Working at one of Toronto’s largest neurological dedicated organizations, I’ve had the opportunity to work closely in developing CT imaging protocols for patients arriving at the hospital with stroke like symptoms.
For the second time, Toronto Western Hospital has received Stroke Accreditation and has held the highest standard in which many other Canadian hospitals are compared to. With this in mind, it is important to investigate the global impact of stroke prevention as well as limits to treatment and recovery.
When reviewing this serious medical condition, it is imperative to note how a multilevel model would impact the prevalence of stroke occurrences. A multilevel approach to population health is predicated on the understanding that exposures at many levels of an organization's work together to produce health outcomes (Galea, 2015). Essentially, this approach requires asking questions that help one understand what factors contribute to influencing the ultimate goal of improving the health of a patient and a community.
According to the journal article Prevention of Stroke: a global perspective, there are 10.3 million people who experience new strokes and 113 million disability adjusted life years (DALYs) per year. Stroke is now the third leading global cause of death and disability (Pandian et al., 2020), but the differences in the burden of strokes is exceedingly different, depending on the country one lives in, as about 75% of deaths from stroke and more than 80% of DALYs are now occurring in low-income and middle-income countries (LMICs). In the past 40 years, there has been a 42% decrease in stroke incidence in high-income countries and a 100% increase in LMICs (Pandian et al., 2018). This peaked my interest in what is causing the differences between LMICs and high-income countries? Interestingly, it is a combination of both social determinants of health as well as socioeconomic factors which are causing the disparities. Social determinants of health (SDoH) is defined as a specific group of social and economic factors within the broader determinants of health. These relate to an individual's place in society, such as income, education or employment (Government of Canada, 2020). A Socio-economic model considers the complex interplay between individual, relationship, community, and societal factors (CDC, n.d.).
The Socio Economic Model can be visualized as:
In order to attempt to prevent stroke-related morbidity and mortality, there first needs to be a focus on predicting and preventing upstream risk factors associated with the disease, from there, the impact of treatment and recovery can then be assessed. Studies show that approximately 80% of strokes are preventable, but there is often very little investment in upstream interventions (Bufalino et al., 2020). Reducing upstream risk inequities can have numerous effects in stroke prevention tactics (Bufalino et al., 2020). In order for a stroke prevention program to be successful, it must be cost effective, scalable, and tailorable intervention that can be modified (Bufalino et al., 2020).
Hypertension is one of the leading modifiable factors which lead to strokes, accounting for 65.1% of the DALYs lost due to stroke in LMICs and 59.8% in high-income countries (Pandian et al., 2018). It’s been shown that very small improvements in blood pressure have shown to have a significant reduction in stroke. Reducing blood pressure by only 10mm Hg is associated with a 10% reduction in stroke. Identifying patients who are at risk of high blood pressure would result in a downstream affect in stroke prevention (Bufalino et al., 2020). Reducing hypertension inequities can reduce atrial fibrillation , which in turn result in a downstream reduction of rates of stroke. By focusing early detection of hypertension on low-resource settings within a community would ensure that disparities in a community are not worsened (Bufalino et al., 2020).
Additional risk factors leading to stroke are tobacco use, alcohol consumption, incidence of diabetes, obesity, socioeconomic status, and psychosocial stress (a combination of home and work stress) in both LMICs and high-income countries (Pandian et al., 2018). In an effort to address tobacco control, the WHO Framework Convention on Tobacco Control and associated MPOWER policy package was developed:
Approximately 172 countries have adopted the FCTC framework and 88 countries (69% of which are LMICs) implemented at least one MPOWER policy. The result was a reduction of approximately 53million smokers and 22 million less deaths. Of these measures, raising the cost of tobacco was the most effective (Pandian et al., 2018). Unfortunately, the additional factors mentioned are difficult to address as they would require a global initiative to address both behavioral and societal changes. The hope is that addressing these changes would ultimately result in societal lifestyle changes (Bufalino et al., 2020).
In an effort to implement screening in low-income communities and improve screening equity, there has been an increase in using community health workers (CHWs) to perform the screenings in common gathering settings such as barbershops, beauty shops, grocery stores, pharmacies, and churches. For example, barbershops offering blood pressure checks with haircuts and promoting physician follow-up improved hypertension control among Black men. Similarly, cosmetologists can be important health care promoters for women from diverse racial and ethnic backgrounds. In one study, cosmetologists that promoted awareness of healthy behaviors yielded 46% of clients reporting healthier food consumption. In Canada, paramedics have played a similar role and improved hypertension screening through weekly visits to subsidized senior living facilities. Internationally, SMARThealth India, allows CHWs in low-resource settings to collect patient information, such as blood pressure and glucose level, via mobile devices to upload to an Electronic Health Records. CHWs make a referral to a physician, who provide a diagnosis and management plan. The program increases access to screening facilities by engaging in treatment at home during convenient times (Bufalino et al., 2020). One barrier to this model, however, is that not all countries allow for CHWs to perform such evaluations based on variable restrictions in health care systems (Bufalino et al., 2020).
Multiple pharmacological interventions can reduce stroke risk through hypertension, but people may not take medications regularly. A solution may be a cardiovascular polypill; a pill containing at least one antihypertensive with rate-controlling properties and one lipid-lowering medication. In countries with free healthcare, the prescription of polypills has shown to be effective in low-income settings because of affordability and improved adherence relative to patients needing to take multiple pills. It is important to note, however, that development of new polypills would likely result in patented pills with high list prices. It would take many years until a generic option is available and, without an affordable generic, price barriers could exacerbate existing socioeconomic inequities in hypertension and stroke (Bufalino et al., 2020).
