Effect of a nurse-led secondary stroke prevention intervention on medium-term stroke outcome in a teaching hospital in Nigeria: A quasi-experimental study

Iyabo Yewande Ademuyiwa; Njideka U Okubadejo

doi:10.4103/jcls.jcls_6_21

ORIGINAL RESEARCH REPORT

Year : 2021 | Volume : 18 | Issue : 3 | Page : 168-173

Effect of a nurse-led secondary stroke prevention intervention on medium-term stroke outcome in a teaching hospital in Nigeria: A quasi-experimental study

Iyabo Yewande Ademuyiwa¹, Njideka U Okubadejo²
¹ Department of Nursing Science, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
² Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission	18-Jan-2021
Date of Acceptance	08-Jul-2021
Date of Web Publication	23-Aug-2021

Correspondence Address:
Dr. Iyabo Yewande Ademuyiwa
Department of Nursing Science, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcls.jcls_6_21

Abstract

Background: Mortality and morbidity attributable to stroke remain high in developing countries. Secondary prevention of stroke can reduce recurrence using targeted interventions addressing modifiable risk factors. This study assessed the effect of a nurse-led secondary stroke prevention intervention on compliance to lifestyle, diet, clinic and physical therapy attendance, and drug compliance over the medium-term poststroke. Methods: The study utilized a case (interventional group)–control (noninterventional group) quasi-experimental design. Sixty consenting acute stroke patients surviving till discharge were consecutively recruited into the study and conveniently assigned to either group in a 1:1 ratio. Recruitment was conducted over the initial 3 months of the study. The intervention group received standardized intensive in-person counseling for cases and designated caregivers at discharge. This means that, apart from standardized intensive in-person counseling for cases and designated caregivers at discharge. There was additional telephone calls and weekly short messages to the intervention group in-order to reinforce information and communication during follow-up. The nonintervention group received discharge instructions provided by the managing physician only. Outcome assessment was conducted at 9 months post stroke. Results: The study recruited 39 (65%) males and 21 (35%) females. The mean age of participants in intervention group was 55.0 ± 14.5 years, while it was 56.0 ± 11.2 years in the nonintervention group. Other demographic parameters were similar between both the groups. At the end of the follow-up period of 9 months, compliance with lifestyle and diet modification, clinic and physical therapy attendance, and drug compliance was statistically significantly higher in the intervention compared to the nonintervention group (P < 0.05 for all comparisons). Conclusion: This study demonstrates the potential utility of a nurse-led intervention incorporating targeted lifestyle risk modification on compliance to strategies aimed at reducing stroke recurrence. Adoption of this task shifting/sharing strategy is recommended.

Keywords: Intervention, nurse-led, prevention, secondary stroke, stroke outcomes

How to cite this article:
Ademuyiwa IY, Okubadejo NU. Effect of a nurse-led secondary stroke prevention intervention on medium-term stroke outcome in a teaching hospital in Nigeria: A quasi-experimental study. J Clin Sci 2021;18:168-73

How to cite this URL:
Ademuyiwa IY, Okubadejo NU. Effect of a nurse-led secondary stroke prevention intervention on medium-term stroke outcome in a teaching hospital in Nigeria: A quasi-experimental study. J Clin Sci [serial online] 2021 [cited 2023 May 28];18:168-73. Available from: https://www.jcsjournal.org/text.asp?2021/18/3/168/324404

Introduction

Stroke is a leading cause of mortality and morbidity worldwide. Stroke is responsible for 9% of deaths worldwide, which is the second cause of mortality after heart disease, and the leading cause of disability in adults.^[1],[2],[3] It has been projected that by the year 2030, about 80% of all strokes will occur in low- and middle-income countries.^[1],[4] A recent global review showed that while there is a decline in stroke incidence in developed countries, most developing countries are experiencing about a 100% rise in stroke incidence.^[5] From a global perspective, the number of stroke survivors has increased over the last two decades, increasing the need for secondary prevention.^[1],[6] World Health Organization (WHO) report at a welcome meeting of experts on second prevention of noncommunicable diseases in low- and middle-income countries through community-based and health services intervention stated that a broad array of general and patient-specific strategies have been proven or suggested to prevent stroke recurrence, and include controlling hypertension (through pharmacological and nonpharmacological methods), lowering cholesterol, quitting tobacco use, controlling diabetes, dietary changes, regular aerobic exercise, moderation or abstinence from alcohol, and taking appropriate medications when indicated (e.g., antiplatelets and anticoagulants).^[7]

