Publications by authors named "Ezinne Uvere"

24 Publications

  • Page 1 of 1

A Novel Afrocentric Stroke Risk Assessment Score: Models from the Siren Study.

J Stroke Cerebrovasc Dis 2021 Jul 28;30(10):106003. Epub 2021 Jul 28.

Medical University of South Carolina, SC, USA.

Background: Stroke risk can be quantified using risk factors whose effect sizes vary by geography and race. No stroke risk assessment tool exists to estimate aggregate stroke risk for indigenous African.

Objectives: To develop Afrocentric risk-scoring models for stroke occurrence.

Materials And Methods: We evaluated 3533 radiologically confirmed West African stroke cases paired 1:1 with age-, and sex-matched stroke-free controls in the SIREN study. The 7,066 subjects were randomly split into a training and testing set at the ratio of 85:15. Conditional logistic regression models were constructed by including 17 putative factors linked to stroke occurrence using the training set. Significant risk factors were assigned constant and standardized statistical weights based on regression coefficients (β) to develop an additive risk scoring system on a scale of 0-100%. Using the testing set, Receiver Operating Characteristics (ROC) curves were constructed to obtain a total score to serve as cut-off to discriminate between cases and controls. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at this cut-off.

Results: For stroke occurrence, we identified 15 traditional vascular factors. Cohen's kappa for validity was maximal at a total risk score of 56% using both statistical weighting approaches to risk quantification and in both datasets. The risk score had a predictive accuracy of 76% (95%CI: 74-79%), sensitivity of 80.3%, specificity of 63.0%, PPV of 68.5% and NPV of 76.2% in the test dataset. For ischemic strokes, 12 risk factors had predictive accuracy of 78% (95%CI: 74-81%). For hemorrhagic strokes, 7 factors had a predictive accuracy of 79% (95%CI: 73-84%).

Conclusions: The SIREN models quantify aggregate stroke risk in indigenous West Africans with good accuracy. Prospective studies are needed to validate this instrument for stroke prevention.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106003DOI Listing
July 2021

Sexual Abuse among Female Adolescent Hawkers in Selected Markets in Ibadan, Nigeria.

J Child Sex Abus 2021 Jul 2:1-18. Epub 2021 Jul 2.

Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Involvement of a child or adolescent in a sexual activity is a global public health challenge. This cross-sectional study documented experiences of sexual abuse (SA) among Female Adolescent Hawkers (FAHs) in selected markets in Ibadan, Nigeria. Data were collected from 410 FAHs using interviewer-administered questionnaire. Descriptive statistics, chi-square and logistic regression were used to analyze the data at < .05 significance level. Mean age of respondents was 14.4 ± 1.76 years. The majority (69.0%) have ever experienced at least a form of SA, of which 68.3% occurred 3 months preceding the study. Having had sex and boyfriends were predictors of SA. Male customers (98.6%), traders (98.2%) and peers (69.4%) were major perpetrators. About 67.5% of victims of SA did not seek help. Sexual abuse is a major problem among FAHs. Age-appropriate sexuality education and life-building skills interventions should be targeted at FAHs while advocacy is recommended for caregivers and market stakeholders.
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http://dx.doi.org/10.1080/10538712.2021.1931613DOI Listing
July 2021

Frequency and factors associated with post-stroke seizures in a large multicenter study in West Africa.

J Neurol Sci 2021 Aug 9;427:117535. Epub 2021 Jun 9.

Federal Medical Centre, Abeokuta, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria.

Background: Post-stroke seizures (PSS) are associated with significant morbidity and mortality across the globe. There is a paucity of data on PSS in Africa.

Purpose: To assess the frequency and factors associated with PSS by stroke types across 15 hospitals in Nigeria and Ghana.

