Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke in Sub-Saharan Africa: Reality for Post-Stroke Rehabilitation

*Polycarp Umunna Nwoha, Florence Osita Okoro, Emmanuel Chukwudi Nwoha, Augustine Obi, Chidinma Oluchi Nwoha, Iyanu Ayoola, Nkeiru Christiana Ogoko, Peace Ngozi Nwoha, Anna Idaguko, Catherine Wali, Nnenna Chinagozi-Amanze and Ifeoma H. Nwoha-Okpara*

## **Abstract**

This work considered post-stroke rehabilitation in sub-Saharan Africa, referencing psychosocial stress and wrongful cultural beliefs. Stroke, a neurological disease preventable by lifestyle changes, is increasing at, particularly in sub-Saharan Africa (SSA). First-ever stroke cases stand the risk of a second, which could be fatal; hence the need for review of post-stroke rehabilitation strategies. In our work on survivors, we noted that most established risk factors do not necessarily apply in SSA. Of the 10 risk factors studied, hypertension was the commonest reported. In our study of 149 survivors in Nigeria, 73.1% suffered from hypertension; only 53.7% were aware of their hypertensive status before stroke incidence. When asked about risk factors, 19.4% mentioned hypertension, 0.7% diabetes mellitus but 13.1% psychological stress, and 13.4% spiritual attack/diabolical; 39.6% had no idea what caused stroke. The findings show the role hypertension, psychological stress and cultural ignorance play in fueling stroke in SSA. Further, 97.3% of survivors were married, 65.1% had 5 to 8 children, engaged in sedentary occupations, trading, farming, civil service, occupations also prone to economic woes in Nigeria. Commonest age of survivors was 60 to 75 years; a period of very stressful life in Nigeria. All these culminate to sustained psychosocial pressures, hypertension and stroke. There is urgent need to reduce psychosocial pressures, correct wrongful cultural beliefs, especially among survivors in sub-Saharan Africa. The strength of this work lies in the observation of lack of awareness and community screening as

the most pronounced common variable among the survivors. The place of herbal medicine in post-stroke rehabilitation should be recognised. Of the 117 survivors who visited Bebe Herbal Centre for management, 99.1% were satisfied; 67.5% of them had satisfactory recovery in less than 1 month. Introduction of physiotherapy in Herbal centres would speed up recovery.

**Keywords:** psychosocial stress, family pressure, occupational pressure, herbal treatment, cultural beliefs, stroke awareness

## **1. Introduction**

Stroke is a menace to the society. All over the world, it affects countless number of people, as much as 16 million people per year [1]. Out of this number, 5.7 million die, and the rest becomes disabled for a long period, even for life. It is the second most common cause of death worldwide, after ischaemic heart disease [2–4]. The impact of stroke is mostly felt in low and middle income countries. About 85% of all stroke deaths are registered in low and middle income countries, which also account for 87% of total losses due to stroke in terms disability-adjusted life years calculated worldwide per year [2]. As the burden of stroke has shifted to the developing world, currently two-thirds of stroke mortality cases occur in sub-Saharan Africa (SSA), [2–4]. This is sad because this is the same region that poverty, malnutrition and communicable diseases also exert their greatest toll [5]. The unfortunate thing is that while the proportion of stroke is decreasing in the developed world, it is rising alarmingly in the under-developed world [6]. The World Health has predicted that by the year 2030, majority (80%) of stroke cases would be in the low-income and middle-income countries. Africa, in particular, records some of the highest rates of stroke worldwide, with an annual stroke incidence rate up to 316 per 100,000, prevalence rate up to 1460 per 100,000 and three-year fatality rate up to 84% [7–10]. In Africa, stroke accounts for 4–9% of deaths and between 6.5–41% of neurological admissions, as reported in hospital-based studies [11, 12]. This is not only alarming, it is frightening; and should concern all of us. Two-thirds of stroke cases worldwide occur in SSA [13]. It is, therefore, clear that sub-Saharan Africa has become the epicentre of stroke in the world, calling for strong sustained efforts to reduce the incidence of stroke in the region. This reality should provoke increased attention to stroke issues in the world, especially in the low- and middle-income countries, in order to reverse the trend. In doing this, we must firstly identify the real problems associated with stroke in the region. For post-stroke rehabilitation effort to be effective and set goals of preventing second stroke achieved, it is important to focus attention on the real factors that predispose to stoke in the region. All factors should be taken into account, including the role of herbal centres and cultural beliefs, which have long been neglected. Great effort should be focused in reducing stroke occurrence in sub-Saharan Africa, because of the cumulative positive effect it would have on stroke reduction the world over. Fortunately and surprisingly, stroke is the most preventable of all neurological diseases as many of its risk factors, such as hypertension, high cholesterol, diabetes, and smoking can be prevented either through healthy lifestyle choices or by medication [14, 15]. In sub-Saharan Africa, therefore, psychosocial pressures and cultural beliefs should be given due attention, especially in post-stroke rehabilitation programmes.