Studies have demonstrated and suggested that patient-focused strategies such as behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids are useful methods of improving patient adherence in the UK such as Scotland.^[8],[9] Counseling from informed health providers, particularly nurses who adopt a grassroots approach, can potentially improve adherence by improving knowledge, attitudes, and practice that will ultimately translate to improved outcomes. Hospital-to-home transition care is the most stressful period for stroke survivors, health education has been identified as a strategy to enhance self-management of poststroke care at home. However, interventions in this field that are informed by a health coaching framework are scarce in a study protocol on a nurse-led health coaching intervention for stroke survivors and their family caregivers in hospital–home transition care in China.^[10] Likewise, safe and enjoyable nursing interventions should be developed and implemented to improve disability and related problems for poststroke patients. Another study conducted on the development and evaluation of a nurse-led tailored stroke self-management intervention in Scotland revealed that further work is needed to be developed and refined the intervention strategy, and also to identify how to effectively embed the intervention strategy of secondary prevention of stroke into nurses' routine clinical practice.^[11] A study conducted in Australia on nurse-led intervention to improve knowledge of medications in survivors of stroke or transient ischemic attack (TIA), a cluster randomized controlled trial, shows that there was no evidence that the nurse-led intervention was effective for improving knowledge of secondary prevention medications in patients with stroke/TIA at 12 months.^[12]

This means that studies of this kind is very scanty in Nigeria. There are very few published articles on this type of study i.e nurse-led secondary stroke prevention in Nigeria, and the aim of this study was to assess the effect of a nurse-led secondary stroke prevention intervention on compliance to medications, lifestyle and diet modification, and clinic and physical therapy attendance over the medium term (9 months) in the poststroke period.

Methods

Study design and participant recruitment

This was an interventional study that utilized a case (interventional group)–control (noninterventional group) quasi-experimental design. The research was carried out in Lagos University Teaching Hospital (LUTH), a 760-bedded tertiary institution located at Idi-Araba, Lagos, Nigeria. Approval of the study protocol was obtained from the Health Research Ethics Committee (HREC) in a teaching hospital in Nigeria. The study recruited a total of 60 consecutive stroke survivors at discharge, who consented to participate in the study. Case definition was based on the WHO clinical definition for stroke in addition to radiological confirmation of stroke subtype during hospitalization. Participants were conveniently assigned to one of the two groups – the intervention group or the nonintervention group in a 1:1 ratio (30 per group). As seen in [Figure 1] recruitment was conducted over the initial 3 months of the study to enable follow-up of all participants for the outcome period of 9 months with assessments conducted at 9 months.

Figure 1: CONSORT diagram indicating participant enrollment, allocation, follow-up, and analysis

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Baseline assessments

Baseline information documented for all participants at discharge was as follows: demographics, contact information for patients and caregivers, disability at discharge (using the Modified Rankin Scale),^[13] blood pressure, body mass index, fasting lipid profile, and glycated hemoglobin.

Intervention group

The intervention group received standardized intensive in-person counseling provided by a nurse (the principal investigator) to the patient and caregiver(s) at discharge and again at 3, 6, and 9 months post discharge. The counseling incorporated instructions for generic risk factor modification including lifestyle measures regarding diet composition, alcohol moderation, tobacco cessation, aerobic exercise (where feasible), compliance to medications, and physical therapy requirements. The patient education information was adapted from existing poststroke patient education toolkits.^[14] Telephone - based communication was provided to reinforce information such as reminders for scheduled clinic attendance, weekly short messaging service, fornightly telephone calls which was initiated by the study nurse. At 9 months, outcome assessments were performed. The outcomes measured were compliance to medication, modification of lifestyle, diet, and compliance to clinic and physical therapy attendance.

Nonintervention group

The nonintervention group received only the standard discharge instructions provided by the discharging physicians at the time of discharge (i.e., the standard of care in operation at the time of the study). This would typically include medication instructions, scheduling of follow-up outpatient clinic attendance, and routine counseling regarding compliance to instructions. The participants were requested to be re-contacted by the principal investigator at 9 months post stroke to follow-up. The details of the intervention were not relayed to them to limit bias. A single telephone contact was made to patient/caregiver at the time of the proposed 9-month visit to schedule the home or clinic visit for the assessments.

At 9 months, the same outcome assessments as were performed for the intervention group were applied to the nonintervention group.

