1
|
Nelson AJ, Pagidipati NJ, Bosworth HB. Improving medication adherence in cardiovascular disease. Nat Rev Cardiol 2024; 21:417-429. [PMID: 38172243 DOI: 10.1038/s41569-023-00972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.
Collapse
Affiliation(s)
- Adam J Nelson
- Victorian Heart Institute, Melbourne, Victoria, Australia
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Population Health Sciences, Duke University, Durham, NC, USA.
| |
Collapse
|
2
|
Kaddumukasa M, Edwards AM, Najjuma JN, Mbalinda SN, Nakibuuka J, Burant CJ, Moore SM, Blixen C, Katabira ET, Sajatovic M, Kaddumukasa M. Evidence-Supported Interventions for Reducing Secondary Stroke Risk in Sub-Saharan Africa: A Systematic Review. Neuropsychiatr Dis Treat 2023; 19:2597-2606. [PMID: 38046833 PMCID: PMC10693245 DOI: 10.2147/ndt.s428627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/18/2023] [Indexed: 12/05/2023] Open
Abstract
The study set out to perform a systematic literature review of evidence-based interventions that target the reduction of secondary stroke risk in Africa. The review analyzed longitudinal intervention studies conducted in Sub-Saharan Africa, focusing on adult participants who had suffered a prior stroke. It encompassed publications and peer-reviewed papers sourced from reputable databases, including PubMed, Ovid, Cochrane, and Web of Science. Three randomized clinical trial (RCT) studies were included with sample sizes ranging from 16 to 400 participants, mean age ranged between 50 and 66 years, with 64.5% male participants. All studies applied multidisciplinary team interventions of enhanced patient follow-up involving care givers, nurse educators, physicians, and social workers. Interventions ranged from comprehensive patient education, tracking of medication adherence and enforcing healthy lifestyle behaviors (regular exercise, regular BP checks, and dietary changes). We found a decrease in Systolic Blood Pressure over time in 2 of 3 treatment groups, an improvement in medical adherence in all treatment groups, and a decrease in cholesterol levels in 1 treatment group. Evidence-based interventions involving multidisciplinary teams and comprehensive patient education were found to demonstrate promising results in reducing secondary stroke risk in Africa, leading to significant improvements in medical adherence and reductions in systolic blood pressure in the majority of treatment groups. However, more research is required to confirm the influence of these interventions on cholesterol levels and to establish their lasting advantages in preventing strokes among African communities.
Collapse
Affiliation(s)
- Martin Kaddumukasa
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alyssa M Edwards
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | | | - Jane Nakibuuka
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christopher J Burant
- Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, USA
| | - Shirley M Moore
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Carol Blixen
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Elly T Katabira
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mark Kaddumukasa
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
3
|
Allan LP, Beilei L, Cameron J, Olaiya MT, Silvera-Tawil D, Adcock AK, English C, Gall SL, Cadilhac DA. A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice. Stroke 2023; 54:2935-2945. [PMID: 37800373 DOI: 10.1161/strokeaha.123.043794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.
Collapse
Affiliation(s)
- Liam P Allan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia (L.P.A., J.C., M.T.O., D.A.C.)
- Australian e-Health Research Centre, The Commonwealth Scientific and Industrial Research Organisation, New South Wales, Australia (L.P.A., D.S.-T.)
| | - Lin Beilei
- The Nursing and Health School, Zhengzhou University, Henan, China (L.B.)
| | - Jan Cameron
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia (L.P.A., J.C., M.T.O., D.A.C.)
- Australian Centre for Heart Health, Royal Melbourne Hospital, Victoria, Australia (J.C.)
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia (L.P.A., J.C., M.T.O., D.A.C.)
| | - David Silvera-Tawil
- Australian e-Health Research Centre, The Commonwealth Scientific and Industrial Research Organisation, New South Wales, Australia (L.P.A., D.S.-T.)
| | - Amelia K Adcock
- Cerebrovascular Division, Department of Neurology, West Virginia University, Morgantown (A.K.A.)
| | - Coralie English
- School of Health Sciences, University of Newcastle, New South Wales, Australia (C.E.)
- Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, New South Wales, Australia (C.E.)
- NHMRC Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (C.E., D.A.C.)
| | - Seana L Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (S.L.G.)
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Victoria, Australia (S.L.G.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia (L.P.A., J.C., M.T.O., D.A.C.)
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (D.A.C.)
- NHMRC Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (C.E., D.A.C.)
| |
Collapse
|
4
|
Owolabi P, Adam Y, Adebiyi E. Personalizing medicine in Africa: current state, progress and challenges. Front Genet 2023; 14:1233338. [PMID: 37795248 PMCID: PMC10546210 DOI: 10.3389/fgene.2023.1233338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Personalized medicine has been identified as a powerful tool for addressing the myriad of health issues facing different health systems globally. Although recent studies have expanded our understanding of how different factors such as genetics and the environment play significant roles in affecting the health of individuals, there are still several other issues affecting their translation into personalizing health interventions globally. Since African populations have demonstrated huge genetic diversity, there is a significant need to apply the concepts of personalized medicine to overcome various African-specific health challenges. Thus, we review the current state, progress, and challenges facing the adoption of personalized medicine in Africa with a view to providing insights to critical stakeholders on the right approach to deploy.
