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This medical plan outlines a THET application for a community project titled 'Improving Stroke Knowledge and Awareness of Early Management in a Semiurban Nepalese Community'. 

 

 

 

Improving Stroke Knowledge and Awareness of Early Management in a Semiurban Nepalese Community

 

 

Table of Contents

Table of Contents

Table of Figures i

Chapter One

Introduction: The global burden of acute stroke

Country Information: Nepal

Country Information: United Kingdom

Methodology and Literature Parameters

Methodology

Results

Chapter Two

Stroke Attitudes and Behaviours

Acute Stroke Management

Chapter Three: Global Health Partnership Proposal

Definitions of Health

Global Health

Need

Proposal Principles

Needs Assessment

Project Training Design

Finance and Resources

UK Staffing

Partnership Benefits

Evaluation

Community Training

‘Train the Trainer’ Training

Impact and Sustainability

Conclusion

Appendices

Appendix 1: Search terms

Appendix 2: Prisma diagram

Appendix 3: Distribution of studies between themes

Appendix 4: Literature review matrix

References

 

 

Chapter One

Introduction: The global burden of acute stroke

An acute ischemic stroke (stroke) can be defined as a cerebral arterial occlusion or impairment leading to the death of brain tissue and neurological deficit (Prabhakaran et al., 2015). Stroke remains a significant health burden and is the third-largest cause of morbidity and mortality globally (Devkota et al., 2006). Findings from the Global Burden of Disease study state that 70% of strokes and 87% of stroke-related deaths and stroke-related morbidity occur in low- and middle-income countries (LMIC) such as Nepal (Feigin et al., 2010); concerningly, this figure has more than doubled in LMIC over the previous four decades. In comparison, stroke occurrence has declined by 42% across the same period in high-income countries (HIC) with improved access to health education and advanced pre-hospital care (Feigin et al., 2010; Feigin et al., 2017). The disparity in stroke incidence suggests that HICs have the knowledge and capability to improve global stroke burden. 

The World Health Organisation (WHO) Global Stroke Initiative, alongside the WHO’s Package of Essential Non-Communicable Disease Interventions for Primary Health Care in Low-Resource Settings, recognises the transferable skills and knowledge of health care professionals (HCP) from HIC institutions such as the National Health Service (NHS), which could improve health equality in LMIC through the development of Global Health Partnerships (GHP) (WHO, 2003; WHO, 2010). Further support for GHPs comes from the 2013 report ‘Global Health 2035: A World Converging Within a Generation’ (Jamison et al, 2013). With a focus on healthcare investment, the report proposes a combined international investment in healthcare and technology to improve global health.

This proposal illustrates how HCPs from HIC institutions, such as the NHS, can reduce stroke-related mortality and morbidity within an LMIC by developing a community-led GHP.

Country Information: Nepal

 

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Nepal is a landlocked, sovereign country in South Asia that sits at 142nd out of 190 countries in the Human Development Index (HDR, 2021). The total population in 2020 was 33.4 million, and the average life expectancy at birth was 70.8 years (HDR, 2021). Concerningly, only 27% of the population had access to suitable sanitation, and just 30% had access to safe drinking water (WHO, 2021). According to the WHO (2021), 45% of the population lives below the poverty line, and both non-communicable and communicable diseases such as diarrhoea, dysentery, cholera and typhoid remain prevalent causes of morbidity and mortality. 

The ratio of doctors to population is 1:1,800 persons; however, the WHO estimates that there are between 100,000 and 200,000 internally displaced persons with limited healthcare access (WHO, 2021). Much of this displacement has been caused by a Maoist insurgency that began in 1996, affecting 80% of the countryside (WHO, 2021). Additionally, lack of supervision, fragmented supply chains, staff absenteeism and remote communities further exacerbate healthcare difficulties (WHO, 2021).