Scoring system for the target parameters

The outcomes measured were compliance to medication, modification of lifestyle and diet, and compliance to clinic and physical therapy attendance. For all the parameters measured (lifestyle modification, diet modification, clinic and physical therapy attendance, and drug compliance), the scored options were either 1 (yes) or 0 (no) for target achieved or not achieved, respectively. Drug compliance was assessed by confirming that participants complied with the medication use as prescribed. Any deviation from complete compliance was taken as noncompliance and scored 0. Lifestyle modification was assessed based on counseling instructions which included reduction or cessation/abstinence of alcohol consumption, reduction or cessation/abstinence of tobacco intake, and increased physical activity such as exercise. Patients who successfully reduced or stopped alcohol and tobacco intake and had increase physical activity to at least 30 min per day up to three times a week were regarded as compliant, while those who did not achieve any of the three parameters were regarded as noncompliant. Adherence to diet modification was assessed based on self-reported reduction in salt intake and quantity of carbohydrate intake with increased consumption of fruits and vegetables. Compliance to clinic and physical therapy attendance was measured by verifying the clinic records (including appointment cards) for attendance at scheduled appointments.

Ethical consideration

The study proposal was approved by the College of Medicine University of Lagos, Health Research and Ethics Committee, with approval number CM/HREC/02/17/105. Respondents and caregivers received information on the purpose and objectives of the study and written informed consent was obtained from each respondent. Participation in this study were voluntary. Confidentiality and privacy were strictly adhered to throughout the study. The right to withdraw participation at any time without prejudice to care was emphasized.

Data analysis

The analytical plan was to use intention to treat analysis. There was no participant dropout in either of the two groups and data collection was complete at outcome analysis. Data were analyzed using International Business Machines (IBMs) Corporation Statistical Package for Social Sciences (SPSS) (IBM SPSS®^, IBM Corporation, USA) version 21 (United State of America). Numerical and categorical variables are presented using standard descriptive (mean ± standard deviation and counts [%] respectively). Intergroup differences (between the intervention and nonintervention arms) were assessed using appropriate statistics (Chi-square test), with statistical significance set at the conventional P < 0.05.

Results

The baseline demographic and clinical variables of the intervention and nonintervention groups are shown in [Table 1]. In summary, the intervention and nonintervention groups were similar (P > 0.05) in gender distribution (male-to-female ratio: 39–21), mean age (55.0 ± 15.5 years and 56.0 ± 11.2 year, respectively), and number of years of formal education (10.8 ± 6.5 and 9.83 ± 6.4, respectively). The degree of disability at discharge using the Modified Rankin scale for the groups was comparable (2.2 ± 1.0 and 2.6 ± 1.2). Mean systolic blood pressure and diastolic blood pressure at discharge for the groups were also comparable (134 ± 25.5 and 145.1 ± 24.2) and (83.1 ± 15.2 and 89.8 ± 12.7) (P > 0.05).

Table 1: Sociodemographic and clinical variables in the intervention and nonintervention group

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A comparison of outcomes related to the lifestyle interventions at 9 months is provided in [Table 2], and shows significantly higher compliance rates (P < 0.05) across all parameters in the intervention compared to the nonintervention group. Twenty-five participants (83.3%) complied with lifestyle modification instructions in the intervention group compared with 10 (33.3%) in the nonintervention group. Twenty-seven participants (90%) in the intervention group complied with expected dietary modification, while only three (10%) did so in the nonintervention group. Other data relating to drug compliance, clinic, and physical therapy attendance are shown in [Table 2].

Table 2: Compliance rates (outcome) at 9 months of follow-up in the intervention and nonintervention groups

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Discussion

This study was designed to explore the impact of a planned intervention to educate and follow-up stroke survivors with respect to secondary preventive strategies focusing on generic parameters including modification to more favorable lifestyle, diet, and compliance to standard instructions regarding medication and clinical and physical therapy attendance. The task-sharing strategy of having a nurse-led intervention was adopted in recognition of the integral role that nurses should play in providing postdischarge support to stroke survivors.

