention of stroke. In China, healthcare is still fragmented across different levels of healthcare and is not integrated."
While the stroke burden was concentrated in urban areas two decades ago, it is now a bigger problem in rural China in terms of both prevalence and case fatalities, she says. Yet there is a significant gap in the availability of healthcare between urban and rural areas.
“[After a stroke], there are treatments needed for acute stage and long-term management,” Yan says, explaining that multidisciplinary units for stroke management are generally limited to urban areas in China. “Rural populations with limited healthcare resources receive sub-standard treatment.”
Although China has progressed in recent years in creating preventative networks, establishing surveillance systems and strengthening stroke response, the lack of a developed primary healthcare sector and the fragmented healthcare system remain major challenges, Yan says.
The government’s China Healthy Lifestyle for All initiative targets NCDs and touts the benefits of diets low in sodium and oil, adequate activity and refraining from smoking.
Over the past 10 years, the Chinese government has also promoted sodium reduction and blood pressure screening. The Golden Bridge Stroke is an intervention pilot designed to narrow the gap between guideline-based recommendations and clinical practice to improve the quality of stroke care.
As part of the pilot, 20 hospitals in China received a “quality improvement intervention” involving care protocols, quality oversight and performance monitoring. A control group of 20 hospitals continued with the usual care. At the end of the study, researchers noted a “statistically significant, but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke”. “As far as I know, it has been scaled up and expanded since the first trial,” Yan says.
Yan says she is involved in several projects that seek to strengthen primary care facilities; some of these are involved with screening and prevention of stroke, while others manage treatment after the onset of stroke.
China’s healthcare reform in recent years includes the establishment of a family physician network at the primary care level, Yan says, explaining that this measure is potentially useful for better prevention and management of NCDs, including stroke.
“However, there is generally a lack of incentive for primary care to do this kind of work, which is a major obstacle in the prevention of stroke,” Yan says. “In China, healthcare is still fragmented across different levels of healthcare.
“We also need, ideally, more community health workers who can screen people for stroke. These healthcare workers are usually volunteers or allied health professionals who can complement the work of, and collaborate with primary care providers.
“A strong network of village doctors (primary care providers in rural areas) and urban health centres is needed, but there is a lack of trust among patients because many people think they don’t provide good care.”
In order to create such networks, the health system should clearly define the roles and responsibilities of primary, secondary, and tertiary care and devise a compensation and financial incentive system for doctors so that “work can be aligned with need,” Yan says. Better training and a strategy of engaging with patients are also important.
Sierra Leone: Managing stroke’s aftermath with sparse resources
Stroke is the second most common cause of death in Africa. In Sierra Leone, the west African country that has been plagued by war, disease, and disaster for years, around half of those who survive an initial stroke die within three months.
The country of eight million people had no dedicated stroke service until 2018, when King’s College London and the UK National Institute for Health and Care Research (NIHR)—a state funder of clinical, public health, social care and translational research—launched a EUR2.3-million project to create a dedicated service for stroke management.
"We feel we have made some sustainable difference; we did put stroke on the national health policy agenda."
“There is no universal primary care in Sierra Leone,” says Professor Cath Sackley, the project’s leader. “People have to pay for secondary care. There is a cultural belief in alternative treatments and people come late to hospital post stroke. They come ill, dehydrated, often with aspiration pneumonia, so death rates are really high.”
As in many other LMICs, in Sierra Leone, too, stroke patients tend to be younger, with the largest group aged 50-59, and are often the primary breadwinner at home, Sackley says. Treatment is often prohibitively expensive, and patients are discharged quickly with little follow-up. Stroke rehabilitation was virtually non-existent, with only five physiotherapists in the country at the start of the project and no trained stroke nurses, or speech and occupational therapists.
“It had a devastating effect on families, and children couldn’t afford to go to school,” Sackley adds. “If the breadwinner had a stroke, it knocked not just on their generation, but also the next generation.”