Methods: We analyzed data on all stroke cases recruited into the Stroke Investigative Research and Educational Network (SIREN). We included adults aged ≥18 years with radiologically confirmed ischemic stroke (IS) or intracerebral hemorrhage (ICH). PSS were defined as acute symptomatic seizures occurring at stroke onset and/or during acute hospitalization up until discharge. We used logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

Results: Among 3344 stroke patients, 499 (14.9%) had PSS (95% CI: 13.7-16.2%). The mean duration of admission in days for those with PSS vs no PSS was 17.4 ± 28.6 vs 15.9 ± 24.7, p = 0.72. There were 294(14.1%) PSS among 2091 ischemic strokes and 159(17.7%) among 897 with ICH, p = 0.01. The factors associated with PSS occurrence were age < 50 years, aOR of 1.59 (1.08-2.33), National Institute of Health Stroke Score (NIHSS), 1.29 (1.16-1.42) for each 5 units rise and white cell count 1.07 (1.01-1.13) for each 10^3 mm rise. Factors associated with PSS in ischemic were NIHSS score, aOR of 1.17 (1.04-1.31) and infarct volume of 10-30 cm aOR of 2.17(1.37-3.45). Among ICH, associated factors were alcohol use 5.91 (2.11-16.55) and lobar bleeds 2.22 (1.03-4.82).

Conclusion: The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.
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http://dx.doi.org/10.1016/j.jns.2021.117535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325635PMC
August 2021

Factors associated with hypertension among stroke-free indigenous Africans: Findings from the SIREN study.

J Clin Hypertens (Greenwich) 2021 04 23;23(4):773-784. Epub 2021 Jan 23.

Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Hypertension is one of the most important risk factors for stroke and cardiovascular diseases (CVD) globally. Understanding risk factors for hypertension among individuals with matching characteristics with stroke patients may inform primordial/primary prevention of hypertension and stroke among them. This study identified the risk factors for hypertension among community-dwelling stroke-free population in Ghana and Nigeria. Data for 4267 community-dwelling stroke-free controls subjects in the Stroke Investigative Research and Education Network (SIREN) study in Nigeria and Ghana were used. Participants were comprehensively assessed for sociodemographic, lifestyle and metabolic factors using standard methods. Hypertension was defined as a previous diagnosis by a health professional or use of an anti-hypertensive drug or mean systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Logistic regression analysis was used to estimate adjusted odds ratios (aOR) of hypertension and their 95% confidence intervals (CI) at p < .05. Overall, 56.7% of the participants were hypertensive with a higher proportion among respondents aged ≥60 years (53.0%). Factors including physical inactivity (aOR: 9.09; 95% CI: 4.03 to 20.53, p < .0001), diabetes (aOR: 2.70; CI: 1.91 to 3.82, p < .0001), being ≥60 years (aOR: 2.22; 95% CI: 1.78 to 2.77, p < .0001), and family history of CVD (aOR 2.02; CI: 1.59 to 2.56, p < .0001) were associated with increased aOR of hypertension. Lifestyle factors were associated with hypertension in the current population of community-dwelling stroke-free controls in west Africa. Community-oriented interventions to address sedentary lifestyles may benefit this population and reduce/prevent hypertension and stroke among them.
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http://dx.doi.org/10.1111/jch.14183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263562PMC
April 2021

Gender and educational attainment influence willingness to donate organs among older Nigerians: a questionnaire survey.

Pan Afr Med J 2020 17;36:288. Epub 2020 Aug 17.

Department of Health Promotion and Education, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria.

Introduction: disparity between the demand for and the supply of organs for transplantation remains a major public health issue of global concern. This study evaluated the knowledge and determinants of willingness to donate organs among outpatient clinic attendees in a Nigerian teaching hospital.

Methods: a 43-item semi-structured interviewer-administered questionnaire was designed to assess awareness and willingness of individuals attending Neurology, Psychiatry and Geriatrics Outpatient clinics to donate bodily organs for transplantation. Association between participants' characteristics and willingness towards organ donation was investigated using logistic regression models.

Results: a total of 412 participants were interviewed and mean age was 46.3 (16.1) years. There were 229 (55.6%) females and 92.5% had at least 6 years of formal education. Overall, 330 (80.1%) were aware of donation of at least one organ for transplantation purposes but only 139 (33.7%) were willing to donate organ. In analyses, adjusting for sex, marital status, family setting and educational status, male gender AOR [2.066(1.331-3.2016)] secondary education [AOR 5.57 (1.205-25.729) p= 0.028] and post-secondary education [AOR-6.98 (1.537-31.702) p= 0.012 were independently associated with willingness towards organ donation.