## **2. Demographic study**

This section discusses majorly the demographic features of 149 stroke survivors who visited Bebe Herbal Centre located in Umunomo Ihitteafoukwu, Ahiazu Mbaise, Imo state, Nigeria, for treatment and their import on stroke issues in sub-Saharan Africa. In the study [16] (**Tables 1**–**3**), it was noted that 97.3% of survivors were married while 2.7% were single. What this means is that being married is a potential source of pressure, especially for the low-income group. It was also reported that 65.1% of those married had 5 to 8 children, further strengthening our


#### **Table 1.**

*Distribution of parameters among male and female stroke survivors (n = 149).*


## **Table 2.**

*Distribution of size of variables relative to age (year) of respondents (frequency, percentage).*

position that in SSA, having large families is potentially a big source of psychosocial pressure, which could lead to hypertension and eventual stroke. The reason is because of the low income capacity of most of these families in the region. Inability to cater for one's family poses serious psychosocial pressure; and the larger the family, the more the pressure on parents and guardians. Cooper et al. [17] noted in their work that high blood pressure is the foundation of epidaemic cardiovascular diseases in Africa. To prevent a stroke event, especially for survivors, there is need to reduce avoidable pressures from families, for example, by limiting the number of children one caters for. Government should also help by providing social welfare programmes, including subsidising health and education for her low-income citizens. These, if done, will take a lot of pressure off low-income large families. One's occupation in sub-Saharan Africa could also be a source of psychosocial pressure. In our work, we noted that people most commonly affected by stroke were traders (38.9%) followed by farmers and civil servants, in that order, 22.8% and


*Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke… DOI: http://dx.doi.org/10.5772/intechopen.104516*

## **Table 3.**

*Descriptive characteristic of the survivors and person's chi-squared test between male and female.*

21.5% respectively. Artisans were not much affected (14.1%) while the unemployed were barely affected (2.7%). Pearson's chi-squared test (**Table 3**) shows evidence of strong association between education, and occupation and gender of stroke survivors. Education had strong significant association (X2 = 12.31; df = 3, p < .006). More men than women had primary education (27.5% vs. 25.5%), secondary education (16.8% vs. 9.4%) and tertiary education (12.8% vs. 3.4%). Occupation


#### **Table 4.**

*Stroke risk factors suffered/encountered by survivors and Pearson's chi-squared test of association with gender.*

had significant strong association with gender of the stroke survivors (X2 = 23.65; df = 4; p < .001) with more men than women being unemployed (2.7% vs. 0.7%), being artisans (19.5% vs. 3.4%) and civil servants (17.4% vs. 3.4%) while women more than men were traders (15.4% vs. 12.1%) and farmers (14.1% vs. 7.4%). By the age bracket indicated, most people in these professions would have retired from active service and be faced with the burden of lower income generation for their numerous bourgeoning responsibilities, leading to increased psychosocial pressure and hypertension. We also noted that those with primary education only were highest among the stroke survivors [53.7%], followed by secondary education and tertiary. The higher the educational level, the higher the tendency for better income and also the likelihood of better awareness of stroke risk factors. These add up to better lifestyle and low stroke incidence for those with higher education. Individuals, particularly the first-stroke ones, should be aware of these factors that fuel stroke via psychosocial pressure and hypertension. Socioeconomic status has long been identified as a risk factor for hypertension [18]. In a meta-analysis, multiple indicators of socioeconomic status (i.e., income, occupation, and education) were associated with an increased risk of hypertension. It was suggested that working conditions induce stress that is associated with increased risk of hypertension [18]. We also noted in our work that very few stroke cases were below 40 years of age while the most were between 60 and 74 years, the age group when family pressures are highest in sub-Saharan Africa. High levels of anxiety and depressive symptoms are common in adults, often comorbid with chronic illnesses such as hypertension and can have deleterious effects on individual health and quality of life. A meta-analysis of prospective studies found that depressive symptoms predict a 42% increased risk of hypertension [19]. Similarly a meta-analysis of prospective studies fund that anxiety symptoms were independent risk factor for hypertension [20]. *Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke… DOI: http://dx.doi.org/10.5772/intechopen.104516*

Stressors linked with unemployment, underemployment, job conflict, or financial strain due to low wages may lead to hypertension. An explanation for this was provided by Everson-Rose et al. [21] who noted that psychosocial factors, such as hostility and job strain, are associated with higher circulating levels of catecholamines, higher cortisol levels, and increased blood pressure over time. Psychosocial factors that induce emotional stress can evoke a physiological response mediated in part by activation of the sympathetic nervous system, inflammation, and the hypothalamic–pituitary–adrenal axis (**Table 4**) [22, 23].

## **3. Risk factors**

There are traditional risk factors for stroke, including hypertension, dyslipidemia, diabetes mellitus, obesity, smoking, stress (physical and emotional), sedentary lifestyle, heavy alcohol consumption, previous stroke and family history of stroke [2, 24]. Of these, hypertension is an important risk factor for a variety of health conditions, such as cardiovascular disease, stroke, and kidney failure. Hypertension is the leading risk factor for stroke and is present in nearly 1 in 3 American adults [25]. Hypertension is a pervasive problem in the United States, with approximately a third of Americans reporting being diagnosed with hypertension by their physicians or taking antihypertensive drugs [26]. It is considered the foundation for epidaemic cardiovascular diseases in African populations [17]. In Nigeria and sub-Saharan Africa, hypertension is the most important stroke risk factor [27, 28]. Growing evidence points to multiple psychological and social factors as contributors to the onset of trajectory of hypertension. It is time to understand that greater acculturation is associated with increased risk of hypertension, independent of age, gender, race/ethnicity, education, smoking, alcohol, physical activity, body mass index, and diabetes [29]. Wrong cultural beliefs do more harm than the direct risk factors.

We have greater need to educate people that hypertension is the foremost cause of stroke in sub-Saharan Africa and that psychosocial stress is the factor mostly fuelling hypertension. If we can curtail excessive and sustained psychosocial pressures and wrong cultural beliefs, we would be curtailing stroke incidence considerably. Diabetes mellitus is second causative factor for stroke in SSA but is usually accompanied by hypertension. Rarely does it alone cause stroke. Dyslipidemia (high blood cholesterol) is a third causative factor for stroke in most developed countries but rarely noted in SSA. The remaining seven traditional risk factors, namely obesity, smoking, stress (physical and mental), sedentary lifestyle, heavy alcohol consumption, previous stroke and family history of stroke are rarely recognised in sub-Saharan Africa when issues about stroke are discussed. This observation is supported by findings in our work (**Table 5**) [30] in which the commonest risk factor experienced by stroke survivors was hypertension (73.1%), followed by light alcohol consumption (59.1%), smoking (31.5%) and diabetes mellitus (26.7%). It is to be noted that 15 (10.1%) of survivors had no knowledge of their hypertensive status and 28 (18.8%) none of their diabetic status. No survivor ever did blood cholesterol test. When asked to state factors that could contribute to stroke, just 19.4% mentioned hypertension while insignificant number, 0.7%, each mentioned diabetes, family history, poor diet (excessive salt intake, low vegetables and fruits intake), overweight/obesity and 2.0% mentioned high alcohol consumption. Interestingly, a large number attributed stroke in this part of the world to psychosocial stress (worry) (13.5%), spiritual attack (13.4%) and usual illness (9.4%); factors that have no empirical evidence. Still a very


#### **Table 5.**

*Survivors idea of causes of stroke, their advice for prevention and Pearson's correlation with gender.*

disturbing number (39.6%) had no idea what could cause a stroke. The aforementioned observations paint a gloomy picture of continued growth in stroke epidemic in this part of the world. If stroke survivors could be so ignorant of the cause of their stroke, then the possibility that they would engage in life-changing behaviours that would prevent future stroke is very remote. This study has strongly pointed to lack of awareness and community screening as the most pronounced common variable among the survivors. There is therefore, the strong need for awareness campaign and community screening, especially among post-stroke cases.

Attention should be focused on psychosocial stress as major contributing factor to stroke in this part of the world. We noted that a lot of things that contribute to pressures on the individual, including economic stress which comprises uncertainties in payment of salaries and allowances of workers to unemployment of breadwinners of families, social stress related to taking care of immediate and extended families, occupational stress resulting from uncertainty of daily outcome of market, farming,

## *Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke… DOI: http://dx.doi.org/10.5772/intechopen.104516*

and artisan jobs. All of these converge to cause high blood pressure. The more these psychological and social pressures mount, the more the tendency to high blood pressure and hypertension. These economic anomalies may not obtain in developed countries but they are commonplace in the underdeveloped ones. Prior reviews have also identified a number of psychosocial indicators as potential risk factors for the onset and progression of hypertension [31]. Besides ignorance of actual risk factors for stroke, it is also revealing to note that many individuals, even those who have suffered a stroke, do not know the signs of an impending stroke. In our unpublished work on identifying stroke signs among stroke survivors, very few could identify the 3 cardinal signs of impending stroke, FAST (F for facial palsy, A for arm palsy, S for speech palsy and T for time to call stroke ambulance). There should be emphasis on stroke warning signs, comprising sudden disarthria (speech impairment), haemiparesis, facial palsy, dizziness/vertigo, parasthaesia, acute headache, and visual impairment. People, particularly first-ever stroke cases, should learn to avoid extreme emotional reaction to sudden painful situations in order to avoid sudden spike in blood pressure, which could lead to instant stroke. In our work, some stroke survivors recounted how their stroke occurred immediately they received painful sad news of sudden loss of loved ones, property or goods. Stroke survivors should learn to take life easy and not overreact to avoid the risk of a second stroke. For a disease such as a stroke with high incidence, this study is severely underpowered to draw any meaningful conclusions. More work in this area is needed to augment the present observations.

