Implementing stroke unit care in selected hospitals in Rwanda

Background: The burden of stroke in low-and middle-income countries (LMICs) has risen sharply in recent years and the rate of increase is set to accelerate due to socio-demographic and lifestyle changes related to the industrialization and a rise in many modifiable vascular disease risk factors. Aims: The first aim was to establish, for countries like Rwanda, how much stroke is a major problem. The second aim was to explore whether the existing stroke services were well prepared. The third aim was to develop and implement a relevant service improvement in Rwanda. Methods: First, I conducted systematic reviews of the literature on the epidemiology and impact of stroke, and the available stroke services in Africa. Second, I conducted a systematic review of the literature and analyzed the INTERSTROKE study data to identify the stroke key performance indicators (KPIs) that have been described in stroke care and assessed their association with patient outcomes. Finally, I selected the stroke unit care KPIs relevant to Rwandan and other LMIC settings, and used several strategies including site champions, provision of educational materials, feedback on usual care, training hospital staff on stroke KPIs, consensus discussions on service improvement by local staff, and discussions with the hospital directors to promote the implementation of the selected KPIs in two hospitals in Rwanda. Results: Stroke was found to be common and important in Africa. However, the provision of stroke care was below the recommended standards. After adjustment for case mix and stroke onset-hospital arrival interval, I found a consistent trend of associations between my implementation intervention and improved delivery of stroke KPIs and patient outcomes. Conclusion: Several common KPIs of stroke unit care can be implemented in hospitals in Rwanda. However, there are some major challenges that need to be addressed for optimal implementation of stroke unit care. Chapter abstracts Chapter 1: Epidemiology and impact of stroke in Africa: a systematic review of the literature Background: Stroke is the second most common cause of death, and the third most common cause of disability-adjusted life-years (DALYs) worldwide, but there is limited information on the stroke burden in Africa. Aim: To describe the epidemiology (incidence, prevalence, mortality, one month-case-fatality) and impact (disability, quality of life, and cost) of stroke in Africa. Methods: I performed a systematic review which included full-text manuscripts published between January 1980 and June 2017 that described the epidemiology or impact of stroke. I searched Medline, Embase, PubMed, and African Journals Online (AJOL) databases, and screened references from bibliographies. There was no language restriction. To determine the estimates of stroke epidemiology and impact variables in Africa, the overall means with standard deviation (SD) were calculated. Results: I identified 44 eligible studies among which 21 were hospital based and 23 were community based. The majority (30/44) of the studies were conducted in urban settings. Overall, the crude mean per 100,000 population was 122.4 (SD: 68.1) for the incidence, 539.1 (SD: 381.5) for the prevalence and 84.7 (SD: 30.15) for mortality. The age-adjusted mean per 100,000 population was 162.7 (SD: 117.5) for incidence, 788.3 (SD: 536.7) for the prevalence and 192.7(SD: 155.2) for mortality. The overall mean rate for stroke one-month case fatality was 30.4% (SD: 11.7%). It was also reported that 30.6% of stroke survivors had moderate or severe disability at one-year post stroke, and at 29 months post stroke, the stroke survivors in general had neither poor nor good quality of life (the mean for the health-related quality of life was 71%). The overall mean for the in-hospital care cost was found to be 1971 (SD: 1108) United States Dollars (USDs). Conclusions: This review provides an overview of the epidemiology and impact of stroke in Africa, despite the paucity of available data. I found that stroke was common and important in Africa. Robust high-quality studies are needed to help policy makers and health care professionals to control the stroke burden in Africa. Appropriate preventive and therapeutic measures should be promoted to decrease the incidence of stroke, improve the outcomes, and maintain the survivors’ quality of life in Africa. Chapter 2: Stroke care in Africa: a systematic review of the literature Background: Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim: To describe the status of stroke care in Africa. Methods: I undertook a systematic search of the published literature to identify recent (January 1st, 2006-June 20th, 2017) publications that described stroke care in any African country. Results: My initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for my review, the proportion of stroke patients reported to arrive at hospital within three hours from stroke onset varied between 10─43%. The median time interval between stroke onset and hospital admission was 31 hours. The reported proportions of stroke patients who received brain imaging within three hours of stroke onset varied between 0% and 13%, and the overall proportion of patients who received brain imaging varied between 13% and 36%. Only twenty-three stroke units in Africa were reported, and two studies indicated that stroke unit admission was associated with a decrease in in-patient case fatality rate of 17-30%. Access to in- and out-patient rehabilitation services was reported to be very low. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions: This review provided an overview of stroke care in Africa and highlighted the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access to organised stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e. registries or audits) are also needed to inform policy and practice. Chapter 3: Key performance indicators of quality stroke care and their association with patient outcomes: a systematic review of the literature and meta-analysis Background: Translating research evidence into clinical practice often uses key performance indicators (KPIs) to monitor quality of care. However, information on KPIs for stroke care is limited. Aims: To identify the stroke KPIs used in large registries, and to estimate their association with patient outcomes. Methods: I sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of KPIs with patient outcome (adjusting for age and stroke severity). I searched Ovid Medline, Embase and PubMed and screened references from bibliographies. I used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% Confidence Interval) with death or poor outcome (death or disability) at the end of follow up. Results: I identified 30 studies (324,409 patients) eligible for the qualitative review. Among these, only 22 were eligible for the meta-analysis. The commonest KPIs were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischemic stroke, brain imaging, anticoagulant use for ischemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilization. Lower case fatality was associated with swallow/nutritional assessment (OR: 0.78; 0.66-0.92), stroke unit admission (OR: 0.79; 0.72-0.87), antiplatelet use for ischemic stroke (OR: 0.61; 0.50-0.74), anticoagulant use for ischemic stroke with atrial fibrillation (OR: 0.51; 0.43-0.64), lipid management (OR: 0.52; 0.38-0.71), and early physiotherapy or mobilization (OR: 0.78; 0.67-0.91). Reduced poor outcome (death or disability) was associated with adherence to swallowing/nutritional assessment (OR: 0.58; 0.43-0.78) and stroke unit admission (OR: 0.83; 0.77-0.89). Adherence to several KPIs appeared to have an additive benefit. Conclusions: I found that the most frequently reported KPIs for stroke care were swallowing assessment, stroke unit admission, antiplatelets for ischemic stroke, brain imaging, anticoagulants for ischemic stroke with atrial fibrillation, lipid management, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Adherence to common KPIs was consistently associated with a lower risk of death or disability after stroke. Policy makers and health care professionals should implement and monitor those KPIs supported by good evidence. Chapter 4: Stroke services in African and other low and middle-income countries in an international study Background: Stroke key performance indicators (KPIs) have been used to monitor service improvement in high-income countries (HICs), but information regarding their utility in low and middle-income countries (LMICs) is limited. Aims: To explore the association of recording of stroke KPIs with patient outcomes in LMICs, generally and African settings in particular. Methods: I analysed data collected from the INTERSTROKE case control study (conducted between January 2007 and August 2015). I had full data for 12343 participants and analysed 9766 from LMICs. I calculated the odds ratios (OR) with 95% confidence intervals (CI) for the associations of KPIs with 30-day patient outcomes using univariate and multivariate regression analyses to account for patient casemix. I also used the Bonferroni correction method to control the familywise error rate and considered 0.006 as the p-value of significance. Results: In LMICs, availability of a stroke unit (OR: 0.71, 0.60-0.83; p<0.0001) or a stroke specialist (OR: 0.74, 0.64-0.85; p<0.0001), receiving antiplatelet therapy for ischemic stroke (OR: 0.69, 0.56-0.85; p=0.001), and the availability of acute (OR: 0.70, 0.57-0.87; p=0.001) and post-discharge (OR: 0.41, 0.34-0.48; p<0.0001) rehabilitation were independently associated with lower risk for 30-day case fatality. Early brain imaging (OR: 0.71, 0.58-0.88; p=0.001) and stroke unit availability (OR: 0.62, 0.55-0.71; p<0.0001) were independently associated with lower risk of death or severe disability at 30 days. There was a dose dependent relationship of number of KPIs recorded with a better outcome. For the African countries alone, I had no enough evidence to show an association between any of the stroke KPIs investigated and patient outcomes. Conclusions: In LMICs, achieving several common KPIs was associated with a statistically significant reduction in post-stroke death or disability. Policy makers and health care professionals should be encouraged to implement the commonly established stroke KPIs even in settings with limited resources. Chapter 5: Implementing stroke unit care in Rwanda: a two-hospital before and after implementation trial Background: Stroke unit care has become established as the central component of a modern stroke service to improve patient outcomes, but it requires several resources. This raises the question of whether stroke unit care is feasible and applicable to low and middle-income country settings. Aims: To explore the feasibility and effectiveness of implementing stroke unit care in selected hospitals in Rwanda. Methods: I used a before and after implementation trial design. The clinical intervention consisted of 11 key stroke unit care elements that were identified from the results of chapters three and four, the World Stroke Organisation (WSO) recommendations and the Rwandan clinical guidelines. The implementation intervention consisted of identification of site champions, provision of educational materials, face-to-face educational seminar (including feedback on usual care, training on stroke KPIs and local consensus discussions), and discussions with the study hospital directors. Results: Overall, after case mix adjustment for stroke severity (using six simple variables), stroke type and stroke onset-hospital arrival interval, I found a consistent trend of associations between the intervention and an increase in participants who received the KPIs investigated and an increase in better patient outcomes. However, the results were statistically significant for only the use of standardized assessment tools (OR: 2.98, 1.36-6.51; p=0.006), swallowing assessment recorded (OR: 5.73, 2.08-15.74; p=0.001), mobilization recorded (OR: 2.30, 1.16-4.56; p=0.017) and multidisciplinary team meetings recorded (OR: 9.04, 2.74-29.86; p<0.0001). Survival in hospital (OR: 2.97, 1.25-7.05; p=0.014) and at three months post stroke (OR: 2.30, 1.10-4.78; p=0.026) significantly improved. Conclusions: Several common KPIs for stroke unit care can be implemented in two selected hospitals in Rwanda although there were limited resources, and some important KPIs such as geographic stroke unit and thrombolysis could not be implemented. The data also suggested that there may be improved patient outcomes. There is a need for combined efforts to continue improving the implementation of stroke KPIs including those that are not yet initiated like a geographic stroke unit. Chapter 6: Final discussion In this final chapter, I aim to discuss to what extent the aims of the thesis have been achieved, the contributions made by this thesis and future work