In a 2020 voluntary national review, Nepal documented good progress toward the Sustainable Development Goals (SDG) outlined in the WHO’s 2030 agenda. In the health sector specifically, a significant reduction in maternal, infant and child mortality has been recorded; however, the prevalence of non-communicable diseases such as diabetes, stroke and heart attack remains high (Nepal et al., 2020). Also, of note, the COVID-19 pandemic has had an unprecedented impact on Nepal’s SDG progress; as of January 2020, there is little literature to suggest the level of detriment caused (Mahato et al., 2020), but it is estimated to push back Nepal’s SDG progress by four years (Poudel and Subedi, 2020). Despite SDG improvements, stroke, alongside other non-communicable disease, remains a prominent cause of reduced disability-adjusted life years, and a significant cause of mortality and morbidity in Nepal (HDR, 2021; WHO, 2010).

Kathmandu, the capital of Nepal, is the epicentre for hospitals, the majority of which are private and unaffordable for much of the native population. Additionally, there are fewer than 30 neurologists across the nation and few imaging centres; thus, stroke treatment and management remain challenging (Chandra et al., 2019). Lastly, busy, dangerous roads are significant hurdles in reducing pre-hospital delays of stroke patients. 

Country Information: United Kingdom

A stark contrast to Nepal, the United Kingdom (UK) is an affluent country that sits at 13th out of 190 countries in the Human Development Index (HDR, 2021). The population of 66.65 million have access to the world’s 18th best health system, and consequentially, the average life expectancy at birth is 81.3 years (Dhsprogram, 2021; HDR, 2021). Similarly to Nepal, non-communicable diseases such as ischaemic heart disease and cerebrovascular disease are prevalent, and are the leading causes of death in the UK (ONS, 2021). Furthermore, stroke is the fourth-largest cause of death in the UK. However, unlike Nepal, stroke incidence fell by almost a quarter between 1990 and 2010, and 80% of those suffering a stroke will receive treatment and leave the hospital with an independent quality of life (Feigin et al., 2014; SSNAP, 2017). 

The UK also has ten NHS Ambulance Trusts that deliver pre-hospital care to patients across the nation and provide timely transfer to one of 247 emergency departments (ED) (NHS, 2021). Importantly, any emergency care provided is NHS funded, thus removing the financial barrier to health care commonly seen in Nepal. 

Despite the UK delivering world-class emergency care, there is an increasing feeling among HCPs of being ‘stressed, exhausted and burnt out’ (Wilkinson, 2015). In a 2013 study, the Royal College of Emergency Medicine (RCEM) found that 62% (668) of NHS ED consultants felt that their work in its current form was unsustainable (RCEM, 2021). To overcome such dissatisfaction, there is an increasing trend of HCPs undertaking additional voluntary work. One 2016 study reported that 42% of staff undertake voluntary international healthcare work (Chatwin and Ackers, 2016). 

The RCEM recognises and supports the benefits of international healthcare roles in improving work-life balance; however, the NHS has few national plans to accommodate staff overseas (RCEM, 2021). Consequently, there is an increasing trend towards HCPs leaving the NHS and emigrating to a healthier working environment. Furthermore, the NHS continues to face a high rate of turnover (11.9% in ED nursing staff) (Improvement’s, 2021) and therefore, in light of the benefits and improvements overseas opportunities present, one could argue that a lack of NHS co-operation is underpinned by an institutional fear of losing staff. 

The Tropical Health and Education Trust (THET) is an internal scheme funded by the Department for International Development to improve health partnerships overseas (THET, 2021). Managed by the eight ‘Principles of Partnership’ (Figure 2), THET enables and supports collaborative projects that provide mutual benefits, contributing to effective, efficient LMIC health systems while improving the knowledge, leadership skills and limited-resource healthcare abilities of NHS staff. 

Based on THET’s eight principles, this partnership will deliver life-saving pre-hospital stroke knowledge and management training to semi-urban Nepalese communities, delivered in partnership with experienced UK HCPs (Figure 3: Aims and Objectives). 

 

 

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Methodology and Literature Parameters

A literature review was undertaken to investigate knowledge of stroke risk factors and pre-hospital management in laypersons in Nepal.

Methodology

A systematic review of the literature was undertaken. EBSCO, MEDLINE, PubMed, Science Direct, CINHAL and Cochrane databases were searched. Primary search terms were: ‘stroke’, ‘knowledge’, ‘pre-hospital’, ‘management’ and ‘training’. Appendix Four presents all the search terms used.  Appendix Five presents the Boolean string used in an adapted PRISMA flow diagram (Prisma-statement, 2021). 

 

Inclusion criteria:

  • Published between 2001 and 2021
  • Systematic reviews, primary research, meta-analysis, reports
  • English language
  • Full text available 

Results that did not meet the inclusion criteria were removed, as were duplicates and irrelevant articles. Remaining articles were collated for review. 

In addition to the published literature, ‘grey literature’ was searched using Google; however, no literature was identified to meet the inclusion criteria. 

Results

Five hundred twenty-one papers were identified for review by the literature search. Following further analysis, ten were relevant to layperson knowledge of stroke. From the ten included papers, two key themes emerged.

Chapter Two

Stroke Attitudes and Behaviours

Contemporary literature has investigated the underlying beliefs, attitudes and behaviours that contribute to Nepal’s cardiovascular disease (CVD) burden. It has been suggested that attitudes towards tobacco, alcohol consumption and CVD health knowledge are areas requiring significant change (Dhungana et al., 2014; Tharu and Rawal, 2020). 

Vaidya et al. (2013) conducted a descriptive, cross-sectional study investigating CVD knowledge, attitudes and behaviours among laypersons (n=777) aged 25 to 59 years old, living in the Bhaktapur district of Kathmandu, Nepal. Face-to-face interviews were conducted, and a structured questionnaire was distributed. Findings were analysed through descriptive and inferential statistics using statistic package for social science (SPSS), version 17 and StataCorp, version 10.

Vaidya et al. (2013) identified CVD knowledge as 11.5% lower than the national average, poor CVD health attitudes as 19.6% higher than average and poor CVD health practices as 31.1% higher than average. There was a strong correlation between poor health knowledge and poor health attitudes; this also applied vice-versa. 

In contrast to previous studies Vaidya et al. (2013) found participants with no formal schooling more likely to have satisfactory knowledge than those with formal schooling; however, health practices were lower among those without formal schooling. Vaidya et al. (2013) recognise that this contradictory finding may have been influenced by the oversampling (72.7%) of female participants. One explanation for the oversampling bias is that culturally, women within the sample age range are housewives and are therefore more available for sampling than their male counterparts. Regardless, the gender bias limits a broader generalisation of findings.

In a study investigating knowledge, attitude and practice of stroke, Thapa et al. (2016) overcame Vaidya et al.’s (2013) gender bias by conducting the study in high schools of Bharatpur, Chitwan district, Nepal. Thapa et al. (2016) surveyed 1,360 students. A non-prompted structured questionnaire was distributed, and a statistical analysis was performed using SPSS, version 20. Additionally, a chi-square test was used to evaluate associations between demographic variables and stroke risk factors. Silwal et al. (2019) also conducted a similar study investigating stroke knowledge, however, the participants were aged 40 to 65 years. 

Thapa et al.’s (2016) results showed a good knowledge of risk factors, warning signs, attitude and practice regarding stroke. In support of the Vaidya et al. (2013) study’s gender generalisability, Thapa et al. (2016) showed no significant association between gender and knowledge of risk factors; however, they did find that males identify warning signs better than females. However, Thapa et al. (2016) suffer the risk of bias and lack of qualitative analysis due to their retrospective, closed question research methodology. Moreover, ethical approval and participant consent is omitted from the paper, a particularly concerning shortfall given the participants’ ages. 

Silwal et al. (2019) also found participants to have average stroke knowledge, but, like Thapa et al. (2016), concluded that a widespread stroke training and awareness program is required to reduce stroke morbidity and mortality.

