Stroke Rehabilitation in Low- and Middle-Income Countries: Challenges and Opportunities.

ABSTRACT: Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia.

BACKGROUND: Factors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia. METHODS: Data from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality. RESULTS: In-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27-6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14-406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01-1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30-11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses. CONCLUSION: This Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Neurophobia in Africa: Survey responses from fifteen African countries.

OBJECTIVE: To assess the prevalence of "neurophobia," or fear of the neurosciences and neurology, and perceptions of neurology education among medical trainees in African countries. BACKGROUND: Perceptions of neurology and characterization of neurophobia have been studied among medical trainees around the world. However, few studies on neurophobia have been conducted in African countries despite having a disproportionately high burden of neurological disease and fewer neurologists per capita than all other world regions. DESIGN/METHODS: We conducted a cross-sectional survey of medical students and post-graduate trainees in internal medicine and pediatrics across Africa. A 23-item online survey containing multiple-choice, Likert-scale, and free-response questions was adapted from prior literature, translated into English and French, and distributed through listservs and social media. RESULTS: 294 surveys were completed by 197 medical students and 97 post-graduate trainees from 15 countries, with the greatest representation from Zambia (n = 110), Nigeria (n = 54) and Kenya (n = 35). One-fifth of respondents endorsed interest in a future career in neurology while 36% reported discomfort with neurology and almost one-third endorsed neurophobia. Participants rated neurology as the most difficult compared to six other medical subspecialties (p < 0.001) and rated their confidence managing patients with neurological complaints lower than other medical subspecialties except rheumatology (p < 0.005). CONCLUSIONS: Medical trainees in multiple African countries endorse fear and discomfort with the subject of neurology. Strategies to mitigate neurophobia, including investments in neurological educational, diagnostic and treatment capacity, are needed to increase the number of medical trainees pursuing careers in neurology.