There are nearly 26m stroke survivors in the world, including over a million in the UK – and the numbers are rising. The number of strokes in the UK is projected to increase by 44% in the next 20 years for example, mainly because of the ageing population.
Not only do many stroke survivors have to live with physical or cognitive disabilities, they also live in fear of a second attack. One in four stroke survivors experience a second stroke within five years. As many as 30% of all strokes are secondary strokes. They tend to be more disabling and costly, and are more likely to be fatal.
They are often also avoidable. Patients can reduce their risks through lifestyle choices, but this depends on doctors, nurses and other health professionals encouraging and facilitating appropriate behaviour change.
Instead, those working in health care are often not given adequate support in what messages to pass on and the best way to do this, per the current UK guidelines. As a result, the education that patients receive can be distinctly varied. In many cases, the professionals may instead be prioritising helping patients to recover from their original episode. As a result, an important piece of the jigsaw is being left out.
Strokes and support
The causes of recurrent strokes are complex and involve numerous factors. Some risks cannot be modified, such as family history of stroke, getting older, being male and belonging to certain ethnic groups, including African Caribbeans.
Yet behaviour-related factors such as smoking, poor diet, high alcohol consumption and not taking enough exercise can all be addressed. So can certain medical conditions, such as high blood pressure.
While the individual must of course take responsibility for these things, this has to go hand in hand with medical support. The current guidelines are clear about this. They recommend that healthcare professionals initiate a plan with the patient to prevent a second stroke as soon after the first episode as possible. This has to be part of the patient’s long-term care programme.
The reality is that patients may not always be aware of the importance of managing risk factors to prevent a further stroke. The best study evidence on this is from South Korea, where patients, doctors and nurses were asked to rank the importance of various features of stroke education, including lifestyle risk factors. Doctors ranked managing risks as the first priority in stroke education, while nurses ranked it second and patients ranked it fourth.
Yet while the professionals will generally be aware that managing risks is important, limited knowledge of stroke guidelines and recommendations may in some cases be a barrier. That was the conclusion of a UK study of nurses, for instance. Meanwhile, an American study of occupational therapists and physiotherapists reported that only half were aware of guidelines relevant to modifiable risk factors. Some said that addressing risk factors was not part of their role.
These studies highlight the need for all health professionals involved with stroke care to receive training about theories and techniques for achieving behaviour change, the stroke prevention guidelines and other relevant resources. In Scotland, for example, we know anecdotally that the training is very varied by area – ranging from well organised to non-existent. It is all very well having recommendations, but they are unlikely to be effective if there is no plan that gives support to the health professionals involved.
There is limited evidence on what is happening in practice when it comes to educating patients. We know little about which professionals are taking the lead, what they are doing, and how long after the original stroke they are doing it. Part of the problem is that studies into preventing secondary strokes through lifestyle changes appear to have underrepresented the role of the health professional.
The newly formed International Network for Stroke Secondary Prevention Researchers (INSsPiRE) is hoping to address research shortfalls regarding stroke secondary prevention. Bringing together relevant researchers from across the UK and EU, it is also aiming to raise the scientific profile of secondary prevention as a key element of stroke rehabilitation.
The #MakeMayPurple campaign does a fantastic job in fundraising and raising awareness in the UK each May for people who have been affected by a stroke. But every two seconds, someone in the world suffers a stroke. With a greater focus on secondary prevention it should be possible to make a dent on that statistic. As the rate of strokes continues to climb, that would be an important consolation.