Conclusion: the survey revealed high level of awareness but poor willingness towards organ donation among older Nigerians attending outpatient clinics of a premier tertiary hospital. Male gender and educational attainment were significantly associated with willingness to donate. Educational programs that particularly target women and less educated older Nigerians are needed to promote organ donation in Nigeria.
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http://dx.doi.org/10.11604/pamj.2020.36.288.21125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572693PMC
January 2021

Unraveling the Ethical, Legal, and Social Implications of Neurobiobanking and Stroke Genomic Research in Africa: A Study Protocol of the African Neurobiobank for Precision Stroke Medicine ELSI Project.

Int J Qual Methods 2020 Jan-Dec;19. Epub 2020 Jun 23.

Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria.

The ethical, legal, and social implications (ELSI) of emerging neurobiobanks and data resources are unclear in an African scientific landscape with unique cultural, linguistic, and belief systems. The overarching goal of the African Neurobiobank for Precision Stroke Medicine-ELSI Project is to identify, examine, and develop novel approaches to address ELSI issues of biobanking and stroke genomic research in sub-Saharan Africa (SSA). To accomplish the goal we will (1) explore knowledge, attitude, perceptions, barriers, and facilitators influencing ELSI issues related to biobanking and stroke genomic research; (2) use information obtained to craft a community intervention program focused on ELSI issues; and (3) build capacity and careers related to genomics and biobanking for effective client/community engagement while enhancing regulatory, governance, and implementation competences in biobanking science in SSA. A community-based participatory research and mixed-methodological approach, focused on various levels of the social ecological model, will be used to identify and examine relevant ELSI issues. Contextual intervention tools, platforms, and practices will be developed to enhance community understanding and participation in stroke biobanking and genomics research activities while facilitating enduring trust, and equitable and fair utilization of biobanking resources for genetic and trans-omics research. A concurrent capacity building program related to genetic counseling and biobanking will be implemented for early career researchers. The huge potential for neurobiobanking and genomics research in Africa to advance precision medicine applicable to stroke and other neurological disorders requires addressing ELSI challenges while building sustainable research, career, and regulatory capacities in trans-omics and biobanking science.
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http://dx.doi.org/10.1177/1609406920923194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284747PMC
June 2020

Randomized Trial of an Intervention to Improve Blood Pressure Control in Stroke Survivors.

Circ Cardiovasc Qual Outcomes 2019 12 6;12(12):e005904. Epub 2019 Dec 6.

Department of Neurology, University of California, San Francisco (B.O.).

Background: We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke.

Methods And Results: Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mm Hg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mm Hg, =0.82). In an exploratory analysis of subjects with baseline BP >140/90 mm Hg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mm Hg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mm Hg at 12 months.

Conclusions: THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivors.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01900756.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.005904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139215PMC
December 2019

Gender differential in inclination to donate brain for research among Nigerians: the IBADAN Brain Bank Project.

Cell Tissue Bank 2019 Jun 26;20(2):297-306. Epub 2019 Apr 26.

Department of Health Promotion and Education, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Background: Laboratory-based studies of neurological disease patterns and mechanisms are sparse in sub-Saharan Africa. However, availability of human brain tissue resource depends on willingness towards brain donation. This study evaluated the level of willingness among outpatient clinic attendees in a Nigerian teaching hospital.

Methods: Under the auspices of the IBADAN Brain Bank Project, a 43-item semi-structured interviewer-administered questionnaire was designed to evaluate knowledge, attitude, and beliefs of individuals attending Neurology, Psychiatry and Geriatrics Outpatient clinics regarding willingness to donate brain for research. Association between participants characteristics and willingness towards brain donation was investigated using logistic regression models. Analysis was conducted using Stata SE version 12.0.

Results: A total of 412 participants were interviewed. Their mean age was 46.3 (16.1) years. 229 (55.6%) were females and 92.5% had at least 6 years of formal education. Overall, 109 (26.7%) were willing to donate brains for research. In analyses adjusting for educational status, religion, ethnicity, marital status and family setting, male sex showed independent association with willingness towards brain donation OR (95% CI) 1.7 (1.08-2.69), p = 0.023. Participants suggested public engagement and education through mass media (including social media) and involvement of religious and community leaders as important interventions to improve awareness and willingness towards brain donation.

