Stroke Prevention: Meeting Challenges in Nigeria

Stroke care and stroke prevention in the Western world have seen great gains.

Stroke is often preventable but in sub-Saharan countries such as Nigeria, where the primary care services are often limited, the burden of stroke mortality is high.

Addressing that situation researchers at the Department of Family Medicine and Public Health at the University of California in San Diego found a need for independent health support groups to educate stroke victims and their families as a preventive intervention.

The study was conducted by Samantha Hurst, PhD, MA, and colleagues at the UCSD’s Department of Family Medicine and Public colleagues, and was published in the Journal of Clinical Hypertension on April 1, 2016.

The researchers say they undertook this study, known as THRIVES, to gather information from stroke survivors, their families, and physicians, and “to capture feedback from this community to adapt the design of the THRIVES multimodal intervention for testing in a phase 2 randomized controlled clinical trial of secondary stroke risk reduction.”

The researchers conducted a total of 34 interviews, with 22 of them with individuals and 6 patient and caregiver focus groups. There were four operational domains under consideration: barriers to optimal adherence, patient health beliefs and perceptions of patient beliefs by others, whether or not patients are adopting the patient report card, and a medical action plan and how families manage that plan.

One notable barrier was that patients often do not take drugs as prescribed because they cannot afford the medication and do things like split pills or skip days in order to make the supply last longer.

“When they run out of money, they don't take their drugs and sometimes they want to come to the hospital … often they don't have the money for transportation,” one subject told the researchers.

One solution might be to find a polypill that would mean fewer medications and a lower cost. It would also address another problem of patients seeing multiple providers, professionals who might not know what other drugs the patient has been taking.

The availability of healthy food was another issue, the team found.

Food in Nigeria can be expensive based on seasonality and to require a patient to eat five servings of fruit a day was frequently described by providers as “too high an expectation.”

In addition, providers reported that most families do not have the extended financial means to buy healthy foods exclusively for only the stroke victim. Several patients described challenges with the frequent “intake of more western or junk diets” that were compromised by “excessive salt intake and starchy food that worsens my high blood pressure.”

For those recovering from strokes and at risk of having another, getting proper exercise and physical therapy could also be problem, since physiotherapists tend to work mainly in hospitals.

Stroke patients with limited mobility have to rely on a family members or caregivers to get to therapy.

At the other end of the spectrum, recovering patients who are able to return to work told researchers they did not have time to exercise three times a week or were unable to leave work to get to physical therapy appointments.

They subjects said they also found the cost of these sessions prohibitive by Nigerian standards.

Tobacco use is yet another problem. Providers favored a national ban on tobacco products, or at least an anti-tobacco campaign.

Finally, the team encountered cultural resistance to seeing a stroke as a medical problem.

One clinical psychologist shared a story about a woman who was convinced her stroke was caused by not following God's instructions.

In another case Yoruba families attribute a stroke event to a “spirit from another world” and to witchcraft. Most patients will continue to look out for herbal medicine and spiritual aides to combat their disease, one physiotherapist told the team.

The team came up with some recommendations to address these issues, including drawing up an “action plan” for each patient, and involving family members in trying to implement the plan. The family unit is a center of the culture and is expected to take responsibility for all family members, the team noted, so it is essential to get them to take ownership of the care plan.

They also found that nurses, rather than doctors might be better suited to helping families with these strategies.

The researchers acknowledge the data they collected through these interviews may only be relevant to the population sampled, saying it “may not be representative of medical care conditions for other stroke survivors in other regions of Nigeria or the continent of Africa as a whole.”

However, they add, “We believe the findings demonstrate support for the practical benefits of using qualitative research to identify, explore, and characterize many of the contextual factors that influence the process and potential effectiveness of an intervention, not to mention the related patient experience with respect to healthcare provision and improved access to medical care.”