The King’s College London project has partnered with Connaught Hospital, the country’s main tertiary centre, deploying specialist-trained volunteers to start a support group for stroke survivors and their families, in association with WSO.
The project organised camps to monitor blood pressure on World Stroke Day in October, and provided training for nurses and therapists in Ghana at its Korle-Bu Hospital Stroke Unit. It added a ramp and renovated the bathrooms at its unit to turn it into a centre of excellence.
Leaders of the support group for survivors and families, which is an independently registered non-governmental organisation, are exploring ways to influence policy and attract funding for tackling the disease, Sackley says. They have used mass media, as well as local churches, to get the message out. Activists have also worked to reduce the stigma surrounding stroke, since some in Sierra Leone still associate it with “inappropriate moral behaviour”.
“We feel we have made some sustainable difference; we did put stroke on the national health policy agenda,” Sackley says.
Community engagement has been a vital part of the project, she notes, adding that the fundamental basics of stroke care—from culturally appropriate training resources to blood pressure monitoring to thrombolysis—need not be unaffordable for LMICs provided they have the right assistance.
Middle East and North Africa: A focus on prevention among young people
Amid rapidly rising rates of stroke globally, the Middle East and North African region—stretching from Iran and Turkey in the north to Morocco in the west and Sudan in the south—faces a particularly acute crisis.
“More than 70% of stroke [cases] can be prevented. 60% of young people in [their] 30s and 40s are hypertensive, but we found in our cohort that a large number of patients are not aware of their hypertension.”
The median age for stroke here is 48, around two decades earlier than in Canada, according to Dr Suhail Alrukn, a Dubai-based consultant neurologist and president of the Middle East & North Africa Stroke Organization (MENA Stroke). The average age for stroke in the United Arab Emirates (UAE) is 45, he adds. In a region where 60% of the population is under 25 , the societal burden is enormous.
The challenge in addressing stroke in the Middle East, Alrukn says, is primarily a preventative one. Hypertension is one of the region’s main health challenges, with 72% of the stroke population having either treated or untreated hypertension, and 40% presenting with diabetes.
The lack of specialised stroke units is another key concern, he adds. Although standard guidelines call for one stroke unit per one million population, Egypt, with a population of 100 million, has just 35 stroke units.
By comparison with the lowest-income countries in the MENA area, the Gulf Cooperation Council—comprising the UAE, Bahrain, Kuwait, Saudi Arabia, Qatar and Oman—has seen enormous progress over the past decade, with more than 11 stroke units now in the UAE—enough to cover the country’s needs, Alrukn says.
In addition, MENA Stroke has supported more than 50 neurologists from the region’s lowest-income countries, including Eqypt, Tunisia, Iraq and Iran, to attend the World Stroke Congress in Singapore in 2022; it also continues to work with Sweden’s Karolinska Institute to build what Alrukn says is the largest stroke registry in the world, which will enable the region to collect data that can help inform policy.
At the same time, he adds, public health officials must spread awareness about the potential for better outcomes, especially in a region where many people believe stroke is untreatable. Going forward, screening and prevention should be the main focus.
“More than 70% of stroke [cases] can be prevented,” Alrukn says. “60% of young people in [their] 30s and 40s are hypertensive, but we found in our cohort that a large number of patients are not aware of their hypertension.”
Alrukn says a positive outcome of the covid-19 pandemic has been an expansion of virtual training, which is helping to extend best practices in stroke care to countries with few resources. “The pandemic opened us to the virtual world,” he says. “We are training younger physicians in Africa and younger nurses in India… we are having local and regional webinars.”
Stroke remains a major global challenge, especially for LMICs, but progress is possible and achievable. A strong public health message that creates awareness and the ramping up of screening and preventative treatment could sharply reduce the number of acute stroke cases. Ensuring an adequate number of stroke units with well-trained specialist care and emphasising the importance of timely treatment could improve outcomes. Finally, a well-organised care pathway can make it easier to manage patients and collect valuable data to help improve treatment and services in the future.