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Advanced Neurology Stroke care in sub-Sahara Africa

worldwide. Although the 2020 COVID-19 pandemic inadequate, and, in some cases, non-existent. Among
and its impact on the global economy may have slowed the four pillars of the stroke quadrangle (surveillance,
progress toward meeting WHO recommendations, there prevention, acute care, and rehabilitation), low- to middle-
has been minimal to no progress in this regard in SSA income countries consistently fall behind high-income
countries. Studies investigating the state of rehabilitation countries. Evidence for this was shown in the 2021
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after stroke in SSA are limited. A comprehensive review report of the World Stroke Organization–World Health
of published studies on stroke rehabilitation services in Organization survey on the availability of the four pillars of
Africa found that, of the 51 studies included, 43% were the stroke quadrangle. The global scores for the availability
from South Africa, 37% from West Africa, and 15% from of surveillance, prevention, acute care, and rehabilitation
East Africa. Not only are robust studies scarce in this were 52.4%, 39.6%, 51.5%, and 38.7%, respectively, for
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area but there is also a noticeable lack of comprehensive high-income countries, compared to 39.2%, 28.9%, 29.5%,
rehabilitation services. The few available studies indicate and 25.1% for low-income countries. 109
inadequate rehabilitation facilities and an extremely low
number of available rehabilitation professionals, such 6.1. Cultural beliefs, awareness, and misinformation
as physiotherapists, speech/language therapists, and about stroke
occupational therapists. This shortage severely limits Like many diseases, regrettably, stroke is often viewed as
the availability of tertiary prevention avenues for people a spiritual curse in some African countries. This belief is
with stroke in SSA. Factors limiting the availability of reflected in some African languages where the stroke is
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rehabilitation services include poor knowledge of the described as mba agbara (hug from the spirit) in parts of
role of rehabilitation services, lack of incorporation of Ibo, Nigeria; ekpo mia (a sleep from the ghost) in Ibibio and
rehabilitation practices as part of standard stroke care, long Efik, Nigeria; ofa (an evil arrow) in Yoruba, Nigeria; and
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intervals from stroke onset to initiation of rehabilitation, shan inna (paralysis by the spirit) in Hausa, Nigeria. A
short duration of rehabilitation for the few patients who study carried out in Abeokuta, Nigeria, appallingly showed
receive it, and inadequate or absence financial support that up to 14% of participants believed that stroke is a
for rehabilitation services. As a result, the responsibility spiritual illness caused by evil spirits. These sociocultural
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of post-hospital discharge rehabilitation falls squarely on beliefs affect the health-seeking behavior of believers,
the patients, their families, and caregivers. Task shifting leading some stroke patients, especially those in rural
to home rehabilitation strategies has been proposed as communities, to seek out traditional healers and churches
a means of mitigating the shortage and financial burden for healing. Anecdotal reports suggest that a common cure
associated with standard rehabilitation paradigms. The for stroke victims among the Hausas in Northern Nigeria’s
ATTTEND trial, a prospective randomized open trial with rural communities is to tie a ram to the paralyzed limb of
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a blinded endpoint, investigated a family-led, caregiver- the stroke victim. Traditional and faith healers are often
delivered, home-based rehabilitation intervention sought for curing patients with diverse medical conditions,
conducted in India. Unfortunately, it failed to show a including stroke, in many parts of SSA. 112,113
benefit of home rehabilitation compared to usual care The spiritual misconception about stroke is further
in the composite outcomes of death or dependence at complicated and fueled by low awareness of stroke as
6 months. However, this model of rehabilitation care has a medical disorder that affects the brain. In a study
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been suggested for further investigation, particularly in conducted in Nigeria, the brain was identified as the organ
SSA. In a limited study of 20 stroke survivors in Ghana, associated with stroke by only 40% of respondents, while
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a tele-rehabilitation model utilizing a tele-therapist for 10% identified the heart and 44% identified other body
12 weeks demonstrated the feasibility of administering a organs. Similarly, a Ugandan study found that 76% of
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tele-mobile physical therapy intervention with high user participants did not recognize stroke as a disease affecting
satisfaction among participants. the brain, while another study found that 54% incorrectly
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identified the heart as the organ involved during a stroke.
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6. Challenges of stroke care in SSA These studies highlight the need to raise awareness about
Stroke care in SSA, as in many low- to middle-income stroke risk factors and treatment among the general public
countries, faces numerous challenges that impede the while involving traditional healing health practitioners in
advancement of health care in general and stroke in health-care delivery in SSA.
particular. Epidemiological surveillance by the Ministry of
Health or a federally designated agency, organized health 6.2. Access to stroke care in SSA
promotion, risk factors identification and management, Access to high-quality stroke care is limited, and in many
access to care, costs, and stroke systems of care are all grossly rural communities in SSA countries, it is non-existent.

Volume 3 Issue 2 (2024) 11 doi: 10.36922/an.2804