Collapse
Affiliation(s)
- Paul Owolabi
- Covenant Applied Informatics and Communication, Africa Centre of Excellence (CApIC-ACE), Covenant University, Ota, Ogun State, Nigeria
- Department of Computer and Information Science, Covenant University, Ota, Ogun State, Nigeria
| | - Yagoub Adam
- Covenant University Bioinformatics Research (CUBRe), Covenant University, Ota, Ogun State, Nigeria
| | - Ezekiel Adebiyi
- Covenant Applied Informatics and Communication, Africa Centre of Excellence (CApIC-ACE), Covenant University, Ota, Ogun State, Nigeria
- Department of Computer and Information Science, Covenant University, Ota, Ogun State, Nigeria
- Covenant University Bioinformatics Research (CUBRe), Covenant University, Ota, Ogun State, Nigeria
- Applied Bioinformatics Division, German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
5
|
Deshpande N, Wu M, Kelly C, Woodrick N, Werner DA, Volerman A, Press VG. Video-Based Educational Interventions for Patients With Chronic Illnesses: Systematic Review. J Med Internet Res 2023; 25:e41092. [PMID: 37467015 PMCID: PMC10398560 DOI: 10.2196/41092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 01/30/2023] [Accepted: 03/21/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND With rising time constraints, health care professionals increasingly depend on technology to provide health advice and teach patients how to manage chronic disease. The effectiveness of video-based tools in improving knowledge, health behaviors, disease severity, and health care use for patients with major chronic illnesses is not well understood. OBJECTIVE The aim of this study was to assess the current literature regarding the efficacy of video-based educational tools for patients in improving process and outcome measures across several chronic illnesses. METHODS A systematic review was conducted using CINAHL and PubMed with predefined search terms. The search included studies published through October 2021. The eligible studies were intervention studies of video-based self-management patient education for an adult patient population with the following chronic health conditions: asthma, chronic kidney disease, chronic obstructive pulmonary disease, chronic pain syndromes, diabetes, heart failure, HIV infection, hypertension, inflammatory bowel disease, and rheumatologic disorders. The eligible papers underwent full extraction of study characteristics, study design, sample demographics, and results. Bias was assessed with the Cochrane risk-of-bias tools. Summary statistics were synthesized in Stata SE (StataCorp LLC). Data reporting was conducted per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. RESULTS Of the 112 studies fully extracted, 59 (52.7%) were deemed eligible for inclusion in this review. The majority of the included papers were superiority randomized controlled trials (RCTs; 39/59, 66%), with fewer pre-post studies (13/59, 22%) and noninferiority RCTs (7/59, 12%). The most represented conditions of interest were obstructive lung disease (18/59, 31%), diabetes (11/59, 19%), and heart failure (9/59, 15%). The plurality (28/59, 47%) of video-based interventions only occurred once and occurred alongside adjunct interventions that included printed materials, in-person counseling, and interactive modules. The most frequently studied outcomes were disease severity, health behavior, and patient knowledge. Video-based tools were the most effective in improving patient knowledge (30/40, 75%). Approximately half reported health behavior (21/38, 56%) and patient self-efficacy (12/23, 52%) outcomes were improved by video-based tools, and a minority of health care use (11/28, 39%) and disease severity (23/69, 33%) outcomes were improved by video-based tools. In total, 48% (22/46) of the superiority and noninferiority RCTs and 54% (7/13) of the pre-post trials had moderate or high risk of bias. CONCLUSIONS There is robust evidence that video-based tools can improve patient knowledge across several chronic illnesses. These tools less consistently improve disease severity and health care use outcomes. Additional study is needed to identify features that maximize the efficacy of video-based interventions for patients across the spectrum of digital competencies to ensure optimized and equitable patient education and outcomes.
Collapse
Affiliation(s)
- Nikita Deshpande
- Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Meng Wu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Colleen Kelly
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
| | - Nicole Woodrick
- Corporate Engagement & Strategic Partnerships, Arizona State University, Tempe, AZ, United States
| | - Debra A Werner
- The University of Chicago Library, Chicago, IL, United States
| | - Anna Volerman
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Valerie G Press
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, United States
| |
Collapse
|
6
|
Otieno P, Agyemang C, Wao H, Wambiya E, Ng'oda M, Mwanga D, Oguta J, Kibe P, Asiki G. Effectiveness of integrated chronic care models for cardiometabolic multimorbidity in sub-Saharan Africa: a systematic review and meta-analysis. BMJ Open 2023; 13:e073652. [PMID: 37369405 PMCID: PMC10410889 DOI: 10.1136/bmjopen-2023-073652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES This review aimed at identifying the elements of integrated care models for cardiometabolic multimorbidity in sub-Saharan Africa (SSA) and their effects on clinical or mental health outcomes including systolic blood pressure (SBP), blood sugar, depression scores and other patient-reported outcomes such as quality of life and medication adherence. DESIGN Systematic review and meta-analysis using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES We systematically searched PubMed, Embase, Scopus, Web of Science, Global Health CINAHL, African Journals Online, Informit, PsycINFO, ClinicalTrials.gov, Pan African Clinical Trials Registry and grey literature from OpenSIGLE for studies published between 1999 and 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomised controlled trial studies featuring integrated care models with two or more elements of Wagner's chronic care model. DATA EXTRACTION AND SYNTHESIS Two independent reviewers used standardised methods to search and screen included studies. Publication bias was assessed using the Doi plot and Luis Furuya Kanamori Index. Meta-analysis was conducted using random effects models. RESULTS In all, we included 10 randomised controlled trials from 11 publications with 4864 participants from six SSA countries (South Africa, Kenya, Nigeria, Eswatini, Ghana and Uganda). The overall quality of evidence based on GRADE criteria was moderate. A random-effects meta-analysis of six studies involving 1754 participants shows that integrated compared with standard care conferred a moderately lower mean SBP (mean difference=-4.85 mm Hg, 95% CI -7.37 to -2.34) for people with cardiometabolic multimorbidity; Hedges' g effect size (g=-0.25, (-0.39 to -0.11). However, integrated care compared with usual care showed mixed results for glycated haemoglobin, depression, medication adherence and quality of life. CONCLUSION Integrated care improved SBP among patients living with cardiometabolic multimorbidity in SSA. More studies on integrated care are required to improve the evidence pool on chronic care models for multimorbidity in SSA. These include implementation studies and cost-effectiveness studies. PROSPERO REGISTRATION NUMBER CRD42020187756.