## **4. Stroke Management in Herbal Centre (cultural/traditional hospital)**

For effective stroke prevention and post-stroke management in sub-Saharan Africa, due attention should be paid to the contribution of herbal centres in stroke management. This aspect of health delivery has been neglected for far too long. Yet traditional healing and herbal centres seem to matter a lot in stroke management in sub-Saharan Africa. Our work on satisfactory management of stroke by herbal homes, which is the first documented of such research, is quite informative [32]. In the study of 117 survivors who patronised Bebe Herbal Centre, we found that with the onset of stroke event, 72 (61.5%) went firstly to hospital before going to Bebe Centre, 25 (21.4%) went to other places, including prayer houses, before going to the Centre while 20 (17.1%) went firstly to the Centre. Regarding satisfactory recovery of the survivors, 116 (99.1%) said they had satisfactory recovery while attending Bebe Centre; and only one person (0.9%) said he had no recovery. Regarding time taken before the satisfactory recovery, 79 (67.5%) experienced it within 1 month of attending Bebe Centre while 73 (67.5%) had theirs after 1 month but under 6 months of attendance. All the seventy-two survivors (61.5%) that firstly went to hospital said they were not satisfied with treatment received in the hospitals while the remaining that did not go said hospital was not suitable for stroke management. None of the hospitals visited by the survivors was equipped with CT scan or MRI test machines. The consensus statement by the Helsingborg Conference demands computerised tomography for all patients with symptoms suggestive of stroke [33]. With CT scan and MRI test, ischaemic is differentiated from haemorrhagic stroke, and in case of ischaemic, recombinant tissue plasminogen activator (rt-PA) can be administered early enough to open up clogged arteries and allow reflow of blood to the injured cells, hence aiding quick recovery of the cells [34]. This benefit is only for patients who arrive stroke centres within 4.5 hours of stroke icthus. In our work, out of 72 (61.5%) survivors that


#### **Table 6.**

*Experience of stroke survivors with hospital and Bebe Centre, Pearson's Chi-Square test of association with sex.*

visited hospital first at the onset of stroke, 93.3% reached hospital within 6 hours of onset but none within 4.5 hours. Nonetheless, in the absence of CT and MRI in the hospitals visited, the survivors would not have benefitted even if they had arrived within the 4.5 hours window because of absence of neurodiagnostic machines. The

*Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke… DOI: http://dx.doi.org/10.5772/intechopen.104516*

above findings suggest two things namely the need for the establishment of stroke centres and units with neurodiagnostic equipment and expert personnel and the need for victims to arrive early at specialised hospitals within 4.5 hours of event. Unfortunately, only very few centers in sub-Saharan Africa have CT scan and MRI testing machines unlike in developed countries [35].

While considering factors that discourage stroke patients from seeking early hospital intervention, it should also be remembered that cultural beliefs have also become unintended setback in seeking behaviour among stroke patients in Nigeria [36]. Every ethnic group has a culture and tradition that may impact on their perception and understanding of an ailment. Stroke has been interpreted as a sign of the "gods" or "spirits" being angry [36]. Public education on risk factors will help diffuse these perceptions and hopefully increase patients being brought in for early hospital intervention in Nigeria [37], and other developing countries like Ghana [38], India [39] and even China [40]. Stroke rehabilitation services in Nigeria and most sub-Saharan Africa are limited to physiotherapy, only available in limited number of hospitals. They are rarely available outside hospital settings and certainly not in herbal homes. So there is urgent need to extend physiotherapy and other rehabilitation services to outside hospital settings, particularly to herbal homes to quicken recovery of stroke patients. The management of Bebe Centre, in our interaction, said their treatment was based purely on leaves and roots of trees and plants. If that is so, then there is the need for stroke survivors to embrace high vegetables and fruits in their diet. It is important to note the findings of Opie and Seedat [41] about risk factors for stroke in sub-Saharan Africa. They noted the impact of 6 topmost modifiable factors associated with stoke in descending order of population attributable risk (95% CI) to be hypertension 88.7%, dyslipidemia 48.2%, diabetes mellitus 22.6%, low green vegetable consumption 18.2%, stress 14.5% (**Table 6**).