Conclusion: The survey revealed low willingness among outpatient clinic attendees to donate brain for research, although men were more inclined to donate. It is imperative to institute public engagement and educational interventions in order to improve consent for brain donation for research.
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http://dx.doi.org/10.1007/s10561-019-09769-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556418PMC
June 2019

The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma.

PLoS One 2019 8;14(4):e0214454. Epub 2019 Apr 8.

School of Public Health, Imperial College London, London, United Kingdom.

Introduction: Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process.

Methods: Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level.

Results: Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process.

Conclusions: Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214454PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453477PMC
December 2019

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action.

PLoS One 2018 16;13(11):e0206548. Epub 2018 Nov 16.

University of Ghana Medical School, Accra, Ghana.

Introduction: Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.

Purpose: In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.

Methods: Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman's Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.

Results And Discussion: The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206548PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239297PMC
April 2019

Knowledge, attitudes and practices of West Africans on genetic studies of stroke: Evidence from the SIREN Study.

Int J Stroke 2019 01 24;14(1):69-79. Epub 2018 Jul 24.

7 Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria.

Background: It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa.

Objective: To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies.

Methods: A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed.

Results: Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25-1.81) and a family history of stroke (OR 1.20, 1.03-1.39) while Islamic religion (OR=0.82, CI: 0.72-0.94), being currently unmarried (OR = 0.81, CI: 0.70-0.92), and alcohol use (OR = 0.78, CI: 0.67-0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03-1.74) but inversely associated with a medical history of high blood pressure (OR = 0.79, 0.65-0.96).

Conclusion: To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.
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http://dx.doi.org/10.1177/1747493018790059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325169PMC
January 2019

Biobanking in a Challenging African Environment: Unique Experience from the SIREN Project.

Biopreserv Biobank 2018 Jun 7;16(3):217-232. Epub 2018 May 7.

Neurology Unit, Department of Medicine, Federal Medical Center, Umuahia, Nigeria.

Africa was previously insufficiently represented in the emerging discipline of biobanking despite commendable early efforts. However, with the Human, Heredity, and Health in Africa (H3Africa) initiative, biorepository science has been bolstered, regional biobanks are springing up, and awareness about biobanks is growing on the continent. The Stroke Investigative Research and Educational Network (SIREN) project is a transnational, multicenter, hospital and community-based study involving over 3000 cases and 3000 controls recruited from 16 sites in Ghana and Nigeria. SIREN aims to explore and unravel the genetic and environmental factors that interact to produce the peculiar phenotypic and clinical characteristics of stroke as seen in people of African ancestry and facilitate the development of new diagnostics, therapeutics, and preventative strategies. The aim of this article is to describe our experience with the development of the procedure for collection, processing, storage, and shipment of biological samples (blood, serum, plasma, buffy coat, red cell concentrates, and DNA) and brain imaging across coordinating and participating sites within the SIREN Project. The SIREN network was initiated in 2014 with support and funding from the H3Africa Initiative. The SIREN Biobank currently has 3015 brain images, 92,950 blood fractions (serum, plasma, red cell concentrates, and buffy coat) accrued from 8450 recruited subjects, and quantified and aliquoted good-quality DNA extracts from 6150 study subjects. This represents an invaluable resource for future research with expanding genomic and trans-omic technologies. This will facilitate the involvement of indigenous African samples in cutting-edge stroke genomics and trans-omics research. It is, however, critical to effectively engage African stroke patients and community members who have contributed precious biological materials to the SIREN Biobank to generate appropriate evidence base for dealing with ethical, legal, and social issues of privacy, autonomy, identifiability, biorights, governance issues, and public understanding of stroke biobanking in the context of unique African culture, language, and belief systems.
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http://dx.doi.org/10.1089/bio.2017.0113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995267PMC
June 2018

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches.

J Clin Hypertens (Greenwich) 2018 01 11;20(1):47-55. Epub 2017 Dec 11.

Medical University of South Carolina, Charleston, SC, USA.

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.
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http://dx.doi.org/10.1111/jch.13152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777902PMC
January 2018

Short-term pilot feasibility study of a nurse-led intervention to improve blood pressure control after stroke in Nigeria.

J Neurol Sci 2017 Jun 7;377:116-120. Epub 2017 Apr 7.

Department of Neurology, Medical University of South Carolina, Charleston, USA.

Background: Given the paucity of neurologists in Sub-Saharan Africa (SSA), task-shifting post-stroke care to nurses could be a viable avenue for enhancing post-stroke outcomes. This pilot study assessed the feasibility and short-term impact of a nurse-led intervention to manage blood pressure (BP) control in recent stroke survivors in Nigeria.

Methods: A randomized pilot trial allocated patients within one month of an index stroke from two participating hospitals in Nigeria to either nurse-led group clinic or standard care for 14days. Key study endpoints were successful execution of the protocol, subject retention, and short-term BP effects.

Results: There were no significant differences between the intervention (n=17) and control (n=18) groups at baseline. At the post-intervention clinic, patient retention rate was 100%. In the intervention group, both the systolic and diastolic BPs measured at home were lower than the clinic BPs post-intervention (127±12.88/78.13±19.26mmHg versus 137.50±23.05/84.06±9.67mmHg; p=0.05). However, there was no significant change in clinic blood pressure (BP) recordings in both the intervention and control groups.

Conclusion: It is possible to initiate a nurse-led group clinic intervention to address BP management among stroke survivors in SSA with good early retention of participants. A larger and longer-term trial is being planned.
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http://dx.doi.org/10.1016/j.jns.2017.04.005DOI Listing
June 2017

Stroke-related stigma among West Africans: Patterns and predictors.

J Neurol Sci 2017 Apr 9;375:270-274. Epub 2017 Feb 9.

Medical University of South Carolina, USA.

Background: Disability-adjusted life-years lost after stroke in Low & Middle-Income Countries (LMICs) is almost seven times those lost in High-income countries. Although individuals living with chronic neurological and mental disorders are prone to stigma, there is a striking paucity of literature on stroke-related stigma particularly from LMICs.

Objective: To assess the prevalence, severity, determinants and psycho-social consequences of stigma among LMIC stroke survivors.

Methods: Between November 2015 and February 2016, we conducted a cross-sectional survey of 200 consecutive stroke survivors attending a neurology clinic in a tertiary medical center in Ghana. The validated 8-Item Stigma Scale for Chronic Illness (SSCI-8) questionnaire was administered to study participants to assess internalized and enacted domains of stigma at the personal dimension with further adaptation to capture family and community stigma experienced by stroke participants. Responses on the SSCI-8 were scored from 1 to 5 for each item, where 1=never, 2=rarely, 3=sometimes, 4=often and 5=always with a score range of 8-40. Demographic and clinical data on stroke type and severity as well as depression and Health-Related Quality of Life indicators were also collected. Predictors of stroke-related stigma were assessed using Linear Models (GLM) via Proc GENMOD in SAS 9.4.

Results: 105 (52.5%) subjects recruited were males and the mean±SD age of stroke survivors in this survey was 62.0±14.4years. Mean SSCI-8 score was highest for personal stigma (13.7±5.7), which was significantly higher than family stigma (11.9±4.6; p=0.0005) and social/community stigma (11.4±4.4; p<0.0001). Approximately 80% of the cohort reported experiencing mild-to-moderate degrees of stigma. A graded increase in scores on the Geriatric Depression Scale and Centre for Epidemiological Studies-Depression scale was observed across the three categories. Living in an urban setting was associated with higher SSCI-8 scores. Moreover, stroke subjects with more severe post-stroke residual symptom deficits reported a significantly higher frequency of stigma.

Conclusion: Four out of five stroke survivors in this Ghanaian cohort reported experiencing some form of stigma. Stigmatized individuals were also more likely to be depressed and have lower levels of quality of life. Further studies are required to assess the consequences of stigma from stroke in LMIC.
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http://dx.doi.org/10.1016/j.jns.2017.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364027PMC
April 2017

Exploring Overlaps Between the Genomic and Environmental Determinants of LVH and Stroke: A Multicenter Study in West Africa.

Glob Heart 2017 06 13;12(2):107-113.e5. Epub 2017 Mar 13.

University of Ibadan, Ibadan, Nigeria.

Background: Whether left ventricular hypertrophy (LVH) is determined by similar genomic and environmental risk factors with stroke, or is simply an intermediate stroke marker, is unknown.

Objectives: We present a research plan and preliminary findings to explore the overlap in the genomic and environmental determinants of LVH and stroke among Africans participating in the SIREN (Stroke Investigative Research and Education Network) study.

Methods: SIREN is a transnational, multicenter study involving acute stroke patients and age-, ethnicity-, and sex-matched control subjects recruited from 9 sites in Ghana and Nigeria. Genomic and environmental risk factors and other relevant phenotypes for stroke and LVH are being collected and compared using standard techniques.

Results: This preliminary analysis included only 725 stroke patients (mean age 59.1 ± 13.2 years; 54.3% male). Fifty-five percent of the stroke subjects had LVH with greater proportion among women (51.6% vs. 48.4%; p < 0.001). Those with LVH were younger (57.9 ± 12.8 vs. 60.6 ± 13.4; p = 0.006) and had higher mean systolic and diastolic blood pressure (167.1/99.5 mm Hg vs 151.7/90.6 mm Hg; p < 0.001). Uncontrolled blood pressure at presentation was prevalent in subjects with LVH (76.2% vs. 57.7%; p < 0.001). Significant independent predictors of LVH were age <45 years (adjusted odds ratio [AOR]: 1.91; 95% confidence interval [CI]: 1.14 to 3.19), female sex (AOR: 2.01; 95% CI: 1.44 to 2.81), and diastolic blood pressure > 90 mm Hg (AOR: 2.10; 95% CI: 1.39 to 3.19; p < 0.001).

Conclusions: The prevalence of LVH was high among stroke patients especially the younger ones, suggesting a genetic component to LVH. Hypertension was a major modifiable risk factor for stroke as well as LVH. It is envisaged that the SIREN project will elucidate polygenic overlap (if present) between LVH and stroke among Africans, thereby defining the role of LVH as a putative intermediate cardiovascular phenotype and therapeutic target to inform interventions to reduce stroke risk in populations of African ancestry.
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http://dx.doi.org/10.1016/j.gheart.2017.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583025PMC
June 2017

Gaps in Hypertension Guidelines in Low- and Middle-Income Versus High-Income Countries: A Systematic Review.

Hypertension 2016 12 3;68(6):1328-1337. Epub 2016 Oct 3.

From the Department of Medicine and University College Hospital (M.O., J.Y., T.M., L.O., T.F., E.S.M., B.S.) and Institute for Advanced Medical Research and Training, College of Medicine (R.A.), University of Ibadan, Nigeria; WFNR-Blossom Specialist Medical Center, Ibadan, Nigeria (M.O., E.U.); Federal Teaching Hospital, Ido-Ekiti, Nigeria (P.O.); Department of Medicine, CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru (J.J.M.); Department of Neurology (W.F., R.S., B.O.) and Department of Public Health Sciences (M.G.), Medical University of South Carolina, Charleston; School of International Development and Global Studies, University of Ottawa, Ontario, Canada (S.Y.); Department of Family and Emergency Medicine, University of Montreal, Quebec, Canada (J.K.); Department of Public Health, Health Service Organization, Hamilton, Ontario, Canada (L.T.); Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada (J.V.O.); Department of Health Research, Ministry of Health & Family Welfare, Government of India, New Delhi, India (P.M.); Sydney Medical School, University of Sydney, New South Wales, Australia (C.C., R.J.); Non Communicable Diseases Research Unit, South African Medical Research Council, Tygerberg, South Africa (A.K.); School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.G.T.); Cardiovascular Global Health Division of Cardiology, Duke University Medical Center, Durham, NC (G.S.B.); Global Alliance for Chronic Diseases, UCL Institute for Global Health, London, United Kingdom (G.P.); Department of Public Health, Academic Medical Centre, University of Amsterdam, The Netherlands (C.A.); Department of Experimental and Clinical Medicine, University of Florence, Italy (P.A.M.); and Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa (S.N.).

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http://dx.doi.org/10.1161/HYPERTENSIONAHA.116.08290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5159303PMC
December 2016

Experience of Using an Interdisciplinary Task Force to Develop a Culturally Sensitive Multipronged Tool to Improve Stroke Outcomes in Nigeria.

eNeurologicalSci 2016 Sep 16;4:10-14. Epub 2016 Apr 16.

Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.