Collapse
Affiliation(s)
- Peter Otieno
- Chronic Disease Management Unit, African Population and Health Research Center, Nairobi, Kenya
- Department of Public & Occupational Health, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Amsterdam, Netherlands
| | - Charles Agyemang
- Department of Public & Occupational Health, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Hesborn Wao
- Research and Related Capacity Strengthening, African Population and Health Research Center, Nairobi, Kenya
| | - Elvis Wambiya
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- African Network of Research Scientists, Nairobi, Kenya
| | - Maurine Ng'oda
- Emerging and Re-emerging infectious Diseases Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Daniel Mwanga
- Chronic Disease Management Unit, African Population and Health Research Center, Nairobi, Kenya
| | - James Oguta
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- African Network of Research Scientists, Nairobi, Kenya
| | - Peter Kibe
- Chronic Disease Management Unit, African Population and Health Research Center, Nairobi, Kenya
- African Network of Research Scientists, Nairobi, Kenya
| | - Gershim Asiki
- Chronic Disease Management Unit, African Population and Health Research Center, Nairobi, Kenya
- Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
7
|
Jalo H, Seth M, Pikkarainen M, Häggström I, Jood K, Bakidou A, Sjöqvist BA, Candefjord S. Early identification and characterisation of stroke to support prehospital decision-making using artificial intelligence: a scoping review protocol. BMJ Open 2023; 13:e069660. [PMID: 37217266 DOI: 10.1136/bmjopen-2022-069660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Stroke is a time-critical condition and one of the leading causes of mortality and disability worldwide. To decrease mortality and improve patient outcome by improving access to optimal treatment, there is an emerging need to improve the accuracy of the methods used to identify and characterise stroke in prehospital settings and emergency departments (EDs). This might be accomplished by developing computerised decision support systems (CDSSs) that are based on artificial intelligence (AI) and potential new data sources such as vital signs, biomarkers and image and video analysis. This scoping review aims to summarise literature on existing methods for early characterisation of stroke by using AI. METHODS AND ANALYSIS The review will be performed with respect to the Arksey and O'Malley's model. Peer-reviewed articles about AI-based CDSSs for the characterisation of stroke or new potential data sources for stroke CDSSs, published between January 1995 and April 2023 and written in English, will be included. Studies reporting methods that depend on mobile CT scanning or with no focus on prehospital or ED care will be excluded. Screening will be done in two steps: title and abstract screening followed by full-text screening. Two reviewers will perform the screening process independently, and a third reviewer will be involved in case of disagreement. Final decision will be made based on majority vote. Results will be reported using a descriptive summary and thematic analysis. ETHICS AND DISSEMINATION The methodology used in the protocol is based on information publicly available and does not need ethical approval. The results from the review will be submitted for publication in a peer-reviewed journal. The findings will be shared at relevant national and international conferences and meetings in the field of digital health and neurology.
Collapse
Affiliation(s)
- Hoor Jalo
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Mattias Seth
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Minna Pikkarainen
- Department of Occupational Therapy, Prosthetics and Orthotics, Oslo Metropolitan University, Oslo, Norway
| | - Ida Häggström
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Katarina Jood
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Bakidou
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- PreHospen - Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Bengt Arne Sjöqvist
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Stefan Candefjord
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| |
Collapse
|
8
|
SPRINT INDIA trial collaborators. Secondary prevention with a structured semi-interactive stroke prevention package in INDIA (SPRINT INDIA): a multicentre, randomised controlled trial. Lancet Glob Health 2023; 11:e425-35. [PMID: 36796986 DOI: 10.1016/S2214-109X(22)00544-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/27/2022] [Accepted: 12/02/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND There is a high burden of stroke, including recurrent stroke, in India. We aimed to assess the effect of a structured semi-interactive stroke prevention package in patients with subacute stroke to reduce recurrent strokes, myocardial infarction, and death. METHODS This was a multicentre, randomised, clinical trial conducted in 31 centres of the Indian Stroke Clinical Trial Network (INSTRuCT). Adult patients with first stroke and access to a mobile cellular device were randomly allocated (1:1) to intervention and control groups by the research coordinators at each centre using a central, in-house, web-based randomisation system. The participants and research coordinators at each centre were not masked to group assignment. The intervention group received regular short SMS messages and videos that promoted risk factor control and medication adherence and an educational workbook, in one of 12 languages, and the control group received standard care. The primary outcome was a composite of recurrent stroke, high-risk transient ischaemic attack, acute coronary syndrome, and death at 1 year. The outcome and safety analyses were done in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT03228979 and Clinical Trials Registry-India (CTRI/2017/09/009600) and was stopped for futility after interim analysis. FINDINGS Between April 28, 2018, and Nov 30, 2021, 5640 patients were assessed for eligibility. 4298 patients were randomised to the intervention group (n=2148) or control group (n=2150). 620 patients were not followed up at 6 months and a further 595 patients were not followed up at 1 year because the trial was stopped for futility after interim analysis. 45 patients were lost to follow-up before 1 year. Acknowledgment of receipt of the SMS messages and videos by the intervention group patients was low (17%). The primary outcome occurred in 119 (5·5%) of 2148 patients in the intervention group and 106 (4·9%) of 2150 patients in the control group (adjusted odds ratio 1·12; 95% CI 0·85-1·47; p=0·370). Among the secondary outcome measures, alcohol cessation and smoking cessation were higher in the intervention group than in the control group (alcohol cessation 231 [85%] of 272 in the intervention group vs 255 [78%] of 326 in the control group; p=0·036; smoking cessation 202 [83%] vs 206 [75%]; p=0·035). Medication compliance was better in the intervention group than in the control group (1406 [93·6%] of 1502 vs 1379 [89·8%] of 1536; p<0·001). There was no significant difference between the two groups in other secondary outcome measures at 1 year: blood pressure, fasting blood sugar (mg/dL), low-density lipoprotein cholesterol (mg/dL), and triglycerides (mg/dL), BMI, modified Rankin Scale, and physical activity. INTERPRETATION A structured semi-interactive stroke prevention package did not reduce vascular events when compared with standard care. However, there was an improvement in some lifestyle behavioural factors, including adherence to medication, which might have long-term benefits. There was a possibility of type 2 error owing to reduced power since there were fewer events and a high number of patients could not be followed up. FUNDING Indian Council of Medical Research.
