Study shows community-based model can improve secondary prevention of stroke

Stroke survivors can significantly improve medication adherence and control of risk factors when they are supported through a structured and coordinated follow-up programme delivered by trained community health workers (CHWs), a community-based study among stroke survivors in Kollam district has demonstrated.

The CHW intervention model for secondary stroke prevention has been designed by the Department of Neurology and public health researchers at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) here.

Conducted from March 2022, the study enrolled 896 stroke survivors from 16 health blocks across Kollam district who had experienced the stroke event in 2020 or later. The mean age of the stroke survivors was 64.5 years, of whom 63% were male and 85% of them (765 persons) had suffered ischaemic stroke. Hypertension was present in 755 persons (84%) and 447 had diabetes (49.9%). Of the behavioural factors, 3% were current users of chewable tobacco, 3.6% were alcohol users, and 5% were smokers.

Managing vascular risk factors through a combination of medication adherence and lifestyle modification can reduce the risk of recurrent stroke by 80%. Stroke recurrence is high in India, with one-year recurrence rate in the broad range of 5-15 %, with three to five year risk of recurrence reaching 15-25%.

“But medication adherence and control of risk factors have remained sub-optimal amongst our stroke patients once they leave the hospital after the acute event. Post-stroke care services for secondary stroke prevention and continuum of care are quite poor in Kerala. Our attempt was to see if a community care model can improve medication adherence and risk factor monitoring so that stroke recurrence can be reduced in the long term,” says PN Sylaja, Professor of Neurology and the lead investigator of the study.

Researchers from the SCTIMST trained more than 1,400 CHWs – including ASHA workers, public health nurses, health inspectors and palliative-care nurses – along with 21 physicians, to deliver the intervention model to support stroke patients directly in their homes. The model was so devised that every study participant received at least three home visits from health workers, a follow-up call from health workers once every three months, systematic blood pressure and other risk factors monitoring, and tailored health education using culturally and linguistically adapted material.

Second phase

In the second phase of the study, periodic SMS-based intervention through health workers was also introduced to 220 study participants for six months to reinforce medication adherence. The rest 676 participants formed the control group.

Outcome measures were assessed at baseline, three months and six months.

The study results showed that medication adherence improved significantly from 86.3% in the baseline to 94.2% after the involvement of health workers. The most frequent reasons for lack of medication adherence were forgetfulness and carelessness .

In the SMS-based intervention group, though only 24.5% responded to messages, there was improvement in medication adherence at three months. But this dipped at six months, highlighting challenges such as limited digital confidence or dependence on family members to use phones.

Use of tobacco and alcohol reduced among the 896 participants following the intervention of health workers. Risk-factor monitoring improved from 42.7% to 49.7%, while average systolic blood pressure dropped from 138 mmHg to 132 mmHg.

The study showed that even in resource-constrained settings, a coordinated CHW-led model, using Kerala’s existing health workforce, can strengthen continuity of care and improve secondary stroke prevention among stroke survivors living in the community.

The researchers say that the model can be integrated into the State’s non-communicable disease clinics and that it can help in capacity building and task shifting of the overburdened health system.

The study was funded by the NCD division of the Department of Health and Family Welfare, Kerala.