The burden of stroke is on the rise in Nigeria. A multi-faceted strategy is essential for reducing this growing burden and includes promoting medication adherence, optimizing traditional biomarker risk targets (blood pressure, cholesterol) and encouraging beneficial lifestyle practices. Successful implementation of this strategy is challenged by inadequate patient health literacy, limited patient/medical system resources, and lack of a coordinated interdisciplinary treatment approach. Moreover, the few interventions developed to improve medical care in Nigeria have generally been aimed at physicians (primarily) and nurses (secondarily) with minimal input from other key health care providers, and limited contributions from patients, caregivers, and the community itself. The Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) study is assessing the efficacy of a culturally sensitive multidimensional intervention for controlling blood pressure in recent stroke survivors. A key component of the intervention development process was the constitution of a project task force comprising various healthcare providers and administrators. This paper describes the unique experience in Sub-Saharan Africa of utilizing of an interdisciplinary Task Force to facilitate the development of the multipronged behavioral intervention aimed at enhancing stroke outcomes in a low-middle income country.
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http://dx.doi.org/10.1016/j.ensci.2016.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908828PMC
September 2016

The Use of Qualitative Methods in Developing Implementation Strategies in Prevention Research for Stroke Survivors in Nigeria.

J Clin Hypertens (Greenwich) 2016 10 1;18(10):1015-1021. Epub 2016 Apr 1.

Department of Neurosciences, Medical University of South Carolina, Charleston, SC.

Implementing complex clinical interventions is a key challenge in many global regions. Local communities play a necessary role in enhancing feasibility and strengthening adaptive issues in the design and implementation of stroke interventions in developing countries. Drawing on the knowledge of physicians, patients, and caregivers, the authors employed qualitative methods as a phase 1 strategy to explore the challenges of stroke management and improve the adaptability and efficient delivery of a multimodal preventive intervention for secondary stroke disease in Nigeria. A total of 22 individual interviews were conducted with healthcare professionals, as well as 12 focus groups with patients and caregivers. Findings revealed four operational domains to improve strategies for phase 2 implementation and intervention: (1) barriers influencing optimal adherence in stroke survivors, (2) patient health beliefs and perceptions of patient health beliefs by others, (3) adoption of the "patient report card," and (4) "medical action plan" and family management strategies.
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http://dx.doi.org/10.1111/jch.12817DOI Listing
October 2016

Task-shifting training improves stroke knowledge among Nigerian non-neurologist health workers.

J Neurol Sci 2015 Dec 24;359(1-2):112-6. Epub 2015 Oct 24.

Department of Medicine, College of Medicine, University of Ibadan, Nigeria.

Background: The increasing stroke burden in sub-Saharan Africa far outstrips the availability of skilled human resource to provide timely and efficient acute, rehabilitative and preventive services. The objective of this study was to examine the impact of a short-term task-shifting stroke training program on the stroke knowledge of a cohort of Nigerian non-neurologist health workers (NNHWs).

Methods: Utilizing a quasi-experimental design, NNHWs drawn from 53 local government areas of Ogun and Oyo states participated in an intensive, multicomponent one-day stroke workshop. Stroke knowledge was evaluated before and after the training using a self-administered questionnaire.

Results: Out of a total of 210 NNHWs who participated in the session, 116 (55.2%) completed the pre-workshop questionnaire survey of stroke knowledge while 191 (91.0%) completed the post-workshop questionnaire survey. There were no statistically significant differences in the distribution of the age, gender and professional categories of the two groups. The participants' knowledge was significantly increased at the end of the training about stroke risk factors (p<0.001), stroke symptoms (p<0.001) and how stroke develops (p=0.009). The proportion of respondents who understood the FAST mnemonic increased from 10.3% before the training to 90.6% at the end of the training (p<0.001). The professional category of participants was associated with knowledge gain about swallowing test and thrombolysis.

Conclusion: Our data support the effectiveness of stroke-specific task-shifting training for non-neurologist health workers in a low resource setting. Interim studies with intermediate outcomes are needed to show that improved knowledge results in better care despite resource limitation. Randomized controlled trials will be useful to confirm findings and translate knowledge improvement into practical intervention.
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http://dx.doi.org/10.1016/j.jns.2015.10.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904227PMC
December 2015

Cost and cost-effectiveness analysis of a bundled intervention to enhance outcomes after stroke in Nigeria: Rationale and design.

eNeurologicalSci 2015 Jun;1(2):38-45

Department of Neurosciences, Medical University of South Carolina, Charleston, SC ( ).