Collapse
|
9
|
Zheng L, Liu S, Jiao Y, Wu Y, Wang Y, Yu Z, Xu J, Sun Y, Sun Z. Effect of Financial Incentives on Hypertension Control: A Multicenter Randomized Controlled Trial in China. Hypertension 2022; 79:2202-2211. [PMID: 35862120 PMCID: PMC9444259 DOI: 10.1161/hypertensionaha.122.19568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Poorly controlled hypertension is a great challenge to global public health. Incentive approaches, based on behavioral and economic concepts, may improve patients’ adherence to treatment.
Collapse
Affiliation(s)
- Liqiang Zheng
- School of Public Health, Shanghai Jiao Tong University School of Medicine, China (L.Z., Y. Wu, J.X.).,Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| | - Sitong Liu
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| | - Yundi Jiao
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| | - Yani Wu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, China (L.Z., Y. Wu, J.X.)
| | - Yali Wang
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| | - Zhecong Yu
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| | - Jiahui Xu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, China (L.Z., Y. Wu, J.X.)
| | - Yingxian Sun
- Department of Cardiology, First Hospital of China Medical University, Shenyang (Y.S.)
| | - Zhaoqing Sun
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang (L.Z., S.L., Y.J., Y. Wang, Z.Y., Z.S.)
| |
Collapse
|
10
|
Wang B, Bai X, Yang Y, Cui J, Song L, Liu J, Lu J, Cai J. Prevalence, treatment, and attributed mortality of elevated blood pressure among a nationwide population-based cohort of stroke survivors in China. Front Cardiovasc Med 2022; 9:890080. [PMID: 36247443 PMCID: PMC9561361 DOI: 10.3389/fcvm.2022.890080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 09/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background Elevated blood pressure (BP) is associated with substantial morbidity and mortality in stroke survivors. China has the highest prevalence of stroke survivors and accounts for one-third of stroke-related deaths worldwide. We aimed to describe the prevalence and treatment of elevated BP across age, sex, and region, and assess the mortality attributable to elevated BP among stroke survivors in China. Materials and methods Based on 3,820,651 participants aged 35–75 years from all 31 provinces in mainland China recruited from September 2014 to September 2020, we assessed the prevalence and treatment of elevated BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) among those with self-reported stroke and stratified by age group, sex, and geographic region. We estimated the age- and sex-specific population attributable fractions of death from elevated BP. Results Among 91,406 stroke survivors, the mean (SD) age was 62 (8) years, and 49.0% were male. The median interquartile range (IQR) stroke duration was 4 (2, 7) years. The prevalence of elevated BP was 61.3% overall, and increased with age (from 47.5% aged 35–44 years to 64.6% aged 65–75 years). The increment of prevalence was larger in female patients than male patients. Elevated BP was more prevalent in northeast (66.8%) and less in south (54.3%) China. Treatment rate among patients with elevated BP was 38.1%, and rates were low across all age groups, sexes, and regions. Elevated BP accounted for 33 and 21% of cardiovascular and all-cause mortality among stroke survivors, respectively. The proportion exceeded 50% for cardiovascular mortality among patients aged 35–54 years. Conclusion In this nationwide cohort of stroke survivors from China, elevated BP and its non-treatment were highly prevalent across all age groups, sexes, and regions. Elevated BP accounted for nearly one-third cardiovascular mortality in stroke survivors, and particularly higher in young and middle-aged patients. National strategies targeting elevated BP are warranted to address the high stroke burden in China.
Collapse
Affiliation(s)
- Bin Wang
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Xueke Bai
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Yang Yang
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jianlan Cui
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Lijuan Song
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jiamin Liu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Jiapeng Lu
- National Clinical Research Center for Cardiovascular Diseases, National Health Commission of People’s Republic of China (NHC) Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
- *Correspondence: Jiapeng Lu,
| | - Jun Cai
- Hypertension Center, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
- Jun Cai,
| |
Collapse
|
11
|
Nowrin I, Bhattacharyya DS, Saif-Ur-Rahman KM. Community-based interventions to prevent stroke in low-income and middle-income countries: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e063181. [PMID: 35940843 PMCID: PMC9364391 DOI: 10.1136/bmjopen-2022-063181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Stroke is the second leading cause of death and morbidity across the globe. In low-income and middle-income countries (LMICs), it has become an overwhelming burden over the past few decades. This burden is escalating at a much greater pace compared with that of high-income countries. It is considered the most frequent cause of adult disability that affects the quality of life. 'Prevention' is one of the key components to combating stroke. In this regard, community-based interventions can play a vital role in improving population-level health and well-being. Considering the escalating trend of stroke in LMICs, this systematic review aims to map the available community-based interventions in preventing stroke and to conduct further analysis regarding the effectiveness of the identified interventions. METHODS AND ANALYSIS We have searched Medline, Web of Science and Scopus using a comprehensive search strategy in October 2021. Two reviewers will independently perform screening, data extraction and risk of bias (ROB) assessment. The ROB assessment and applicability of results of eligible studies will be performed using the Cochrane ROB tool for assessing randomised controlled trials and the ROBANS (Risk Of Bias Assessment tool for Non-randomised Studies) to assess non-randomised studies. A random-effect model meta-analysis will be used to calculate pooled results and to obtain weighted OR and risk ratio of incidence of stroke along with corresponding 95% CI. ETHICS AND DISSEMINATION The results will be disseminated through publishing in a peer-reviewed journal and public presentations at relevant national and international conferences. Ethical approval is not required as this is a systematic review of publicly available data. PROSPERO REGISTRATION NUMBER CRD42021283670.