Bridging the gap between stroke and general CVD knowledge, Tharu and Rawal (2020) conducted a descriptive, cross-sectional research study investigating knowledge and attitudes of cardiovascular risk factors among laypersons (n=100) aged 20 to 60 years living in Dhamboji-1, Nepalgunj, Banke district, Nepal. Face-to-face interviews were conducted, and a structured questionnaire was distributed. Collected data was categorised by knowledge of CVD risk factor, health behaviours and health attitude; results were analysed through descriptive and inferential statistics using SPSS, version 22.

Tharu and Rawal (2020) found 32% of participants to have good knowledge, 35% had average knowledge, and 33% had poor knowledge. Regarding attitudes, 68% had an unfavourable attitude, 32% had a neutral attitude, and none had a favourable attitude. 

Unsurprisingly, a significant (P < 0.05) association between good knowledge and higher education status was noted, though there was no significant correlation between knowledge and other socio-demographic variables; this correlated with a similar study by Vaidya et al (2013). However, a small sample size limited to one sub-metropolitan city limits generalisability, especially since 80.26% of Nepalis reside in rural areas (Data.worldbank, 2021). Moreover, individuals residing in a sub-metropolitan city will likely have better access to education that those in rural areas (Pradhan, 2012), thus affecting bias in education status within the results. 

Dhungana et al. (2014) improved on some statistical limitations of the Tharu and Rawal (2020) study in a descriptive, cross-sectional study that identified the prevalence of CVD risk factors within Tinkanya Village, Dindhuli, Nepal. The Dhungana et al. (2014) study’s increased sample size of 406 participants aged 20 to 50 years old and its adherence to the WHO-NCD STEPwise approach to surveillance questionnaires improved both generalisability and reliability of results. 

Dhungana et al. (2014) identified a high prevalence of high-risk CVD behaviours and hypothesised that CVD cases are likely to increase without a community-based training program. Similarly, this finding correlated with the Vaidya et al. (2013) study. However, both the Dhungana et al. (2014) and the Tharu and Rawal (2020) studies suffered from participant recall bias based on a descriptive, cross-sectional methodology. Furthermore, the rural location of the Dhungana et al. (2014) study limits comparability with the Tharu and Rawal study, and both studies lack a scale for determining socioeconomic status within Nepal; further research is required to enable comparison. 

Acute Stroke Management

Thrombolysis and thrombectomy have been well evidenced to affect the best outcomes in those presenting with acute stroke less than 3–4.5 hours from onset (Pandian et al., 2007). Recently, intravenous (IV) tissue plasminogen activator (tPA) has been licenced in Nepal, however, low emergency service availability, few neurology departments and high financial costs remain prevalent barriers to stroke care (Thapa et al., 2016; Chandra et al., 2019). 

Chandra et al. (2019) completed an institutional experience statement of patients (n=337) presenting to an ED with acute stroke signs and symptoms. Thirty per cent arrived within 24 hours of stroke signs presenting, but later than 4.5 hours since onset. Five per cent received tPA, and the authors noted substantial improvement with improved NIH Stroke Scale scores at the 24-hour post-IV tPA. 

Despite promising findings, Chandra et al. (2019) do not detail the location in which treatment was undertaken, and therefore a socioeconomic comparison is not possible. Additionally, potential delays to treatment such as geographic access cannot be inferred. It is also noted that patients self-funded their tPA treatment, thus results will suffer bias since much of Nepal lacks the financial means to fund this treatment (Gaudel, 2006). 

Thapa et al. (2016) also investigated the feasibility and efficacy of tPA treatment in acute stroke. Improving on Chandra et al.’s (2019) methodology, Thapa et al. (2016) conducted a well-structured, ethically approved retrospective analysis of 496 patients presenting with stroke to an ED in Kathmandu, Nepal, with nine patients receiving tPA thrombolysis within three hours of stroke onset. 

Thapa et al. (2016) found six of the nine patients to have a good neurological outcome post-treatment, as measured by a modified Rankin Scale. Thapa et al. (2016) identified Tenecteplase (TNC) as being a suitable substitute for tPA with equal efficacy, but importantly, a reduced cost. Additionally, Thapa et al. (2016) state that many stroke patients present outside of the thrombolytic window; this may account for the disparity between stroke patients seen in EDs and the low number receiving thrombolysis. However, no explanation is given for the cause of pre-hospital delay. 