## **5. Conclusions**

In conclusions, for serious and successful post-stroke effective rehabilitation in sub-Saharan Africa, there should be dedicated and sustained awareness education of stroke risk factors and warning signs, especially targeted at stroke survivors because they are at high risk of a second stroke. The awareness education should dispel erroneous beliefs about stroke in this region, emphasising the ugly relationship between psychosocial stress and hypertension as the major fuel for stroke in sub-Saharan Africa. Government should contribute to lowering stroke incidence by establishing stroke units, equipped with CT scan, MRI imaging, experts and emergency response ambulances for stroke distress calls. High risk individuals should be taught to be aware of FAST as cardinal warning signs leading eventually to stroke. Herbal centres should be upgraded to continue to provide alternative management of stroke as most stroke survivors are comfortable with treatment received from them. This also calls for the need for stroke patients to favour vegetable and fruit diets because of high fibre content for lowering diabetes and blood pressure, and for their high anti-oxidant content for mopping up excess radicals. Community Physiotherapists should be deployed to herbal centres to teach and train survivors for better treatment outcome. Overall, people, including stroke survivors, should not overstress themselves physically and emotionally, curtailing family and occupational pressures, subjecting themselves to metabolic screening. Overall, this work, conducted in one setting, is severely underpowered to draw any meaningful conclusions. The unique contribution, however, is

the observation of a relation with cultural belief in obtaining stroke care. More work is advocated among stroke survivors.

## **6. Strength and limitations and recommendations**

The strength of this baseline study is the observation of lack of awareness and community screening, especially among stroke survivors. A study of one herbal centre is severely underpowered to draw any generalised meaningful conclusions. There is need to extend study to more survivors, and more herbal centres. One limitation here was the difficulty in having research access to most Herbal centres. The second was that majority of the herbal centres lacked proper structural organisation to allow for meaningful research work. There was also our inability to obtain body-mass index of the survivors due to lack of cooperation in this regard. This baseline study of stroke in an herbal centre should instigate more work in this area, particularly in the sub-Saharan Africa, where patronage is on the increase.

## **Acknowledgements**

The authors wish to acknowledge the cooperation and kind support of Mr. Bebe and all staff of Bebe Herbal Centre, Umunomo, Ihitteafoukwu, Ahiazu Mbaise, Nigeria in the course of this work. We also acknowledge the contributions of Sunday Osonwa and Nkechi Chukwu in doing excellent interview work.

## **Sources of funding**

Funds for this study were contributed from the private budget of the authors. There was no outside funding support.

## **Conflict of interest**

The authors declare that there is no conflict of interest.

*Cultural Beliefs and Psychosocial Stress Are Unseen Potential Predisposing Factors for Stroke… DOI: http://dx.doi.org/10.5772/intechopen.104516*

## **Author details**

Polycarp Umunna Nwoha1,2\*, Florence Osita Okoro2,3, Emmanuel Chukwudi Nwoha2,4, Augustine Obi2,5, Chidinma Oluchi Nwoha2,6, Iyanu Ayoola1 , Nkeiru Christiana Ogoko2 , Peace Ngozi Nwoha2,7, Anna Idaguko2,8, Catherine Wali2,9, Nnenna Chinagozi-Amanze2,10 and Ifeoma H. Nwoha-Okpara2,11

1 Department of Anatomy and Cell Biology, Obafemi Awolowo University, Ile-Ife, Nigeria

2 Centre for Scientific Investigations and Training, Owerri, Imo State, Nigeria

3 School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, USA

4 Bucks New University, United Kingdom

5 Department of Anatomy and Neurobiology, Imo State University, Owerri, Nigeria

6 Health Centre, University of Medical Sciences, Ondo City, Ondo State, Nigeria

7 Celon Clinic, Ibeju-Lekki, Lagos State, Nigeria

8 Edo State University, Iyamho, Edo State, Nigeria

9 Baze University, Abuja, Nigeria

10 St. Catherine's Specialist Hospital Port Harcourt, Rivers State, Nigeria

11 Liviashammah Hospitals Ltd, Maraba, Nasarawa State, Nigeria

\*Address all correspondence to: polycarpnwoha@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 3