Collapse
Affiliation(s)
- Iffat Nowrin
- Health Systems and Population Studies Division, ICDDRB, Dhaka, Bangladesh
| | | | - K M Saif-Ur-Rahman
- Health Systems and Population Studies Division, ICDDRB, Dhaka, Bangladesh
- College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Galway, Ireland
| |
Collapse
|
12
|
Abstract
OBJECTIVE To identify and assess the use of technologies, including mobile health technology, internet of things (IoT) devices and artificial intelligence (AI) in hypertension healthcare in sub-Saharan Africa (SSA). DESIGN Systematic review. DATA SOURCES Medline, Embase, Scopus and Web of Science. ELIGIBILITY CRITERIA Studies addressing outcomes related to the use of technologies for hypertension healthcare (all points in the healthcare cascade) in SSA. METHODS Databases were searched from inception to 2 August 2021. Screening, data extraction and risk of bias assessment were done in duplicate. Data were extracted on study design, setting, technology(s) employed and outcomes. Blood pressure (BP) reduction due to intervention was extracted from a subset of randomised controlled trials. Methodological quality was assessed using the Mixed Methods Appraisal Tool. RESULTS 1717 hits were retrieved, 1206 deduplicated studies were screened and 67 full texts were assessed for eligibility. 22 studies were included, all reported on clinical investigations. Two studies were observational, and 20 evaluated technology-based interventions. Outcomes included BP reduction/control, treatment adherence, retention in care, awareness/knowledge of hypertension and completeness of medical records. All studies used mobile technology, three linked with IoT devices. Short Message Service (SMS) was the most popular method of targeting patients (n=6). Moderate BP reduction was achieved in three randomised controlled trials. Patients and healthcare providers reported positive perceptions towards the technologies. No studies using AI were identified. CONCLUSIONS There are a range of successful applications of key enabling technologies in SSA, including BP reduction, increased health knowledge and treatment adherence following targeted mobile technology interventions. There is evidence to support use of mobile technology for hypertension management in SSA. However, current application of technologies is highly heterogeneous and key barriers exist, limiting efficacy and uptake in SSA. More research is needed, addressing objective measures such as BP reduction in robust randomised studies. PROSPERO REGISTRATION NUMBER CRD42020223043.
Collapse
Affiliation(s)
- Katy Stokes
- School of Engineering, University of Warwick, Coventry, UK
| | - Busola Oronti
- School of Engineering, University of Warwick, Coventry, UK
| | - Francesco P Cappuccio
- Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, UK
| | | |
Collapse
|
13
|
Gebreyohanns M, Akinyemi RO, Owolabi MO, Sarfo FS, Tagge R, Ovbiagele B. The African Stroke Organization Conference 2021: Building Capacity, Careers, Collaborations, and Contributions. J Stroke Cerebrovasc Dis 2022; 31:106385. [PMID: 35317914 PMCID: PMC9397143 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The inaugural African Stroke Organization Conference (ASOC) aimed to create a forum to discuss the latest stroke science, highlight opportunities to address the high burden of stroke in Africa, develop a viable pipeline of emerging African stroke researchers, honor leading scientists and policy makers, and provide networking avenues to bolster future collaboration. Using a virtual platform, ASOC was held from Nov 3-4, 2021, and was attended by 236 participants. ASOC 2021 sessions included: (1) Osuntokun Award Lecture delivered by Prof. Richard Walker of Newcastle University; (2) Distinguished Policy Maker Lecture delivered by Dr. Raj Tajudeen of the African Centers for Disease Control and Prevention; (3) Invited presentations by prominent global stroke academicians on acute stroke, vascular malformations, vascular brain injury, Covid-19, nursing/allied care, rehabilitation/recovery, health services, imaging, pediatric stroke, precision medicine, and unusual causes of stroke; (4) six oral scientific abstract presentations; and (5) fifteen moderated oral poster presentations. Other sessions were (i) Vascular Brain Trust where early career African scholars presented manuscripts and grant proposals under development for feedback from seasoned researchers (ii) Moving on Up during which presentations were given to early career scholars about pathways for success in funding and advancement. A capstone event was the Frontiers of Research in Africa session which showcased the work and capabilities of 20 scientists and sites in Africa. All the ASOC sessions were lively and post-conference feedback from attendees showed high levels of satisfaction for the conference platforms and content. The ASOC marks a new dawn in the era of an escalating stroke burden in Africa, and it is anticipated to serve as a catalyst for exponentially building the capacity, careers, collaborations, and contributions of Africans to ameliorating stroke within and beyond the continent.
Collapse
Affiliation(s)
| | | | | | | | - Raelle Tagge
- Northern California Institute for Research and Education, USA
| | | |
Collapse
|
14
|
Abstract
There are stark inequities in stroke incidence, prevalence, acute care, rehabilitation, risk factor control, and outcomes. To address these inequities, it is critical to engage communities in identifying priorities and designing, implementing, and disseminating interventions. This issue of Stroke features health equity themed lectures delivered during the International Stroke Conference and Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving meetings in 2021 as well as articles covering issues of disparities and diversity in stroke. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, received the 2021 William Feinberg Award Lecture for his lifetime achievements in seeking global and local solutions to cerebrovascular health inequities. The second annual Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving symposium, which took place the day before the International Stroke Conference in February 2021, focused on community-engaged research for reducing inequities in stroke. Phil Gorelick, MD was awarded the Edgar J. Kenton III Award for his lifetime achievements in using community engagement strategies to recruit and retain Black participants in observational studies and clinical trials. Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke delivered the keynote lecture on stroke inequities and Richard Benson, MD, PhD, Director of the Office of Global Health and Health Disparities at National Institute of Neurological Disorders and Stroke, gave a lecture focused on National Institute of Neurological Disorders and Stroke efforts to address inequities. Nichols et al highlighted approaches of community-based participatory research to address stroke inequities. Verma et al showcased digital health innovations to reduce inequities in stroke. Das et al showed that the proportion of underrepresented in medicine vascular neurology fellows has lowered over the past decade and authors provided a road map for enhancing the diversity in vascular neurology. Clearly, to overcome inequities, multipronged strategies are required, from broadening representation among vascular neurology faculty to partnering with communities to conduct research with meaningful impact.
Collapse
Affiliation(s)
- Amytis Towfighi
- University of Southern California, Los Angeles (A.T.).,Los Angeles County-Department of Health Services, CA (A.T.)
| | | |
Collapse
|
15
|
Cernota M, Kroeber ES, Demeke T, Frese T, Getachew S, Kantelhardt EJ, Ngeh EN, Unverzagt S. Non-pharmacological interventions to achieve blood pressure control in African patients: a systematic review. BMJ Open 2022; 12:e048079. [PMID: 35228272 PMCID: PMC8886440 DOI: 10.1136/bmjopen-2020-048079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This systematic review aims to evaluate the evidence of non-pharmacological strategies to improve blood pressure (BP) control in patients with hypertension from African countries. DESIGN We performed a systematic review and searched Medline, Central, CINAHL and study registers until June 2020 for randomised studies on interventions to decrease BP of patients with hypertension in African countries. We assessed the study quality using the Cochrane risk of bias tool and narratively synthesised studies on non-pharmacological hypertension interventions. SETTING We included studies conducted in African countries. PARTICIPANTS Adult African patients with a hypertension diagnosis. INTERVENTIONS Studies on non-pharmacological interventions aiming to improve BP control and treatment adherence. OUTCOMES Main outcomes were BP and treatment adherence. RESULTS We identified 5564 references, included 23 with altogether 18 153 participants from six African countries. The studies investigated educational strategies to improve adherence (11 studies) and treatment by healthcare professionals (5 studies), individualised treatment strategies (2 studies), strategies on lifestyle including physical activity (4 studies) and modified nutrition (1 study). Nearly all studies on educational strategies stated improved adherence, but only three studies showed a clinically relevant improvement of BP control. All studies on individualised strategies and lifestyle changes resulted in clinically relevant effects on BP. Due to the type of interventions studied, risk of bias in domain blinding of staff/participants was frequent (83%). Though incomplete outcome data in 61% of the studies are critical, the general study quality was reasonable. CONCLUSIONS The identified studies offer diverse low-cost interventions including educative and task-shifting strategies, individualised treatment and lifestyle modifications to improve BP control. Especially trialled physical activity interventions show clinically relevant BP changes. All strategies were trialled in African countries and may be used for recommendations in evidence-based guidelines on hypertension in African settings. PROSPERO REGISTRATION NUMBER CRD42018075062.
Collapse
Affiliation(s)
- Monique Cernota
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin-Luther-Universität Halle-Wittenberg Medizinische Fakultät, Halle, Germany
| | - Eric Sven Kroeber
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin-Luther-Universität Halle-Wittenberg Medizinische Fakultät, Halle, Germany
| | - Tamiru Demeke
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Thomas Frese
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin-Luther-Universität Halle-Wittenberg Medizinische Fakultät, Halle, Germany
| | - Sefonias Getachew
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eva Johanna Kantelhardt
- Institute for Medical Epidemiology, Biostatistics and Informatics, Center of Health Sciences, Martin-Luther-Universität Halle-Wittenberg Medizinische Fakultät, Halle, Germany
| | - Etienne Ngeh Ngeh
- Physiotherapy Department, Regional Hospital Bamenda, Bamenda, Cameroon
- Research Organization for Health Education and Rehabilitation-Cameroon(ROHER-CAM), St. Louis University Bamenda, Bamenda, Cameroon
- African Regional Community, Guidelines International Network (G-I-N), Bamenda, Cameroon
| | - Susanne Unverzagt
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin-Luther-Universität Halle-Wittenberg Medizinische Fakultät, Halle, Germany
- Department of Primary Care, Universität Leipzig Medizinische Fakultät, Leipzig, Germany
| |
Collapse
|
16
|
Abstract
Global and local (“glocal”) disparities in stroke incidence, prevalence, care, and mortality are persistent, pervasive, and progressive. In particular, the disproportionate burden of stroke in people of African ancestry compared to most other racial/ethnic groups around the world has been long standing, is expected to worsen, and so far, has defied solution, largely because conventional risk factors likely account for less than half of the Black versus White disparity in stroke outcomes. While hypotheses such as a differential impact or inadequate evaluation of traditional risk factors by race have been suggested as potentially key factors contributing to lingering racial/ethnic stroke disparities, relatively understudied novel risk factors such as psychosocial stress, environmental pollution, and inflammation; and influences of the social determinants of health are gaining the most attention (and momentum). Moreover, it is increasingly recognized that while there is a lot still to understand, there needs to be a major shift from incessantly studying the problem, to developing interventions to resolve it. Resolution will likely require targeting multilevel factors, considering contemporaneous cross-national and cross-continental data collection, creating scalable care delivery models, jointly addressing care quality and community drivers of stroke occurrence, incorporating policy makers in planning/dissemination of successful interventions, and investing in robust transdisciplinary research training programs that address the interrelated issues of health equity and workforce diversity, and regional capacity building. To this end, our international multidisciplinary team has been involved in conducting several epidemiological studies and clinical trials in the area of stroke disparities, as well as executing career enhancing research training programs in the United States and Africa. This award lecture paper shares some of the lessons we have learnt from previous studies, presents objectives/design of ongoing initiatives, and discusses plans for the future.
Collapse
Affiliation(s)
- Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco
| |
Collapse
|
17
|
Adcock AK, Haggerty T, Crawford A, Espinosa C. mHealth impact on secondary stroke prevention: a scoping review of randomized controlled trials among stroke survivors between 2010-2020. Mhealth 2022; 8:19. [PMID: 35449509 PMCID: PMC9014232 DOI: 10.21037/mhealth-21-27] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/11/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND A fundamental gap between clinical prevention and self-management awareness heightens the risk for stroke recurrence in approximately one-fourth of the highest risk stroke survivors annually. Secondary stroke prevention has the potential to be promoted by mobile health (mHealth) applications for effective real-world adoption of vascular risk factor mitigation. This scoping review aims to evaluate the impact of mHealth interventions and their effectiveness to reduce recurrent stroke rates among stroke survivors in randomized controlled trials (RCTs). METHODS Scoping review in Ovid Medline, Cochrane Library, CINAHL, and Scopus for RCT literature employing mHealth among stroke populations published in English from 2010 to November 19, 2020. Small or pilot studies that included randomized design were included. RESULTS A total of 352 abstracts met inclusion criteria; 31 full-text articles were assessed and 18 unique RCTs involving 1,453 patients ultimately fulfilled criteria. Twelve of 18 met the pre-defined primary outcome measure, including 2 studies evaluating feasibility. Eight of 18 only addressed recovery from index stroke deficits. Most outcomes focused on self-reported functional status, mood, quality of life or compliance with intervention; primary outcome was an objective metric in 4/18 (blood pressure readings, step number, obstructive sleep apnea support compliance). Intervention duration 2-12 months, with a median 9 weeks. CONCLUSIONS No high-quality evidence supporting mHealth applications to reduce recurrent stroke was found in this scoping review. Overall, most studies were relatively small, heterogenous, and employed subjective primary outcome measures. mHealth's potential as an effective tool for stroke stakeholders to reduce recurrent stroke rates has not been sufficiently demonstrated in this review. Future randomized studies are needed that explicitly evaluate stroke recurrence rate.
Collapse
Affiliation(s)
- Amelia K. Adcock
- Cerebrovascular Division, West Virginia University, Morgantown, WV, USA
| | - Treah Haggerty
- Obesity Medicine, West Virginia University, Morgantown, WV, USA
| | - Anna Crawford
- Health Sciences Library, West Virginia University, Morgantown, WV, USA
| | - Cristal Espinosa
- Masters of Clinical and Translational Science Program, West Virginia University, Morgantown, WV, USA
| |
Collapse
|
18
|
Lambert CM, Olulana O, Bailey-Davis L, Abedi V, Zand R. "Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review. J Clin Med 2021; 10:4209. [PMID: 34575320 DOI: 10.3390/jcm10184209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.
Collapse
|
19
|
Vedanthan R, Kamano JH, Chrysanthopoulou SA, Mugo R, Andama B, Bloomfield GS, Chesoli CW, DeLong AK, Edelman D, Finkelstein EA, Horowitz CR, Manyara S, Menya D, Naanyu V, Orango V, Pastakia SD, Valente TW, Hogan JW, Fuster V. Group Medical Visit and Microfinance Intervention for Patients With Diabetes or Hypertension in Kenya. J Am Coll Cardiol 2021; 77:2007-2018. [PMID: 33888251 PMCID: PMC8065205 DOI: 10.1016/j.jacc.2021.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Incorporating social determinants of health into care delivery for chronic diseases is a priority. OBJECTIVES The goal of this study was to evaluate the impact of group medical visits and/or microfinance on blood pressure reduction. METHODS The authors conducted a cluster randomized trial with 4 arms and 24 clusters: 1) usual care (UC); 2) usual care plus microfinance (MF); 3) group medical visits (GMVs); and 4) GMV integrated into MF (GMV-MF). The primary outcome was 1-year change in systolic blood pressure (SBP). Mixed-effects intention-to-treat models were used to evaluate the outcomes. RESULTS A total of 2,890 individuals (69.9% women) were enrolled (708 UC, 709 MF, 740 GMV, and 733 GMV-MF). Average baseline SBP was 157.5 mm Hg. Mean SBP declined -11.4, -14.8, -14.7, and -16.4 mm Hg in UC, MF, GMV, and GMV-MF, respectively. Adjusted estimates and multiplicity-adjusted 98.3% confidence intervals showed that, relative to UC, SBP reduction was 3.9 mm Hg (-8.5 to 0.7), 3.3 mm Hg (-7.8 to 1.2), and 2.3 mm Hg (-7.0 to 2.4) greater in GMV-MF, GMV, and MF, respectively. GMV and GMV-MF tended to benefit women, and MF and GMV-MF tended to benefit poorer individuals. Active participation in GMV-MF was associated with greater benefit. CONCLUSIONS A strategy combining GMV and MF for individuals with diabetes or hypertension in Kenya led to clinically meaningful SBP reductions associated with cardiovascular benefit. Although the significance threshold was not met in pairwise comparison hypothesis testing, confidence intervals for GMV-MF were consistent with impacts ranging from substantive benefit to neutral effect relative to UC. Incorporating social determinants of health into care delivery for chronic diseases has potential to improve outcomes. (Bridging Income Generation With Group Integrated Care [BIGPIC]; NCT02501746).
