Effect of an Educational Intervention for Primary Stroke Risk Reduction in Ghana and Nigeria: Pilot Randomized Controlled Trial.

BACKGROUND: Using tailored mobile health interventions to improve global vascular risk awareness and control is yet to be investigated for primary stroke prevention in Africa. METHODS: This 2-arm pilot randomized controlled trial involved 100 stroke-free adults with at least 2 vascular risk factors for stroke. Eligible participants were assigned randomly to a control arm offering 1-time counseling (n=50) or a 2-month educational intervention arm (n=50) comprising a stroke video and riskometer app aimed at improving stroke risk factor awareness and health-seeking behavioral modification to control total vascular risk. Reduction in total stroke risk score was the primary outcome while feasibility and process measures were secondary outcomes. RESULTS: All enrolled participants completed the 2-month follow-up (retention rate=100%). The mean (SD) age of participants was 59.5 (±12.5) years, 38% were males. The mean change in stroke risk score at 2 months was -11.9% (±14.2) in the intervention arm versus -1.2% (±9.1) in the control arm, P=0.0001. Stroke risk awareness improved by 16.1% (±24.7) in the intervention arm versus 8.9% (±24.7) in the control arm, P=0.08. The intervention arm had 11.1 mm Hg reduction in systolic blood pressure compared with 4.8 mm Hg reduction in the control arm. CONCLUSIONS: The intervention demonstrated a positive signal of effect over a 2-month period. A definitive clinical trial with a longer duration of follow-up is warranted on the premise of these promising findings from this pilot randomized clinical trial. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT05619406.

Non-cigarette tobacco use and stroke among West Africans: evidence from the SIREN study.

INTRODUCTION: Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans. METHODS: A total of 7,617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigation Research and Educational Network study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial CT/MRI. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship between NCT and stroke at p<0.05. RESULTS: Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-smokers (62.8±15.7 vs 57.7±14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95%CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95%CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95%CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates. CONCLUSIONS: NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans. IMPLICATIONS: A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance to promote evidence-based recommendations for public health prevention and management of stroke on the African continent.

ASOC Osuntokun Award Lecture 2022: Partnership for stroke prevention and treatment in Africa: Qualitative research processes and findings.

BACKGROUND/OBJECTIVES: Africa has one of the highest rates of stroke and stroke deaths in the world. The burden of stroke is increasing with a 3-year mortality rate of up to 84%. Stroke disproportionately affects the young and middle-aged population contributing to morbidity and mortality affecting families, communities, health systems, and economic progress. My objectives of the 2022 Osuntokun Award Lecture at the African Stroke Organization Conference were to explore our qualitative research findings from our communities and to propose future qualitative methods for improving stroke outcomes in Africa. METHODS: Qualitative research processes and findings related to stroke prevention, treatment/ongoing care, recovery, and knowledge and attitudes influencing ethical, legal and social implications related to stroke neuro-biobanking were explored. For each qualitative study, methods were developed by the research team including: (1) plans to implement aims and ethics review; (2) guides and detailed steps for implementation; (3) training for team; (4) pilot testing, data collection, transport, transcription, storage; (5) data analysis and manuscript development. RESULTS: The research focused on genetics, genomics and phenomics of stroke and more recently on exploring the ethical, legal, and social implications of stroke neuro-biobanking. All included a qualitative component to obtain input and guidance from the community. As in quantitative research, questions were developed by the research team, reviewed for clarity by a small group of community members, and 1,289 community members (ages 22-85) participated in the focus groups and key informant interviews from 2014 through 2022. Answers to questions were diverse with some knowledgeable about the science of stroke prevention and treatment, but many had ideas about prevention and causes of stroke that were not supported by science and many reported using traditional healers for treatment and religious beliefs preventing brain biobanking. CONCLUSIONS: In addition to our current qualitative research related to stroke in Africa and beyond, we must form research partnerships with communities that not only answer researchers' and community members' questions but identify and implement ways to prevent stroke and improve stroke outcomes.

Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria.

OBJECTIVES: To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk. MATERIALS AND METHODS: A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk. RESULTS: The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application. CONCLUSIONS: Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.

Are there differences in perceptions, preferences and attitudes towards disclosure of genetic testing for Stroke? A qualitative study among stroke-free SIREN-SIBS genomics study participants.

OBJECTIVE: This study explored perceptions, preferences and attitudes towards disclosure of genetic testing results for stroke among stroke-free controls (and their family members) in the SIREN-SIBS Genomics Study, healthcare providers and policymakers. MATERIALS AND METHODS: We conducted a qualitative thematic analysis of key informant interviews with 61 participants recruited from community advisory boards (30) and health care providers (31) across seven sites in Nigeria and Ghana. RESULTS: Major findings illustrate differences in the knowledge of genetic testing with superior knowledge among health care professionals. Relatives and religious leaders were opined as the best to receive the disclosure as they would be able to break the news to the patient in a culturally sensitive manner to reduce the likely resultant emotional outburst. Poor level of awareness of national guidelines for disclosing genetic results exist. Key facilitating factors for disclosure are education, enabling environment, involvement of religious and community leaders, campaigns, and possible treatment options. Disclosure inhibitors include inadequate information, fear of marital break-up or family displacement, fear of stigmatization, fear of isolation, religious beliefs, health worker attitude, and lack of preparedness to accept results. CONCLUSIONS: These necessitate culturally sensitive interventions for continuing education, increased awareness and sustained engagement to equip all stakeholders in genetic testing disclosure process.

Crafting Community-Based Participatory Research Stroke Interventions.

Stroke exerts a tremendous burden on individuals, families, communities, and health systems globally. Even more troublesome are the striking disparities faced across diverse populations. These disparities are further exacerbated by the COVID-19 pandemic. Despite efforts to advance stroke research, substantial gaps remain in understanding factors that contribute to stroke disparities, including the Social Determinants of Health. Strategically designed studies and tailored interventions are needed to bridge the inequities high-risk populations face and to meet their specific needs. Community-based participatory research offers an approach to equitably partner with community members to understand and work collaboratively to address community-specific health priorities. In this focused update, we highlight the main processes of community-based participatory research studies and share exemplars from our team's work in stroke research and from the literature. As we continue to face an increasing prevalence of stroke, compounded by the COVID-19 pandemic and ongoing implications of the Social Determinants of Health, partnering with communities to address community-driven health priorities can inform interventions targeted to overcome the disparities faced by certain populations.

Risk Factor Characterization of Ischemic Stroke Subtypes Among West Africans.

BACKGROUND AND PURPOSE: To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans. METHODS: The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI. RESULTS: There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91-15.45); dyslipidemia, 5.16 (3.78-7.03); diabetes, 3.44 (2.60-4.56); low green vegetable consumption, 1.89 (1.45-2.46); red meat consumption, 1.89 (1.45-2.46); cardiac disease, 1.88 (1.22-2.90); monthly income $100 or more, 1.72 (1.24-2.39); and psychosocial stress, 1.62 (1.18-2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001). CONCLUSIONS: Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.

African Rigorous Innovative Stroke Epidemiological Surveillance: Protocol for a Community-Based Mobile-Health Study.

Despite projections of stroke being a leading cause of mortality in Africa, reliable estimates of stroke burden on the continent using rigorous methods are not available. We aimed to implement a mobile-Health community-based interactive Stroke Information and Surveillance System to sustainably measure stroke burden and improve stroke health literacy and outcomes in urban and rural sites in Nigeria. African Rigorous Innovative Stroke Epidemiological Surveillance (ARISES) is an observational cohort study, which will be conducted in urban (Ibadan North LGA Ward 3) and rural (Ibarapa Central LGA) sites with a combined base population of over 80,000 people. The study will use a consultative approach to establish an mHealth-based Stroke Information and Surveillance System comprising a Stroke Alert System and a Stroke Finding System. These systems will enable the community to report stroke events and the research team/health workers find stroke cases using phone calls, short message service, and Voice Over Internet Protocols (VoIP). We will update community household data and geo-locate all households. Over the 5 years of the study, the system will collect information on stroke events and educate the community about this disease. Reported stroke cases will be clinically adjudicated at home and in prespecified health facilities. Baseline and endline community surveys will be conducted to assess stroke occurrence and other important study variables. The proportion of strokes alerted and found will be determined over the study period. Focus group discussions and key informant interviews will be conducted to understand community stroke literacy and perspectives. The study will also assess any impact of these efforts on time from stroke onset to referral, community uptake of orthodox health services for stroke patients. ARISES is anticipated to establish proof of concept about using mHealth for stroke surveillance in Africa. The potential impact of the SISS on improving patient outcomes will also be determined.

Differential associations between pre-diabetes, diabetes and stroke occurrence among West Africans.

BACKGROUND: There are limited data from Africa on the burden and associations between pre-diabetes (pre-DM), diabetes mellitus (DM) and stroke occurrence in a region experiencing a profound rise in stroke burden. PURPOSE: To characterize the associations between stroke and dysglycemic status among West Africans. METHODS: The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with clinical and radiological evidence of an acute stroke. Controls were age-and-gender matched stroke-free adults. Detailed evaluations for vascular factors were performed. Pre-diabetes was defined as HBA1c of 5.7%-6.4% or Fasting blood glucose (FBG) 5.6-7.0 mmol/L and DM as HBA1c >6.5% or FBG>7.0 mmol/L. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval. RESULTS: Among 2,935 stroke cases the mean age was 60.0 ± 14.2 years with 55.2% being males. By glycemic status, 931 (31.7%) were euglycemic, 633 (21.6%) had Pre-diabetes and 1371 (46.7%) had DM. Of the age- and sex-matched stroke-free controls 69.2% were euglycemic, 13.3% had pre-DM and 17.5% had DM. Pre-DM [aOR (95% CI): 3.68(2.61-5.21)] and DM [4.29 (3.19-5.74)] were independently associated with stroke. The aOR of Pre-DM for ischemic stroke 3.06 (2.01-4.64)] was lower than 4.82 (3.37-6.89) for DM. However, the aOR of Pre-DM for hemorrhagic stroke 6.81 (95% CI: 3.29 - 14.08)] was higher than 3.36 (1.94-5.86) for DM. Furthermore, the aOR of pre-DM for ischemic stroke subtypes were 9.64 (1.30-71.57) for cardio-embolic stroke, 3.64 (1.80-7.34) for small-vessel occlusive disease and 4.63 (0.80-26.65) for large-vessel disease. CONCLUSION: Pre-DM is strongly and independently associated with stroke in Africans. Improving glycemic control through screening, healthy lifestyle and pharmacotherapy at a population level may be strategic in reducing the rising burden of stroke in Africa.

Legal Implications of Stroke Biobanking and Genomics Research in Sub-Saharan Africa.

Stroke is a major cause of death in Sub-Saharan Africa (SSA) and genetic factors appear to play a part. This has led to stroke biobanking and genomics research in SSA. Existing stroke studies have focused on causes, incidence rates, fatalities and effects. However, scant attention has been paid to the legal issues in stroke biobanking and genomics research in the sub-region. Therefore, this article examines the legal implications of stroke biobanking and genomics research in SSA. The article adopts a textual analysis of primary and secondary sources in law. It reports that there are laws from the perspectives of human right, the common law, and intellectual property. However, there are gaps to be filled. The article therefore argues for legislative intervention. It concludes that pending the time the statute will be enacted, genomics researchers in Africa should adopt the ethical guidelines prepared by Human Heredity and Health in Africa (H3 Africa).

Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk factor: Protocol of a RCT.

BACKGROUND: Geographical and racial disparities in stroke outcomes are especially prominent in the Southeastern United States, which represents a region more heavily burdened with stroke compared to the rest of the country. While stroke is eminently preventable, particularly via blood pressure control, fewer than one third of patients with a stroke have their blood pressure controlled ≥ 75% of the time, and low consistency of blood pressure control is linked to higher stroke risk. OBJECTIVE: To demonstrate that a mHealth technology-centered, integrated approach can effectively improve sustained blood pressure control among stroke patients (half of whom will be Black). DESIGN: The Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk-factor is a prospective randomized controlled trial, which will include a cohort of 200 patients with a stroke, encountered at two major safety net health care systems in South Carolina. The intervention comprises utilization of a Vaica electronic pill tray & blue-toothed UA-767Plus BT blood pressure device and a dedicated app installed on patients' smart phones for automatic relay of data to a central server. Providers will follow care protocols based on expert consensus practice guidelines to address optimal blood pressure management. STUDY OUTCOMES: Primary outcome is systolic blood pressure at 12-months, which is the major modifiable step to stroke event rate reduction. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. DISCUSSION: We anticipate that a successful intervention will serve as a scalable model of effective chronic blood pressure management after stroke, to bridge racial and geographic disparities in stroke outcomes in the United States. TRIAL REGISTRATION: ClinicalTrials.gov - NCT03401489.

A Novel Afrocentric Stroke Risk Assessment Score: Models from the Siren Study.

BACKGROUND: Stroke risk can be quantified using risk factors whose effect sizes vary by geography and race. No stroke risk assessment tool exists to estimate aggregate stroke risk for indigenous African. OBJECTIVES: To develop Afrocentric risk-scoring models for stroke occurrence. MATERIALS AND METHODS: We evaluated 3533 radiologically confirmed West African stroke cases paired 1:1 with age-, and sex-matched stroke-free controls in the SIREN study. The 7,066 subjects were randomly split into a training and testing set at the ratio of 85:15. Conditional logistic regression models were constructed by including 17 putative factors linked to stroke occurrence using the training set. Significant risk factors were assigned constant and standardized statistical weights based on regression coefficients (ß) to develop an additive risk scoring system on a scale of 0-100%. Using the testing set, Receiver Operating Characteristics (ROC) curves were constructed to obtain a total score to serve as cut-off to discriminate between cases and controls. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at this cut-off. RESULTS: For stroke occurrence, we identified 15 traditional vascular factors. Cohen's kappa for validity was maximal at a total risk score of 56% using both statistical weighting approaches to risk quantification and in both datasets. The risk score had a predictive accuracy of 76% (95%CI: 74-79%), sensitivity of 80.3%, specificity of 63.0%, PPV of 68.5% and NPV of 76.2% in the test dataset. For ischemic strokes, 12 risk factors had predictive accuracy of 78% (95%CI: 74-81%). For hemorrhagic strokes, 7 factors had a predictive accuracy of 79% (95%CI: 73-84%). CONCLUSIONS: The SIREN models quantify aggregate stroke risk in indigenous West Africans with good accuracy. Prospective studies are needed to validate this instrument for stroke prevention.

Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States.

We write this article amid a global pandemic and a heightened awareness of the underlying structural racism in the United States, unmasked by the recent killing of George Floyd and multiple other unarmed Black Americans (Spring 2020). Our purpose is to highlight the role of social determinants of health (SDOH) on stroke disparities, to inspire dialogue, to encourage research to deepen our understanding of the mechanism by which SDOH impact stroke outcomes, and to develop strategies to address SDOH and reduce stroke racial/ethnic disparities. We begin by defining SDOH and health disparities in today's context; we then move to discussing SDOH and stroke, particularly secondary stroke prevention, and conclude with possible approaches to addressing SDOH and reducing stroke disparities. These approaches include (1) building on prior work; (2) enhancing our understanding of populations and subpopulations, including intersectionality, of people who experience stroke disparities; (3) prioritizing populations and points along the stroke care continuum when racial/ethnic disparities are most prominent; (4) understanding how SDOH impact stroke disparities in order to test SDOH interventions that contribute to the disparity; (5) partnering with communities; and (6) exploring technological innovations. By building on the prior work and expanding efforts to address SDOH, we believe that stroke disparities can be reduced.

Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes.

OBJECTIVE: This secondary analysis examined the relationships between Patient Activation Measure (PAM) scores, use of health services, and HgA1C. DESIGN: A feasibility study was conducted for a community-based intervention for high-risk adults with uncontrolled diabetes. Data were collected at baseline and monthly, including PAM and modified Diabetes Self-Management Assessment Report Tool. INTERVENTION: Participants (n = 58) were randomized to a 3-month nurse (RN) telephone management or community health worker (CHW) in-home intervention, focusing on medication adherence, timely follow-up, diabetes self-management coaching, and linkage to resources. RESULTS: Sample was mostly female (73%), African-American (90%), low income (75%), high school education or less (80%), and mean age of 59 years. A positive association between PAM score and self-reported diabetes care recommendations was found (r = .356, p = .014) and significant correlation between baseline PAM score and HgA1C levels (r = -.306, p = .029). A paired samples t test showed statistically significant increases in PAM scores in the CHW intervention group (mean increase +8.5, CI [+2.49 to +14.65]); baseline (M = 60.31, SD = 13.3) to end of study ([M = 68.89, SD = 16.39], t(22) = 2.924, p = .008 [two-tailed]). CONCLUSION: A community-based approach to diabetes management demonstrated a positive effect on patient activation. Although disparities in health care access among rural, low-income populations exist, community-based interventions show potential for improving patient engagement in diabetes management and recommended health services.

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa.

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians.

BACKGROUND AND PURPOSE: Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients. METHODS: Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as "fatigued." A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9. RESULTS: Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF. CONCLUSIONS: Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Barriers and Facilitators of Stroke Recovery: Perspectives From African Americans With Stroke, Caregivers and Healthcare Professionals.

INTRODUCTION AND GOAL: Stroke is a serious health condition that disproportionally affects African-Americans relative to non-Hispanic whites. In the absence of clearly defined reasons for racial disparities in stroke recovery and subsequent stroke outcomes, a critical first step in mitigating poor stroke outcomes is to explore potential barriers and facilitators of poststroke recovery in African-American adults with stroke. The purpose of this study was to qualitatively explore poststroke recovery across the care continuum from the perspective of African-American adults with stroke, caregivers of African-American adults with stroke, and health care professionals with expertise in stroke care. MATERIALS AND METHODS: This qualitative descriptive study included in-depth key informant interviews with health care providers (n = 10) and focus groups with persons with stroke (n = 20 persons) and their family members or caregivers (n = 19 persons). Data were analyzed using thematic analysis according to the Social Ecological Model, using both inductive and deductive approaches. FINDINGS: Persons with stroke and their caregivers identified social support, resources, and knowledge as the most salient factors associated with stroke recovery. Perceived barriers to recovery included: (1) physical and cognitive deficits, mood; (2) medication issues; (3) lack of support and resources; (4) stigma, culture, and faith. Health care providers identified knowledge/information, care coordination, and resources in the community as key to facilitating stroke recovery outcomes. CONCLUSIONS: Key findings from this study can be incorporated into interventions designed to improve poststroke recovery outcomes and potentially reduce the current racial-ethnic disparity gap.

Stroke Among Young West Africans: Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case-Control Study.

BACKGROUND AND PURPOSE: Stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries. Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged <50 years old. METHODS: The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged ≥18 years with computed tomography/magnetic resonance imaging-confirmed stroke. Controls were age-and gender-matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed. We used conditional logistic regression to estimate odds ratios and population attributable risks with 95% confidence intervals. RESULTS: Five hundred fifteen (24.3%) out of 2118 cases enrolled were <50 years old. Among subjects <50 years old, hemorrhagic stroke proportion was 270 (52.5%) versus 245 (47.5%) for ischemic strokes. Etiologic subtypes of ischemic strokes included large artery atherosclerosis (40.0%), small vessel disease (28.6%), cardioembolism (11.0%), and undetermined (20.4%). Hypertension (91.7%), structural lesions (3.4%), and others (4.9%) were causally associated with hemorrhagic stroke. Six topmost modifiable factors associated with stroke in descending order of population attributable risk (95% confidence interval) were hypertension: 88.7% (82.5%-94.8%), dyslipidemia: 48.2% (30.6%-65.9%), diabetes mellitus: 22.6% (18.7%-26.5%), low green vegetable consumption: 18.2% (-6.8%-43.2%), stress: 14.5% (4.9%-24.1%), and cardiac disease: 8.4% (5.8%-11.1%). CONCLUSIONS: The high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.

Technology as a Means to Address Disparities in Mental Health Research: A Guide to "Tele-Tailoring" your Research Methods.

We must include rural participants in health-related research if we are to address health-related disparities and inequity, particularly in mental health. However, the first step of the research process, in person, witnessed, signed informed consent is often a limiting factor and insurmountable barrier to precisely the type of research (e.g., telehealth) designed to overcome barriers of geographic distance and travel time. Telehealth, or the provision of medical care or services to patients by means of audio/video and procedure-specific technology, addresses some barriers to health created by rurality by making health care professionals more accessible to patients. A logical complement to telehealth is "teleconsent." Teleconsent can be defined as using remote, facial integrated identity verification to allow (a) remote guidance of participants through consent documents, and (b) digital signing by all parties, obviating the need for in person signed consent. The ability to review and sign consent documents via telehealth with synchronous viewing is a novel, innovative means by which to overcome the initial significant barrier to recruitment of rural participants into healthcare research. By leveraging the growing capabilities of telehealth, teletailoring studies can improve the efficiency of research recruitment and facilitate the consent process for under-represented populations in research. Strategies for implementation are clearly relevant to increasing the success of clinical trial recruitment.

Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors.

BACKGROUND AND PURPOSE: The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA). METHODS: SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies. RESULTS: There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%). CONCLUSIONS: Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.