Stroke In Middle-income Countries Research Articles

Determinants of access to rehabilitation professionals by individuals with stroke in the first six months after hospital discharge in Brazil: a study based on the Andersen model

ABSTRACT Background determinants of accessto rehabilitation professionals after stroke in middle-income countries, wherethe burden of this disease is higher, are little known. Objectives To identify the determinants of accessto rehabilitation professionals by individuals with stroke at one, three, andsix months after hospital discharge in Brazil and compare referral and accessrates after discharge. Methods Longitudinal and prospective study, withindividuals with primary stroke, without previous disabilities. At hospitaldischarge, the number of rehabilitation professionals referred by themultidisciplinary team was recorded. The possible determinants of access,according to Andersen’s model, were: a) predisposing factors: age, sex,education levels, and belief that they could improve with treatment; b) needfactors: stroke severity, levels of disability; c) enabling factors:socioeconomic status, disposable income for health care, and quality of careprovided by rehabilitation professionals. One, three, and six months afterhospital discharge, individuals were contacted to identify which rehabilitationprofessionals were accessed. Multiple linear regression model and Wilcoxon tests were used(α=5%). Results 201 individuals were included.Disability levels and stroke severity explained 31%, 34%, and 39% (p<0.01)of access at one, three, and six months after hospital discharge, respectively.In all periods, there was less access than that recommended at the time ofhospital discharge (p<0.01). Conclusion Need factors (disability levels andstroke severity) were determinants of access in all assessed periods. Inaddition, in all periods, the comprehensiveness of care for individuals withstroke was compromised.

Elevated Depressive Symptoms and the Risk of Stroke among the Mexican Older Population.

Several longitudinal studies in high-income countries suggest that depression increases stroke risk. However, few prior studies have evaluated this association in low- and middle-income countries (LMICs), where rapidly aging populations may have markedly different vascular risk profiles. Prospective cohort study. The Mexican Health and Aging Study is a national population-based study of older adults in Mexico. A total of 10,693 Mexican adults aged 50 and older enrolled in 2001 with no history of prior stroke. Depressive symptoms were assessed with a modified 9-item Centers for Epidemiologic Studies Depression Scale (elevated depressive symptom cutoff ≥5) in 2001 and 2003. We evaluated associations between baseline and short-term (2-year) changes in elevated depressive symptoms (categorized as stable low, recently remitted, recent-onset, or stable high symptoms) with incident self-reported or next-of-kin reported doctor-diagnosed stroke through 2015 using Cox proportional hazards models and sensitivity analyses applying inverse probability weights. Over an average follow-up of 11.4 years (standard deviation = 4.2), 10,693 respondents reported 546 incident strokes. Individuals with elevated baseline depressive symptoms experienced a moderately higher hazard of incident stroke (hazard ratio [HR] = 1.13; 95% confidence interval [CI] = .95-1.36) compared with those without elevated baseline depressive symptoms. In analyses of short-term changes in elevated depressive symptoms (n = 8,808; 414 incident stokes), participants with recent-onset (HR = 1.38; 95% CI = 1.06-1.81) or stable high (HR = 1.42; 95% CI = 1.10-1.84) elevated depressive symptoms had a greater hazard of incident stroke compared to those with stable low/no depressive symptoms, whereas recently remitted (HR = 1.01; 95% CI = .74-1.37) symptoms was not associated with stroke hazard. Strategies to reduce depressive symptoms merit evaluation as approaches to prevent stroke in middle-income countries. Findings are similar to those in high-income countries but should be replicated in other LMICs.

Past, Present, and Future of Stroke in Middle-Income Countries: The Brazilian Experience

Stroke is one of the major public health challenges in middle-income countries. Brazil is the world's sixth largest economy but was clearly behind the milestones in the fight against stroke, which is the leading cause of death and disability in the country. Nevertheless, many initiatives are now reshaping stroke prevention, care, and rehabilitation in the country. The present article discusses the evolution of stroke care in Brazil over the last decade. We describe the main characteristics of stroke care before 2008; a pilot study in a Southern Brazilian city between 2008 and 2010, the Brazilian Stroke Project initiative; and the 2012 National Stroke Policy Act. The National Stroke Project was followed by a major increased on the number of stroke center in the country. The key elements of the 2012 National Stroke Policy Act included: definition of the requirements and levels of stroke centers; improved reimbursement for stroke care; promotion of stroke telemedicine; definition of the Line of Stroke Care (to integrate available resources and other health programs); increased funding for stroke rehabilitation; funding for training of healthcare professionals and initiatives to increase awareness about stroke within the population. The evolution of stroke care in Brazil over the last decade is a pathway that exemplifies the challenges that middle-income countries have to face in order to improve stroke prevention, treatment and rehabilitation. The reported Brazilian experience can be extrapolated to understand the past, present, and future of stroke care in middle-income countries.