Collapse
Affiliation(s)
- Rajesh Vedanthan
- New York University Grossman School of Medicine, New York, New York, USA.
| | - Jemima H Kamano
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | | | | | | | - Eric A Finkelstein
- Duke University, Durham, North Carolina, USA; Duke-National University of Singapore Medical School, Singapore
| | - Carol R Horowitz
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Simon Manyara
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Diana Menya
- School of Public Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Violet Naanyu
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | | | | | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
20
|
Yan LL, Gong E, Gu W, Turner EL, Gallis JA, Zhou Y, Li Z, McCormack KE, Xu LQ, Bettger JP, Tang S, Wang Y, Oldenburg B. Effectiveness of a primary care-based integrated mobile health intervention for stroke management in rural China (SINEMA): A cluster-randomized controlled trial. PLoS Med 2021; 18:e1003582. [PMID: 33909607 PMCID: PMC8115798 DOI: 10.1371/journal.pmed.1003582] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 05/12/2021] [Accepted: 03/11/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Managing noncommunicable diseases through primary healthcare has been identified as the key strategy to achieve universal health coverage but is challenging in most low- and middle-income countries. Stroke is the leading cause of death and disability in rural China. This study aims to determine whether a primary care-based integrated mobile health intervention (SINEMA intervention) could improve stroke management in rural China. METHODS AND FINDINGS Based on extensive barrier analyses, contextual research, and feasibility studies, we conducted a community-based, two-arm cluster-randomized controlled trial with blinded outcome assessment in Hebei Province, rural Northern China including 1,299 stroke patients (mean age: 65.7 [SD:8.2], 42.6% females, 71.2% received education below primary school) recruited from 50 villages between June 23 and July 21, 2017. Villages were randomly assigned (1:1) to either the intervention or control arm (usual care). In the intervention arm, village doctors who were government-sponsored primary healthcare providers received training, conducted monthly follow-up visits supported by an Android-based mobile application, and received performance-based payments. Participants received monthly doctor visits and automatically dispatched daily voice messages. The primary outcome was the 12-month change in systolic blood pressure (BP). Secondary outcomes were predefined, including diastolic BP, health-related quality of life, physical activity level, self-reported medication adherence (antiplatelet, statin, and antihypertensive), and performance in "timed up and go" test. Analyses were conducted in the intention-to-treat framework at the individual level with clusters and stratified design accounted for by following the prepublished statistical analysis plan. All villages completed the 12-month follow-up, and 611 (intervention) and 615 (control) patients were successfully followed (3.4% lost to follow-up among survivors). The program was implemented with high fidelity, and the annual program delivery cost per capita was US$24.3. There was a significant reduction in systolic BP in the intervention as compared with the control group with an adjusted mean difference: -2.8 mm Hg (95% CI -4.8, -0.9; p = 0.005). The intervention was significantly associated with improvements in 6 out of 7 secondary outcomes in diastolic BP reduction (p < 0.001), health-related quality of life (p = 0.008), physical activity level (p < 0.001), adherence in statin (p = 0.003) and antihypertensive medicines (p = 0.039), and performance in "timed up and go" test (p = 0.022). We observed reductions in all exploratory outcomes, including stroke recurrence (4.4% versus 9.3%; risk ratio [RR] = 0.46, 95% CI 0.32, 0.66; risk difference [RD] = 4.9 percentage points [pp]), hospitalization (4.4% versus 9.3%; RR = 0.45, 95% CI 0.32, 0.62; RD = 4.9 pp), disability (20.9% versus 30.2%; RR = 0.65, 95% CI 0.53, 0.79; RD = 9.3 pp), and death (1.8% versus 3.1%; RR = 0.52, 95% CI 0.28, 0.96; RD = 1.3 pp). Limitations include the relatively short study duration of only 1 year and the generalizability of our findings beyond the study setting. CONCLUSIONS In this study, a primary care-based mobile health intervention integrating provider-centered and patient-facing technology was effective in reducing BP and improving stroke secondary prevention in a resource-limited rural setting in China. TRIAL REGISTRATION ClinicalTrials.gov NCT03185858.
Collapse
Affiliation(s)
- Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- The George Institute for Global Health, Beijing, China
- School of Health Sciences, Wuhan University, Wuhan, Hubei, China
- Peking University School of Global Health and Development, Beijing, China
- * E-mail:
| | - Enying Gong
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
- Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia
| | - Wanbing Gu
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
- Vital Strategies, Jinan Representative Office, Beijing, China
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics & Bioinformatics, Duke University, Durham North Carolina, United States
| | - John A. Gallis
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics & Bioinformatics, Duke University, Durham North Carolina, United States
| | - Yun Zhou
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kara E. McCormack
- Department of Biostatistics & Bioinformatics, Duke University, Durham North Carolina, United States
| | - Li-Qun Xu
- China Mobile Industry Institute, Chengdu, China
| | - Janet P. Bettger
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Orthopedic Surgery, Duke University, Durham North Carolina, United States of America
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Yilong Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Brian Oldenburg
- Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia
| |
Collapse
|
21
|
Akinyemi RO, Ovbiagele B, Adeniji OA, Sarfo FS, Abd-Allah F, Adoukonou T, Ogah OS, Naidoo P, Damasceno A, Walker RW, Ogunniyi A, Kalaria RN, Owolabi MO. Stroke in Africa: profile, progress, prospects and priorities. Nat Rev Neurol 2021; 17:634-56. [PMID: 34526674 DOI: 10.1038/s41582-021-00542-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
22
|
Gebreyohanns M, Akinyemi RA, Owolabi MO, Sarfo FS, Tagge R, Ovbiagele B. Letter to the Editor. J Neurol Sci 2020; 418:117089. [PMID: 32805439 DOI: 10.1016/j.jns.2020.117089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | - Raelle Tagge
- Northern California Institute for Research and Education, USA
| | | |
Collapse
|
23
|
Affiliation(s)
- James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI (J.F.B.)
| | - Brahmajee K Nallamothu
- Michigan Integrated Center for Health Analytics and Medical Prediction, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor (B.K.N.).,Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI (B.K.N.)
| |
Collapse
|