**2. Epidemiology of stroke**

Projected figures indicate that stroke is reaching epidemic proportions due to increased non-communicable diseases and HIV, and will be the number one killer by 2020 [9–11]. According to the Centre for Disease Control and Prevention, the incidence of stroke has increased by 100% in middle-to-low-income countries since 2002 [10, 12]. Although this increase is related to the increasing burden of cardiovascular risk factors and the ageing population, infectious causes of stroke are also thought to contribute. According to the World Health Organisation, 15 million people suffer from a stroke worldwide each year, and of these, 5 million die, 5 million fully recover and another 5 million are permanently disabled and need assistance with activities of daily living [13]. Low- and middle-income countries have 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years [14, 15] consequently making stroke the major cause of disability in Sub-Saharan Africa [16].

The incidence of stroke varies by race and country [17]. In SSA, most cases of stroke occur in relatively young people (mean age < 60 years in most studies), some 10–15 years younger than patients with stroke in developed countries [11, 17–21]. Earlier, Feigin and colleagues had found the mean ages for men and women to be 70 and 75 years respectively [22]. In Chile, the mean age was reported to be 66.4 years [23]; while it was found it to be less than 50 years for sub Saharan Africa [24]. This was in line with findings in Malawi where the mean age was 54.2 ± 16.9 years [11]. A Gambian study found the mean age to be 58 years (10–15 years) younger than patients in developed countries [25]; as is the case with Brazil where the mean age was 64.1 years [26]. In Ghana the mean age of stroke patients is 63.68 years and the male to female ratio is 1:0.96 [27]. In Sudan the mean age was found to be 56.61 [28]. However in Zimbabwe there were more females than male [5, 20, 29].

It is hoped that improved post stroke care, through caregiver support and training would reduce morbidity and mortality among stroke survivors and improve caregiver outcomes in low income countries. Information on causes and prevention of subsequent strokes may be important to give during caregiver support so as to empower them and improve compliance with medications.

## **3. Length of hospital stay (LOS)**

Generally, LOS in African hospitals and other developing countries is short and range from 2 to 30 days [20, 30–37]. Shorter LOS may be indicative of fewer

**317**

als and finances [34, 45].

*Supporting Survivors of Stroke in Low Resource Settings DOI: http://dx.doi.org/10.5772/intechopen.86900*

information about their sick relative.

tives with stroke and are not trained to care [42].

rehabilitation sessions and reduced impact on stroke survivor outcomes [6]. In 2012, 6 ± 4 days were reported in South Africa [32]. This was however lower than the 14 days previously reported for public hospitals in the same country in 2002 [34]. Other authors reported up to 30 days of hospital stay in South Africa [37]. LOS has a bearing on the state at which patients are discharged in terms of function. This may mean that the stroke survivor will still need care, and within 2 days, caregivers may not have been trained on care or even have met rehabilitation personnel to get

There are other reasons too. In most instances, survivors of stroke and their relatives cannot afford long LOS as this means higher hospital bills [33–35]. Hospitals also need beds for other ill patients so once patient is stable, they are discharged home to the care of relatives more likely due to pressure for beds as survivors of stroke do not pay in the public hospitals in many developing countries [36, 38, 39]. Furthermore, most patients would have presented late to hospital due to several factors and the stroke would have progressed, and condition worsened [5, 40]. This is not unique to African countries as this was also the case in Jordan where 32% of the population was not covered by any health and social insurance, and also spent less time in hospital [41]. Short hospital stay also means that patients are discharged before they are fully functional [39, 42]. This may be an indication that patients are kept in hospital until they are medically stable but not for rehabilitation [6]. As in the Zimbabwean setting, there may be no community services available to cater for the stroke survivors and their caregivers in most instances. Even in developed countries, it was found that caregivers lack knowledge on how to care for their rela-

Survivors do better with an organised, multidisciplinary approach to treatment

The short length of stay in most hospitals in developing countries, (on average, up to 2 weeks) may be too short considering the time required to restore function post stroke. After the survivors of stroke are stable in terms of blood pressure, they are discharged back into the community usually with a disability, to the care of their family who have to offer physical, emotional and psychological support. This is indicative of a situation where survivors are discharged home to families who may not be fully prepared to cope with the changes that have occurred in the stroke survivors. This scenario has been going on for a long time even in middle income countries like South Africa [32, 34, 46, 47]. It is therefore necessary to involve caregivers in the pre-discharge planning of stroke survivors as failure to do so may

in which they and the caregivers are a part, hence the need to offer support to caregivers [7, 43]. The ideal management of stroke involves several aspects although these are not uniform in different countries. These include rapid response systems to stroke where patients are seen within 3 hours and proper diagnosis is made which includes Computerised Tomography (CT) scans and Magnetic Resonance Imaging (MRI). Patients are also put in Stroke units for transition of care and given thrombolysis. Once stable they start rehabilitation treatment before being discharged home or to institutions. However, well-organised stroke services are virtually absent in the government sector in most developing countries [44]. For example, in Zimbabwe, current stroke management is hospital-based because most of the hospitals are acute care facilities and are not designed to provide rehabilitation in the wards beyond patient's discharge from the acute ward. From experience, rapid response is not available as most patients are not able to present to hospital on time after stroke. Most survivors also cannot afford the diagnostic procedures hence physicians depend on clinical symptoms for diagnosis. This is also compounded by a high staff turn-over making it difficult for patients to get consistent care. Challenges may then occur with coordination, availability of health care profession-

#### *Supporting Survivors of Stroke in Low Resource Settings DOI: http://dx.doi.org/10.5772/intechopen.86900*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

both the survivors and caregivers [7].

using Kern's six step model [8].

**2. Epidemiology of stroke**

Saharan Africa [16].

improve functional outcomes among survivors of stroke and quality of life among

It also gives an overview of the extent and consequences of the stroke problem in low resource settings, length of hospital stay and the implications on stroke survivors and their caregivers, and the impact of stroke in terms of mortality and morbidity. Furthermore, the chapter looks at the rehabilitation of stroke patients, the impact of stroke on caregivers, and how patient and caregiver training can improve outcomes for both the patient and caregiver in low resource settings. In addition, it highlights the reason why supporting survivors of stroke and their caregivers are important in these settings considering that there are no consistent hospital-based services to support them. Finally, it outlines how a training programme for stroke patients and their caregivers can be developed

Projected figures indicate that stroke is reaching epidemic proportions due to increased non-communicable diseases and HIV, and will be the number one killer by 2020 [9–11]. According to the Centre for Disease Control and Prevention, the incidence of stroke has increased by 100% in middle-to-low-income countries since 2002 [10, 12]. Although this increase is related to the increasing burden of cardiovascular risk factors and the ageing population, infectious causes of stroke are also thought to contribute. According to the World Health Organisation, 15 million people suffer from a stroke worldwide each year, and of these, 5 million die, 5 million fully recover and another 5 million are permanently disabled and need assistance with activities of daily living [13]. Low- and middle-income countries have 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years [14, 15] consequently making stroke the major cause of disability in Sub-

The incidence of stroke varies by race and country [17]. In SSA, most cases of stroke occur in relatively young people (mean age < 60 years in most studies), some 10–15 years younger than patients with stroke in developed countries [11, 17–21]. Earlier, Feigin and colleagues had found the mean ages for men and women to be 70 and 75 years respectively [22]. In Chile, the mean age was reported to be 66.4 years [23]; while it was found it to be less than 50 years for sub Saharan Africa [24]. This was in line with findings in Malawi where the mean age was 54.2 ± 16.9 years [11]. A Gambian study found the mean age to be 58 years (10–15 years) younger than patients in developed countries [25]; as is the case with Brazil where the mean age was 64.1 years [26]. In Ghana the mean age of stroke patients is 63.68 years and the male to female ratio is 1:0.96 [27]. In Sudan the mean age was found to be 56.61 [28].

It is hoped that improved post stroke care, through caregiver support and training would reduce morbidity and mortality among stroke survivors and improve caregiver outcomes in low income countries. Information on causes and prevention of subsequent strokes may be important to give during caregiver support so as to

Generally, LOS in African hospitals and other developing countries is short and range from 2 to 30 days [20, 30–37]. Shorter LOS may be indicative of fewer

However in Zimbabwe there were more females than male [5, 20, 29].

empower them and improve compliance with medications.

**3. Length of hospital stay (LOS)**

**316**

rehabilitation sessions and reduced impact on stroke survivor outcomes [6]. In 2012, 6 ± 4 days were reported in South Africa [32]. This was however lower than the 14 days previously reported for public hospitals in the same country in 2002 [34]. Other authors reported up to 30 days of hospital stay in South Africa [37]. LOS has a bearing on the state at which patients are discharged in terms of function. This may mean that the stroke survivor will still need care, and within 2 days, caregivers may not have been trained on care or even have met rehabilitation personnel to get information about their sick relative.

There are other reasons too. In most instances, survivors of stroke and their relatives cannot afford long LOS as this means higher hospital bills [33–35]. Hospitals also need beds for other ill patients so once patient is stable, they are discharged home to the care of relatives more likely due to pressure for beds as survivors of stroke do not pay in the public hospitals in many developing countries [36, 38, 39]. Furthermore, most patients would have presented late to hospital due to several factors and the stroke would have progressed, and condition worsened [5, 40]. This is not unique to African countries as this was also the case in Jordan where 32% of the population was not covered by any health and social insurance, and also spent less time in hospital [41]. Short hospital stay also means that patients are discharged before they are fully functional [39, 42]. This may be an indication that patients are kept in hospital until they are medically stable but not for rehabilitation [6]. As in the Zimbabwean setting, there may be no community services available to cater for the stroke survivors and their caregivers in most instances. Even in developed countries, it was found that caregivers lack knowledge on how to care for their relatives with stroke and are not trained to care [42].

Survivors do better with an organised, multidisciplinary approach to treatment in which they and the caregivers are a part, hence the need to offer support to caregivers [7, 43]. The ideal management of stroke involves several aspects although these are not uniform in different countries. These include rapid response systems to stroke where patients are seen within 3 hours and proper diagnosis is made which includes Computerised Tomography (CT) scans and Magnetic Resonance Imaging (MRI). Patients are also put in Stroke units for transition of care and given thrombolysis. Once stable they start rehabilitation treatment before being discharged home or to institutions. However, well-organised stroke services are virtually absent in the government sector in most developing countries [44]. For example, in Zimbabwe, current stroke management is hospital-based because most of the hospitals are acute care facilities and are not designed to provide rehabilitation in the wards beyond patient's discharge from the acute ward. From experience, rapid response is not available as most patients are not able to present to hospital on time after stroke. Most survivors also cannot afford the diagnostic procedures hence physicians depend on clinical symptoms for diagnosis. This is also compounded by a high staff turn-over making it difficult for patients to get consistent care. Challenges may then occur with coordination, availability of health care professionals and finances [34, 45].

The short length of stay in most hospitals in developing countries, (on average, up to 2 weeks) may be too short considering the time required to restore function post stroke. After the survivors of stroke are stable in terms of blood pressure, they are discharged back into the community usually with a disability, to the care of their family who have to offer physical, emotional and psychological support. This is indicative of a situation where survivors are discharged home to families who may not be fully prepared to cope with the changes that have occurred in the stroke survivors. This scenario has been going on for a long time even in middle income countries like South Africa [32, 34, 46, 47]. It is therefore necessary to involve caregivers in the pre-discharge planning of stroke survivors as failure to do so may

result in unsatisfactory care-giving as a result of higher caregiver burden and poor quality of life for both the stroke survivor and the caregiver.

It is not clear if during the hospitalisation period the rehabilitation personnel in developing countries meet with the caregivers of people who have survived a stroke to discuss ongoing progress and pre-discharge plans. Maybe this could facilitate caregivers' access to information on stroke and its consequences, prevention and management options.

In Zimbabwe, management of survivors of stroke involves acute care in hospitals and not much of the rapid response and thrombolytic therapy in government hospitals. Even in private hospitals the costs of thrombolytic therapies are prohibitive. Most survivors cannot afford the CT scans and MRIs either. Once survivors are medically stable the rehabilitation professionals intervene whilst patients are still admitted. However, rehabilitation systems to support survivors of stroke have also not been fully developed. This means that hospital management of survivors of stroke is also deficient. Survivors are then discharged home with very minimal preparation and not notwithstanding the challenges of bringing them back for review. There are also no call centres in communities to assist, hence no support systems for caregivers in communities.