In addition to thrombolysis, Phuyal et al. (2020) explain thrombectomy as an equally viable and effective stroke treatment. In a review of 22 patients who received mechanical thrombectomy in a single tertiary centre in Kathmandu, Nepal, 20 had good angiographic recanalisation at a three-month follow-up. In an improvement on tPA, Phuyal et al. (2020) state that thrombectomy is effective in patients who present too late for thrombolysis. However, Phuyal et al. (2020) recognise that cost remains a significant barrier to thrombectomy, and results will be biased to those with incomes higher than the national average. Moreover, thrombectomy’s efficacy has not been reported in remote Nepal; thus, findings from this study cannot be compared or generalised to a rural setting.

Prevalent in Phuyal et al. (2020), Thapa et al. (2016) and Chandra et al.’s (2019) findings is a pre-hospital delay of stroke patients reaching definitive care. Nepal et al. (2019) evaluated the status of pre-hospital delay and thrombolysis in an ethically approved, prospective study of 412 patients attending Tribhuvan University Teaching Hospital in Kathmandu with signs or symptoms associated with stroke. Forty-six (20.2%) presented early (<3hrs of stroke onset) and 182 (79.8%) presented late (>3hrs of stroke onset) to EDs. 

Factors associated with late presentation included heavy traffic, income below $1,000 (USD) and diabetes mellitus. Factors that reduced pre-hospital delay included identifying stroke, awareness of stroke treatment, education above high school and rushing to the ED. 

The large sample size of the Nepal et al. (2019) study improves the reliability of findings; however, like many hospital-based studies in Nepal, findings are limited to a single city-based institution. Therefore, it could be argued that cultural differences could impact results if the study were to be conducted elsewhere in Nepal. Nepal et al. (2019) recognise the study’s limitation and suggest a follow-up multicentred study methodology to improve generalisability. 

To explain the cultural effect on pre-hospital delay, Ghimire et al. (2019) conducted a cross-sectional study of both medical and non-medical participants (n=48) aged 16 to 76 years, measuring beliefs, expectations, and perceived barriers to telestroke in Siddharthangar Municipality, Bhaorajawa, Nepal. Data was obtained via a semi-structured interview and data was analysed using SPSS, version 20.

Significant barriers to telestroke were technology (45%), increased personal work (52%), time and cost (48%), management of treatment effects (35%), online safety (43%), preference of a physical consultation (48%) and time taken away from ED staff (44%).

Surprisingly, Ghimire et al. (2019) claim that 80% of participants had previous knowledge of telestroke. Given that telestroke is a relatively new and advanced stroke treatment, alongside the poor health knowledge discussed in the studies above, this participant cohort appears to have significantly better health knowledge than the general Nepalese population. Secondly, Ghimire et al. (2019) fail to investigate the feasibility and efficacy of telestroke. One reason for this may be that telestroke is not widely available, and therefore the perceived barriers are purely speculative; however, this would contravene the widespread reported knowledge of telestroke. Ultimately, further research is required to determine telestroke’s practical use.

Chapter Three: Global Health Partnership Proposal

Definitions of Health

Exploring and defining concepts of health enables a standard from which progress and failure can be measured. As outlined in the United Nations SGD, Goal Three aims to ‘ensure healthy lives and promote well-being for all ages’. Guided by an overarching objective to achieve universal health coverage, the 2030 agenda recognises the importance of global health partnerships in achieving this goal (Dye and Acharya, 2017). 

In 1946, the WHO defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’, however, this has since been criticised (WHO, 1946; Huber, 2011).

The first criticism of the WHO’s definition is the term 'complete' relating to well-being. It contributes to society's medicalisation by leaving the majority ‘unhealthy most of the time’, and also increases the potential for treatments to be developed for ‘conditions’ not previously addressed as health problems. Secondly, it declares those sufficiently coping with chronic disease to be ‘unhealthy’. