Abstract
Worldwide, most deaths from stroke occur in low- and middle-income countries (1). Overall stroke mortality at one month is about 30% in Africa, much higher than the 20% found in much older populations in the rest of the world (2). There are limited resources for stroke care and a lack of rehabilitation facilities in developing countries particularly in rural areas. There is an urgent need for an adaptable cost-effective approach to community-based stroke care after a patient is discharged from hospital. Our group sought to evaluate discharge planning and continuity of care of stroke patients in the community following discharge from a remote rural hospital in South Africa (3).
Initially, a survey was undertaken of the local demographics and resources available to stroke patients and their caregivers in this rural community in the Ingwavuma region of Northern KwaZulu Natal, South Africa. The local 246-bed hospital at which our study was based supported a population of over 116000. The local community was defined by high levels of poverty with an unemployment rate of around 60%. Most employed people in the area earned less than $320 per month. The HIV rate among antenatal clinic attendees in the health district was 39·8% in 2007. The average life expectancy in the general population was 39·1 years for men and 41·7 years for women.
Thirty consecutive stroke patients from the local hospital were assessed clinically at time of discharge. Patients were reassessed 3 months after discharge in their homes by a trained field worker using a structured questionnaire. All the patients were discharged into family care as there was no stroke rehabilitation facility available to the community. Two-thirds of all families received no stroke education before discharge. Hypertension was by far the most important risk factor, present in 80% of our cohort. At time of discharge 27 (90%) were either bed or chair bound. Of the 30 patients recruited, 20 (66·7%) were alive at 3 months, nine (30%) were deceased, and one was lost to follow-up. At 3 months, 55% of survivors were independently mobile as compared with 10% at discharge. A total of 13 (65%) of the surviving patients in our cohort were visited by home-based carers. Although most survivors showed some degree of functional improvement, their quality of life remained significantly impaired on self-assessment scores. Caregivers were poorly supported and reported high levels of strain. Compliance rates on aspirin were poor.
Any model of community-based stroke care in rural South African settings should include a system of stroke education for caregivers and patients, and should implement structures that strengthen the level of home-based care and training. Awareness of stroke and cardiovascular risk factors, particularly hypertension, needs to be fostered through improved community education. Nurse practitioners and home-based carers could play an important role in checking blood pressure and monitoring treatment and compliance after discharge from hospital. In the absence of adequate numbers of health workers available for rehabilitation in such communities, the caregivers are likely candidates to adopt this surrogate role and could be trained to be more active in the rehabilitation process. These relatively simple interventions have potential to improve stroke outcomes and relieve caregiver strain in such settings.