The economic and social costs of stroke to the society can be enormous. These costs can cause serious economic damage to both the individual and the nation. It is thus important to conduct a cost effectiveness analysis to indicate whether an intervention provides high value where its health benefits justify its costs. This study will provide evidence based on the costs of stroke with a view of improving intervention and treatments of stoke survivors in Nigeria. This study utilizes two types of economic evaluation methods - cost-effectiveness analysis and cost-benefit analysis - to determine the economic impact of Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) intervention. The study is conducted in four Nigerian hospitals where 400 patients are recruited to participate in the study. The cost-effectiveness of THRIVES post-discharge intervention is compared with the control Intervention scenario, which is the usual and customary care delivered at each health facility in terms of cost per quality adjusted life years (QALYs). It is expected that successful implementation of the project would serve as a model of cost-effective quality stroke care for implementation.
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http://dx.doi.org/10.1016/j.ensci.2015.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4667801PMC
June 2015

Multilingual Validation of the Questionnaire for Verifying Stroke-Free Status in West Africa.

Stroke 2016 Jan 17;47(1):167-72. Epub 2015 Nov 17.

From the Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S., S.A., V.O., N.B.-A., L.A.); Department of Neurology, Medical University of South Carolina, (M.G., B.O., K.A., R.S., C.J., D.L.); Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria (L.O., S.I., N.T., A.M., A.D., N.I.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O., E.T.-A., I.P., A.S., P.A.); Department of Medicine, University of Ibadan, Ibadan, Nigeria (O. Akpa, O. Arulogun, A. Adeoye, A.T., O. Adeleye, A. Agunloye, G.O., J.A., S.M., E.U., G.A., S.K., M.O.); Department of Medicine, University of Ghana Medical School, Accra, Ghana (A. Akpalu, Y.M., R.L.); and Department of Biostatistics, University of Alabama at Birmingham (D.A., H.T.).

Background And Purpose: The Questionnaire for Verifying Stroke-Free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological, and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages, Yoruba, Hausa and Akan, for ascertainment of stroke-free status of control subjects enrolled in an on-going stroke epidemiological study in West Africa.

Methods: Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records, and neuroimaging (gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value, and negative predictive value.

Results: The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by gold standard, 98% were determined to have had stroke, whereas of 219 without stroke 87% were determined to be stroke-free by QVSFS. Negative predictive value of the QVSFS across the 3 languages was 0.97 (range, 0.93-1.00), sensitivity, specificity, and positive predictive value were 0.98, 0.82, and 0.80, respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen k=0.92.

Conclusions: QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.
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http://dx.doi.org/10.1161/STROKEAHA.115.010374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696900PMC
January 2016

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol.

Neuroepidemiology 2015 19;45(2):73-82. Epub 2015 Aug 19.

Korle-Bu Teaching Hospital, Accra, Ghana.

Background: As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research.

Methods: SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. STUDY SIGNIFICANCE: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.
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http://dx.doi.org/10.1159/000437372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604029PMC
July 2016

Pretesting Qualitative Data Collection Procedures to Facilitate Methodological Adherence and Team Building in Nigeria.

Int J Qual Methods 2015;14:53-64

Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Qualitative methods are becoming widely used and increasingly accepted in biomedical research involving teams formed by experts from developing and developed practice environments. Resources are rare in offering guidance on how to surmount challenges of team integration and resolution of complicated logistical issues in a global setting. In this article we present a critical reflection of lessons learned and necessary steps taken to achieve methodological coherence and international team synergy. A series of 10 pretest interviews were conducted to assess instrumentation rigor and formulate measures to address any limitations or threats to bias and management procedures before carrying out the formal phase of qualitative research, contributing to an evidence-based stroke-preventive care clinical trial study. The experience of pretesting notably helped to identify obstacles and thus increase the methodological and social reliability central to conducting credible qualitative research, while also ensuring both personal and professional fulfillment of our team members.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393011PMC
http://dx.doi.org/10.1177/160940691501400106DOI Listing
January 2015
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