EDITORIAL: Transforming Neurological Health Outcomes in West Africa: A Focus on Epilepsy and Stroke

West Afr J Med April 2024; 41(4): 358-361 PMID: 39002152

Abstract

The healthcare landscape in Nigeria is evolving, reflecting broader global trends in managing neurological conditions. This editorial synthesizes insights from recent studies on epilepsy and acute stroke, highlighting shifts in health-seeking behaviors and the persistent challenges in managing these conditions. Both studies underscore the importance of public health education, the need for targeted interventions, and the critical role of timely medical care in improving patient outcomes.

Evolving Health-Seeking Behaviors in Epilepsy

Epilepsy, a predilection for recurrent unprovoked seizures, is a neurological disorder that affects millions of people across the globe. According to the World Health Organization (WHO), epilepsy affects approximately 50 million people worldwide, making it one of the most common neurological diseases globally. Alarmingly however, up to 80% of People Living With Epilepsy (PLWE) are located in low- and middle-income countries (LMICs) where limited access to healthcare and lower levels of medical literacy often collude to worsen the scourge of chronic diseases¹.

In West Africa for example, the prevalence of epilepsy is estimated to be between 10 to 20 per 1,000 people. This is significantly higher than in high-income countries, where the prevalence is approximately 4 to 10 per 1,000 people. The elevated prevalence in West Africa can be attributed to several factors, including inadequate healthcare infrastructure, higher incidence of infections that can affect the brain (such as malaria and neurocysticercosis), and genetic predispositions².

The impact of untreated or undertreated epilepsy can be profound and multifaceted. PLWE who do not receive adequate treatment are at increased risk of severe health complications, including injury, psychological issues, and sudden unexpected death in epilepsy (SUDEP). Furthermore, untreated epilepsy can lead to significant social and economic consequences, such as unemployment, stigma, and isolation ^3,4.

Effective treatments for epilepsy can significantly improve the quality of life for individuals living with the condition. Antiseizure medications (ASMs) are the cornerstone of epilepsy treatment and can control seizures in approximately 70% of patients¹. In cases where medications are not effective, other treatment options include surgical interventions, neurostimulation therapies, and dietary modifications such as the ketogenic diet ⁵. Early and appropriate treatment is crucial in reducing the frequency and severity of seizures and minimizing the long-term impact of the disorder. Unfortunately, however, three out of every four PLWE in LMICs are either untreated or undertreated¹.

Prior studies on health-seeking behavior among PLWE in West Africa have shown a tendency for patients to seek care from unorthodox healers and spiritual leaders. This trend is often driven by cultural and spiritual beliefs, as well as a lack of access to formal healthcare facilities. For instance, a study conducted in 2013 found that 61.4% of PLWE in Nigeria first consulted traditional healers or prayer houses for their care⁶. This pattern of health-seeking behavior has contributed to delays in diagnosis and treatment, exacerbating the burden of epilepsy in the region.

The study "Has Treatment Seeking Behaviour Changed in People Living with Epilepsy? Experience of People Living With Epilepsy Attending Adult Neurology Clinics in Enugu" by Ezeala-Adikaibe and colleagues reveals significant shifts in how people living with epilepsy (PLWE) in Southeast Nigeria seek care. Historically, many PLWE turned first to unorthodox healers due to cultural and spiritual beliefs. However, recent data shows a promising decline in this trend. The data indicates that 64.9% of patients initially sought care at a general, teaching, private, or psychiatric hospital, compared to 34.1% who first visited prayer houses or traditional healers. Unsurprisingly, a similar study performed in 2022 in the same region of Nigeria among pediatric patients with epilepsy showed that 50% of caregivers sought orthodox medical care first⁷. Together, this marks a significant improvement from previous reports and underscores the effectiveness of ongoing public health initiatives.

Despite these gains, more work needs to be done as 1 in 3 patients still initially visit traditional healers due to confidence in their cures, and spiritual beliefs continue to drive many to prayer houses. This underscores the need for ongoing public health campaigns that not only provide medical information but also address cultural and spiritual dimensions.

Addressing Acute Stroke Mortality

Each year, 15 million people globally experience a stroke. Out of these, 5 million lose their lives, and another 5 million are left with lasting disabilities⁸. Stroke remains the second leading cause of death worldwide, a position it is expected to maintain through 2030^9,10. However, the burden of stroke mortality is disproportionately high in LMICs with age-standardized stroke-related mortality rates being 3.6 times higher compared to high-income countries¹¹. In either setting, it is important to understand the drivers of stroke mortality in the short and long term. Deciphering predictors of early mortality in hospitalized stroke patients can help clinicians take proactive steps to reduce the risk of death when those factors are modifiable. They can also help in goals of care planning and allocation of medical resources especially when care is likely futile¹².  

Multiple validated prediction models for early stroke mortality have been developed in high-income countries. For example, Predicting Early Mortality of Ischemic Stroke (PREMISE) score was developed using data from the Austrian Stroke Unite Registry. The underlying study analyzed 77,653 ischemic stroke patients and found that key predictors of early death included advanced age, severe stroke as measured by the National Institutes of Health Stroke Scale, prior functional disability, preexisting heart disease, diabetes mellitus, posterior circulation stroke syndrome, and nonlacunar stroke cause. With a score ranging from 0 to 12 points, patients scoring 10 or higher faced a 1 in 3 odds of dying within the first days of admission¹².  

Similarly, the PLAN score was developed by analyzing data from 9,847 patients in the Canadian Stroke Network registry. The score encompasses preadmission comorbidities, level of consciousness, age, and neurologic deficit. The study identified critical variables, assigning points for preadmission dependence, cancer, congestive heart failure, atrial fibrillation, reduced consciousness, age (1 point per decade), and significant neurological deficits. With a maximum score of 25, the PLAN score accurately predicted 30-day mortality, severe dependence or death at discharge, and 1-year mortality, achieving C statistics of 0.87, 0.88, and 0.84, respectively¹³.

The settings where these predictive models were developed are however resource-rich with the widespread use of dedicated Stroke Units (SU) which limits their application in LMICs

The study "The Prevalence and Pattern of Admission Mortality Among Acute Stroke Patients Managed at a Tertiary Hospital in Abakaliki Nigeria: A Retrospective Study" by Eze and Onyebuchi provides such a tool. First, the study paints a stark picture of acute stroke mortality in Nigeria. With an admission mortality rate of 15.12% at the private specialist hospital in Abakaliki, the study highlights the urgent need for improved stroke management and prevention strategies.

Demographic data from the study reveals a higher prevalence of stroke among males (57%) compared to females (43%), with a mean age of 65.21 years. Factors significantly associated with higher mortality rates include hemorrhagic stroke, severe hypertension, impaired consciousness, renal dysfunction, hypernatremia, neutrophilic leucocytosis, and short admission durations. These findings point to specific areas where targeted interventions could reduce mortality rates.

Hypertension, identified in 63.37% of the patients, emerges as a major risk factor, underscoring the need for aggressive management and public health initiatives to reduce blood pressure levels. Diabetes mellitus, present in 24.42% of patients, also highlights a critical area for intervention.

The study also found that most mortality occurred within the first week of admission, and higher mortality is seen with severe strokes and impaired consciousness. This underscores the need for a nationwide system with tiered levels of stroke care depending on the severity. Even in resource-rich settings such as the United States, the available resources do not support transforming most hospitals into Comprehensive Stroke Centers where the full spectrum of acute reperfusion strategies (intravenous thrombolysis and intra-arterial thrombectomy), neurosurgical interventions (such as craniectomy), and intensive care can be deployed. Instead, stroke centers range from ‘Stroke Ready’ to designated ‘Comprehensive Stroke Centers’. This stratified system of stroke care is integrated into the Emergency Care Services system enabling stroke patients to be triaged on the field and targeted to an appropriate facility, or transferred to a higher level of care when warranted. Additionally, in high-resource settings, dedicated Stroke Units have been shown to be associated with lower stroke mortality^14–16.

Implications for Public Health Policy

Both studies provide valuable insights into the evolving landscape of neurological care in Nigeria and underscore the critical need for comprehensive public health strategies. For epilepsy, public health campaigns must continue to promote scientific understanding while respecting cultural beliefs. Improving the accessibility and affordability of orthodox medical care is crucial for sustaining positive trends in health-seeking behaviors.

For stroke, prioritizing stroke prevention and management is imperative. Public health campaigns should focus on educating the population about stroke risk factors and the importance of early medical intervention. Healthcare facilities must be equipped with the necessary infrastructure and trained personnel to handle acute stroke cases effectively. Investing in research to understand the epidemiology of stroke, developing community-based interventions for managing hypertension and diabetes, and enhancing the capacity of healthcare facilities to provide comprehensive stroke care are essential steps forward.

Conclusion

The evolving health-seeking behaviors among PLWE in Southeast Nigeria and the high mortality rates among stroke patients in Abakaliki reflect broader challenges and opportunities in Nigeria's healthcare system. By addressing both cultural and medical dimensions and prioritizing timely and effective care, we can improve health outcomes for individuals with epilepsy and stroke. The time to act is now, as the future health of the population depends on the measures we take today.

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