When it comes to stroke treatment, the ultimate goal is to provide treatment within the “golden hour”, which is a door-to-treatment time of 60 minutes or less. It is within this hour that tPA must be administered for optimal treatment results. The administration of I.V. fibrinolysis with recombinant tissue plasminogen activator (rt-PA) within 3 to 4.5 hours of stroke symptom onset is the only current treatment shown to reduce disability from acute ischemic stroke (Anderson, 2016). Despite global education about warning signs of stroke, there are still significant delays to care seen in LMICs. For example, in Nigeria, even when stroke symptoms are recognized, medical help is not sought, because people prefer to consult traditional healers because of cultural and spiritual beliefs (Pandian et al., 2020). Studies from India and Nigeria indicate lengthy delays in accessing hospitals, with less than 30% of patients with stroke attending hospital within 3 hours of symptom onset (Pandian et al., 2020). In many LMICs, ambulance services are either not available or have a shortage of trained personnel and proper equipment (Pandian et al., 2020). Additionally, depending on distance from the hospital or cities having many cars and poor infrastructure, ambulances services may be severely delayed (Pandian et al., 2020). The absence of easy and timely access to brain imaging adds to the difficulties in diagnosing stroke in LMICs. Despite LMICs having operational CT or MRI machines, in Africa, only 13–36% of patients underwent CT or MRI scans, and a study in rural India reported that only 12% of patients underwent any brain imaging. In Ghana, only two-thirds of hospitals have a functional CT scanner available during working hours on weekdays (Pandian et al., 2020). In many LMICs, even if the necessary imaging resources were available, a delay in hospital arrival makes most patients ineligible for thrombectomy (Pandian et al., 2020).
Post-stroke quality of life is more negatively affected in LMICs than in high-income communities. Studies from Pakistan and Brazil report depression in more than 50% of stroke survivors. Researchers in Ghana identified mild to moderate stigma in 80% of stroke survivors, with the degree of stigma directly related to the patient’s degree of dependency (Pandian et al., 2020). An Indian study found that 35% of patients with stroke discontinued secondary preventive treatment during a 2-year follow-up period. Factors predicting discontinuation of treatment included lower socioeconomic and educational status, lower awareness of stroke, previous hemorrhagic stroke, higher daily cost of treatment, and longer distance from hospital
Given the high incidence of stroke globally, it is very clear that more focus needs to be made in prevention of strokes by tackling barriers affecting upstream factors. Additionally, having resources that are easily accessible for stroke treatment is essential in optimal treatment and post treatment recovery.
Resources:
Anderson, Jane A. PhD, APRN, FNP-C Acute ischemic stroke, Nursing Critical Care: May 2016 - Volume 11 - Issue 3 - p 28-36. doi: 10.1097/01.CCN.0000482731.69703.82
Bufalino, V. J., Bleser, W. K., Singletary, E. A., Granger, B. B., O’Brien, E. C., Elkind, M. S. V., Lopez, M. H., Saunders, R. S., McClellan, M. B., & Brown, N. (2020, July 20). Frontiers of Upstream Stroke Prevention and reduced stroke inequity through predicting, preventing, and managing hypertension and atrial fibrillation. Circulation: Cardiovascular Quality and Outcomes. Retrieved February 26, 2022, from https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.120.006780
Canada, P. H. A. of. (2020, October 7). Government of Canada. Social determinants of health and health inequalities - Canada.ca. Retrieved February 12, 2022, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Galea, S. (2015, May 31). The determination of health across the life course and across levels of influence. The Determination of Health Across the Life Course and Across Levels of Influence Comments. Retrieved February 27, 2022, from https://www.bu.edu/sph/news/articles/2015/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/
Lennon, O., Blake, C., Booth, J., Pollock, A., & Lawrence, M. (2018, December). Interventions for behaviour change and self-management in stroke secondary prevention: protocol for an overview of reviews. Research Gate. Retrieved February 26, 2022, from https://www.researchgate.net/publication/329613770_Interventions_for_behaviour_change_and_self-management_in_stroke_secondary_prevention_Protocol_for_an_overview_of_reviews/fulltext/5c12531192851c39ebea4bda/Interventions-for-behaviour-change-and-self-management-in-stroke-secondary-prevention-Protocol-for-an-overview-of-reviews.pdf
National Center for Injury Prevention and Control, Division of Violence Prevention. (n.d.). The social-ecological model: A framework for prevention |violence prevention|injury Center CDC. Centers for Disease Control and Prevention. Retrieved February 26, 2022, from https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Pandian, J. D., Gall, S. L., Kate, M. P., Silva, G. S., Akinyemi, R. O., Ovbiagele, B. I., Lavados, P. M., Gandhi, D. B. C., & Thrift, A. G. (2018, October 4). Prevention of stroke: A global perspective. The Lancet. Retrieved February 26, 2022, from https://www.sciencedirect.com/science/article/pii/S0140673618312698
Pandian, J. D., Kalkonde, Y., Sebastian, I. A., Felix, C., Urimubenshi, G., & Bosch, J. (2020, October). Stroke systems of care in low-income and middle-income countries: challenges and opportunities. The Lancet. Retrieved February 26, 2022, from https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2931374-X
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