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose: Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method: We sought publications of recent (January 2000–May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings: We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72–0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66–0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50–0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43–0.64), lipid management (odds ratio 0.52; 0.38–0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67–0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43–0.78) and stroke unit admission (odds ratio 0.83; 0.77–0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion: Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion: Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence

Physical Activity Levels of the Physiotherapy Students in Rwanda during the Coronavirus Disease 2019 Lockdown Period

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic and related social distancing measures have an impact on physical activity levels.ObjectiveTo assess the physical activity (PA) levels of the physiotherapy students in Rwanda during the COVID-19 lockdown period.MethodsWe used a descriptive cross-sectional quantitative study design. Eighty-one participants were recruited, and data were collected using the International Physical Activity Questionnaire. We used descriptive statistics, Pearson Chi-Square and Kruskal-Wallis tests to assess whether there were statistically significant differences in physical activity levels according to demographic variables.ResultsThe median total PA metabolic equivalent of task (MET)-minutes/week score for all the participants together was 3546 (IQR=8714), meaning high PA. The rates for high, moderate, and low PA levels were 54.4%, 31.7% and 13.9% respectively. Male and rural participants had higher median total PA MET score than females (p=0.008) and urban residents (p=0.018) respectively.ConclusionsThe PA levels of the study participants during the COVID-19 lockdown period were higher than the recommended standards. Females and urban participants appeared to be less physically active than their counterparts. Further similar studies and interventions towards PA promotion among university students in Rwanda during the pandemic are suggested.Rwanda J Med Health Sci 2021;4(3):334-34

Exploring the perception of the educational environment among health sciences students at the University of Rwanda: a mixed methods study

The educational environment (EE) plays a very important role in effective learning. However, information about the quality of the EE at the University of Rwanda (UR) is limited. We aimed to explore the perception of health sciences students about their EE at UR. We used a mixed methods design. Of 606 health sciences students in total, 241 participants were recruited for a quantitative survey using the Dundee Ready Education Environment Measure (DREEM) questionnaire. Additionally, we purposively recruited 10 participants for the qualitative data collection using an interview guide. We used descriptive statistics, independent samples t-test and analysis of variance (ANOVA) test to analyse the quantitative data. The interview verbatims were transcribed and analysed using a thematic approach. The overall mean score of DREEM was 133.74±20.00 which indicates a more positive environment. Female students had higher score than males in the academic (p = 0.005) and social (p = 0.001) self-perception sub-domains. There were also differences in academic selfperception (p = 0.008) and learning atmosphere (p = 0.002) across the departments. The qualitative interviews revealed some specific problems that need to be addressed such as the shortage of financial means during clinical placements; occasional lack of lecturers; insufficient time for hands-on-practice; insufficient chairs in classrooms; and delays in providing feedback to students. Health sciences students at the UR had a positive perception towards their EE. However, there is a need for more efforts to make the environment more positive

Stroke care in Africa: a systematic review of the literature

Background: Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim: To describe the status of stroke care in Africa. Summary of review: We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions: This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice

Exploring the perception of the educational environment among health sciences students at the University of Rwanda: a mixed methods study

