World Health organization (WHO) estimates indicate that death from stroke in low-income and middle-income countries (LMIC) accounted for 86% of stroke deaths worldwide, and the disability adjusted life years lost in these countries are almost seven times the number lost in high-income countries. Most of these LMIC are in Africa. Moreover, it is expected that as deaths from infectious diseases wane, the burden of stroke is likely to increase substantially over the next few decades in LMICs. Hypertension, the most potent modifiable risk factor for stroke, and once rare in Africa, is emerging as a serious endemic threat (about 37% of the general population in Nigeria, Africa's most populous country has hypertension). The occurrence of a stroke itself is the strongest predictor of a repeat event (secondary stroke), which carries an even higher risk of death than a first-time stroke. Given the aforementioned, there is an urgent need to craft and validate effective health care delivery programs that can mitigate the devastating consequences of stroke through enhanced control of high blood pressure in LMICs. To improve the delivery of secondary stroke preventive services in a LMIC (Nigeria), we will custom design and then test a chronic care model-based intervention called Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES). To ensure that the THRIVES intervention is culturally-relevant and locally sustainable, we will first obtain information about barriers and facilitators of adherence to evidence-based secondary stroke prevention treatments in Nigeria based on input from stroke patients, caregivers, health providers, and hospital administrators. We will use this information to appropriately refine an intervention comprising a stroke patient report card, cell phone text messaging from providers, and in-clinic educational video sessions. Finally, we will to test the efficacy of the tailored THRIVES intervention among 334 stroke patients recently discharged from four medical care facilities in South Western Nigeria via a randomized-controlled trial. The primary study outcome measure will be systolic blood pressure reduction 12 months after enrollment. A second specific aim is to conduct a cost analysis of THRIVES from the perspective of the local governments in Nigeria, using costs of the intervention, cost equivalents of associated local resource utilization, and cost equivalents of the observed and projected vascular events. These data will be presented to key decision-makers in Nigeria, so they can weigh the benefits and implications of supporting THRIVES beyond the research award period. We anticipate that a successful program could also serve as a model of cost-effective quality stroke preventive care for implementation in other countries in Sub Saharan Africa.
This research seeks to develop an effective and sustainable way of reducing the devastating and deadly impact of stroke in a low-income region of the world with poor medical infrastructure. It will do so by focusing on improving the treatment of the condition most closely tied to stroke, hypertension, using novel methods that incorporate the input of the local community. If successful, the strategy could serve as a ready model to be adapted by decision-makers in other under-resourced areas for lessening the burden of stroke (and other major public health challenges).
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