Our study showed that this nurse-led secondary stroke prevention intervention was effective in improving adherence to lifestyle modification, dietary adjustment, clinic attendance, and physical therapy rehabilitation program and drug compliance, these findings are not in agreement with a study conducted in Australia on nurse-led intervention to improve knowledge of medications in survivors of stroke or TIA: a cluster randomized controlled trial, their findings showed that there was no evidence that the nurse-led intervention was effective for improving knowledge of secondary prevention medications in patients with stroke.^[12]

Heron et al.^[14] conducted a randomized feasibility study in which physical exercise was used as an intervention to prevent secondary stroke, and their findings showed better outcomes in patients that had exercise as part of their rehabilitation program as against controls, these findings are in conformity with this present study. In addition, the findings of this present study also support the findings of some similar studies conducted in the United kingdom, New South Wales, and Germany, the authors found that lifestyle modification such as mild-to-moderate exercise has been shown to have a protective effect on the occurrence of secondary stroke.^{[14],[15],[16],[17]}

The findings of this present study show that there was a significantly higher rate of drug compliance in the intervention group. Presuming that (based on the selection of participants from a similar pool of patients i.e., in LUTH) economic background would be expected to be similar, we hypothesized that this difference is plausibly attributable to the effectiveness of the communication and education strategy in the intervention group. A study conducted on noncompliance to medication is a multifactorial concept that is influenced by financial and nonfinancial considerations. The study conducted on treatment adherence and secondary prevention of stroke among discharged patients in China revealed that there was increasing medication compliance among the respondents, the authors found that there was an increasing medication compliance among the respondents, also another was also conducted on postdischarged evaluation of medication adherence and knowledge of hypertension among hypertensive stroke patients in northwestern China, the findings showed that the medication adherence of the stroke patients was poor, these findings are contrary to the present study. The authors also concluded in their studies that health education, communication, and follow-up are associated with better compliance in treating persons who have suffered stroke.^{[18],[19],[20]}

The greatest influence of the intervention (based on the difference in proportions of person's compliance at the end of 9 months) was seen for clinic and physical therapy attendance and drug compliance, with a difference in compliance of 80% and 76.6%, respectively (higher in the intervention group). This is noteworthy as a significant specific benefit has been demonstrated for physical therapy (in neurorehabilitation and recovery of function) but also for physical therapy in general for secondary stroke prevention in previous studies.^{[20],[21],[22]} In addition, medication adherence is a core requirement to enable the achievement of targets (e.g., blood pressure and blood glucose)) and for ischemic stroke prevention via the use of antiplatelets and statin therapy.^{[19],[22],[23]}

In summary, the study has demonstrated a significant difference in compliance with the specified strategies in the intervention group compared to the nonintervention group that were only provided with the standard of care (nonspecified discharge instructions and presumed routine generic counseling without the benefit of targeted follow-up during the postdischarge period). Worldwide, more patients are surviving the first stroke. As stroke survival in developing countries such as Nigeria improves, the possibility of occurrence of repeat strokes and the need for organized implementation of preventive measures will become even more pertinent. The role of a nurse-led intervention for secondary prevention of stroke has not been evaluated previously in our setting and this study, to the authors' knowledge, is probably, the first to assess such a program.

This study had some limitations. First, the precise content of the instructions provided to the nonintervention group at discharge by the discharging physician was not available for comparison as there was no standardized protocol at the time of the study and no written discharge instructions. Second, nearly all of the study outcomes are self-reported. It is feasible that similar guidance was provided, but the additional details, reinforcement of instructions, and supplementary communication via phone calls and prompting to adhere to the instructions were not available to the nonintervention group. As such, we presume that the difference observed was attributable to the intervention. Our study did not explore the occurrence of repeat strokes or other adverse outcomes as this was not the intended primary purpose. While recognizing the importance of exploring the influence of compliance on other important outcomes, the present study simply sought to demonstrate the effect of the intervention on compliance across the lifestyle modifications and attendance at clinic and physical therapy. Thirdly, the related literatures for this study were very few and scanty, especially in Nigeria, and quite difficult for the authors to be able to compare studies done previously and in this present study, thereby a bit difficult for the authors to do a discussion of findings efficiently and effectively. Considering this, our results should be interpreted in that context.

Conclusion

The nurse-led secondary stroke prevention intervention was effective in improving adoption of and compliance with lifestyle modification, diet modification, clinic and physical therapy attendance, and drug compliance. Adequate health education and follow-up of stroke patients after discharge is an essential component of secondary stroke prevention. We recommend task sharing enabling training and increased participation of nurses to lead secondary stroke prevention programs and contribute to reducing stroke burden in our population.

Acknowledgment

Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW010134. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Financial support and sponsorship

This project was sponsored by Building Research and Innovation in Nigeria's Science (BRAINS) Northwestern University, Harvard University and APIN.

Conflicts of interest

There are no conflicts of interest.

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