The educational environment (EE) plays a very important role in effective learning. However, information about the quality of the EE at the University of Rwanda (UR) is limited. We aimed to explore the perception of health sciences students about their EE at UR. We used a mixed methods design. Of 606 health sciences students in total, 241 participants were recruited for a quantitative survey using the Dundee Ready Education Environment Measure (DREEM) questionnaire. Additionally, we purposively recruited 10 participants for the qualitative data collection using an interview guide. We used descriptive statistics, independent samples t-test and analysis of variance (ANOVA) test to analyse the quantitative data. The interview verbatims were transcribed and analysed using a thematic approach. The overall mean score of DREEM was 133.74±20.00 which indicates a more positive environment. Female students had higher score than males in the academic (p = 0.005) and social (p = 0.001) self-perception sub-domains. There were also differences in academic selfperception (p = 0.008) and learning atmosphere (p = 0.002) across the departments. The qualitative interviews revealed some specific problems that need to be addressed such as the shortage of financial means during clinical placements; occasional lack of lecturers; insufficient time for hands-on-practice; insufficient chairs in classrooms; and delays in providing feedback to students. Health sciences students at the UR had a positive perception towards their EE. However, there is a need for more efforts to make the environment more positive

Expert consensus for in-hospital neurorehabilitation during the COVID-19 pandemic in low- and middle-income countries

Background: People with neurological dysfunction have been significantly affected by the ongoing coronavirus disease 2019 (COVID-19) crisis in receiving adequate and quality rehabilitation services. There are no clear guidelines or recommendations for rehabilitation providers in dealing with patients with neurological dysfunction during a pandemic situation especially in low- and middle-income countries. The objective of this paper was to develop consensus-based expert recommendations for in-hospital based neurorehabilitation during the COVID-19 pandemic for low- and middle-income countries based on available evidence. Methods: A group of experts in neurorehabilitation consisting of neurologists, physiotherapists and occupational therapists were identified for the consensus groups. A scoping review was conducted to identify existing evidence and recommendations for neurorehabilitation during COVID-19. Specific statements with level 2b evidence from studies identified were developed. These statements were circulated to 13 experts for consensus. The statements that received ≥80% agreement were grouped in different themes and the recommendations were developed. Results: 75 statements for expert consensus were generated. 72 statements received consensus from 13 experts. These statements were thematically grouped as recommendations for neurorehabilitation service providers, patients, formal and informal caregivers of affected individuals, rehabilitation service organizations, and administrators. Conclusions: The development of this consensus statement is of fundamental significance to neurological rehabilitation service providers and people living with neurological disabilities. It is crucial that governments, health systems, clinicians and stakeholders involved in upholding the standard of neurorehabilitation practice in low- and middle-income countries consider conversion of the consensus statement to minimum standard requirements within the context of the pandemic as well as for the future

Prevalence and levels of disability post road traffic orthopaedic injuries in Rwanda

Background: Prolonged disability resulting from road traffic injuries (RTIs) contributes significantly to morbidity and disease burden. A good understanding of the prevalence and the level of disability of orthopaedic injuries in developing countries is crucial for improvement; however, such data are currently lacking in Rwanda. Objectives: To determine the prevalence and levels of disability of 2 years post-road traffic orthopaedic injuries in Rwanda. Method: A multicentre, cross-sectional study from five Rwandan referral hospitals of 368 adult RTI victims’ sustained from accidents in 2019. Between 02 June 2022, and 31 August 2022, two years after the injury, participants completed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) Questionnaire for the degree of impairment and the Upper Extremity Functional Scale and Lower-Extremity Functional Scale forms for limb functional evaluation. Descriptive, inferential statistics Chi-square and multinomial regression models were analysed using R Studio. Results: The study’s mean age of the RTOI victims was 37.5 (±11.26) years, with a sex ratio M: F:3: 1. The prevalence of disability following road traffic orthopedic injury (RTOI) after 2 years was 36.14%, with victims having WHODAS score 25.0% and 36.31% were still unable to return to their usual activities. Age group, Severe Kampala Trauma Score and lack of rehabilitation contributed to disability. The most affected WHODAS domains were participation in society (33%) and life activities (28%). Conclusion: The prevalence and levels of disability because of RTOI in Rwanda are high, with mobility and participation in life being more affected than other WHODAS domains. Middle-aged and socio-economically underprivileged persons are the most affected. Contribution: This study showed that a good rehabilitation approach and economic support for the RTI victims would decrease their disabilities in Rwanda

Strategies for specialty training of healthcare professionals in low-resource settings: a systematic review on evidence from stroke care

Background: The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings. Methods: We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion. Results: A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A “train-the-trainer” approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the “train-the-trainer” approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates. Conclusions: The “train the trainer” approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts