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Walking the Talk to Reduce the Burden of Non-Communicable Diseases in Sub-Saharan Africa – A Focus on Stroke

by Bashar Abubakar

Non-Communicable Diseases (NCDs) are increasing globally, thanks to many factors, including sedentary lifestyles and unhealthy diets. One of such NCDs is stroke, globally responsible for five million deaths annually. In Africa, stroke is one of the leading causes of adult deaths, claiming more than 370,000 lives on the continent in 2016. Of particular concern is the higher prevalence of stroke among younger adults. A study in Nigeria and Ghana found a significantly high burden of stroke among individuals younger than 50 years. The high burden of stroke in sub-Saharan Africa is concerning. However, behind this burden could be multiple factors.

Poor health-seeking behaviour

Sub-Saharan Africa is home to 1.2 billion people with many cultures and beliefs and various social and economic backgrounds. In Europe or the United States, the first destination when seeking health care is usually at a formal healthcare setting, which in most cases is easily accessible. That is not always the case in several countries in sub-Saharan Africa. In Nigeria, for instance, which is the continent’s most populous country, seeking health care is influenced by culture, level of education, and socioeconomic status. Some may prefer to use herbs from traditional medicine healers, the contents and safety of which are not scientifically verified. Others may visit medicine vendors who sell medications with no medical knowledge or license to dispense the medicine. Yet others, for financial reasons, may decide not to seek care at all. The consequence of these healthcare approaches is missed diagnosis of impending and potentially fatal medical conditions. For example, an individual with symptoms of rheumatic heart disease, hypertension, or atherosclerosis may never get a correct diagnosis or appropriate treatment from either a traditional medicine healer or from a medicine vendor. These are all diseases that could contribute to stroke, especially hypertension, estimated to affect 46% of adults on the continent. With poor health-seeking behaviour, many people may not be aware of their condition and are not treated, increasing their risk of stroke.

Undiagnosed congenital heart defects and the influence of genetics

Congenital Heart Defects (CHDs), which can be diagnosed at birth or early in life, is a heart condition that could predispose to cardiovascular problems later in life, including stroke. The risk of developing a stroke is 11 times higher in young adults with CHDs than those without. It is estimated that about 500,000 children are born with CHDs every year in Africa, the majority in sub-Saharan Africa. Giving birth in a healthcare facility provides an opportunity to identify complications in a newborn early. However, on the continent, poor socioeconomic status, low education level, and cultural influences are some of the factors hindering giving birth at a healthcare facility. In Nigeria, for example, only about 39% of pregnant women give birth in healthcare facilities. In Ethiopia, it is just 32%.

A study conducted in the United States shows that the black race has higher risks of developing hypertension and other cardiovascular diseases and higher deaths than other races. Genetics has been suggested to be responsible for the increased cardiovascular disease risks among the black race. Untreated CHDs alone or other risk factors could contribute to the increased stroke cases in sub-Saharan Africa. These risk factors were magnified during the COVID-19 pandemic. Another study found that patients with ischemic stroke and COVID-19 are generally younger adults. The stroke severity is more significant in these patients and with worse morbidity and mortality than a similar patient population without COVID-19.

Lack of access to quality health care

Healthcare is expensive and to some in sub-Saharan Africa is not affordable. Furthermore, seeking care for chronic diseases such as hypertension, atherosclerosis, and diabetes could increase medical expenses due to the need for long-term treatment. For a continent without universal healthcare coverage in most countries, access to healthcare, especially for people in the lower socioeconomic level, is a huge task. Many other factors contribute to the lack of access to healthcare on the continent. These include poor infrastructures and an inadequate healthcare workforce due to insufficient funding. Low education also plays a role because it can influence healthcare-seeking behaviour—lack of access to healthcare results in undiagnosed stroke risk factors.

Additionally, among people with symptoms and signs of a stroke, receiving prompt treatment is critical to optimal outcomes. Emergency care for a patient with stroke symptoms or who has had a first stroke can prevent a secondary stroke. Time is vital and requires prompt admission to a hospital and medical care provided by a team of stroke specialists with access to appropriate equipment. However, stroke specialists and proper equipment are not readily available in several countries in sub-Saharan Africa. In addition, an inadequate transportation system delays hospital admission, increasing the risk of irreversible complications or death.

What sub-Saharan African countries are doing

Non-communicable diseases share common causes, including insufficient physical inactivity, an unhealthy diet, and smoking. The two major risk factors for stroke, hypertension, and atherosclerosis, are exacerbated by these health habits. Several sub-Saharan African countries have developed policies to mitigate the rising epidemic of NCDs. South Africa developed its NCDs strategic plan in 2013, which included increased taxation on tobacco products and sweetened drinks, and regulation on salt. Nigeria’s 2013 NCDs strategic plan focuses on preventing and managing NCDs at the primary healthcare level through increased awareness campaigns and routine screening for risk factors, including hypertension, diabetes, and obesity. However, most African countries are not imposing the WHO specified 75% tax on tobacco products; South Africa at 52% taxation on tobacco is the highest on the continent, Kenya 35% and Nigeria 20%.

A ray of hope

The continent’s most comprehensive and widely implemented plan is possibly the Rwanda NCDs Strategic Plan. Rwanda has implemented high taxation on sugary drinks, tobacco products, and alcohol and reduced salt and saturated fats in foods. In addition, Rwanda is also leveraging its community health workers to provide home palliative care to people suffering from NCDs. The health workers link patients and community healthcare centres for easy treatment follow-up, including blood pressure and blood sugar measurements.

Rwanda has a patient referral system from community health centres to district hospitals to specialized care hospitals. In cases of emergencies such as stroke, patients are quickly referred to receive timely care. Arguably the country’s most admirable approach to prevent NCDs, including stroke, is the car-free day program. On the first and third Sunday each month, between 7 AM and 10 AM, only pedestrians or bicycles are allowed in the country’s capital Kigali; cars, buses, and motorcycles are barred. In addition, on these days, there are mobile medical stations at strategic places where screening for NCDs such as hypertension, diabetes, and breast cancer are offered. The car-free day, which started in 2016 in Kigali, is now being adopted by other African countries to prevent NCDs.

To control the high burden of stroke and, to a larger extent, achieve Sustainable Development Goal (SDG 3.4), countries in sub-Saharan Africa must begin to walk the talk. Developing strategies to reduce NCDs is a good start, but only implementing those strategies will make an impact. Click here to learn more about stroke, its risk factors, prevention, and treatment.

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The Missing Link to Improved Health Outcomes (MiLHO) Initiative provides online CME courses that recognize and consider Africa’s unique medical practice environment by developing evidence-based and relevant content. The initiative aims to expand opportunities for CME to assist healthcare practitioners in staying current with evidence supporting patient care in their local setting. Courses are certified by the CPD Certification Service. Visit the MiLHO Initiative to learn more.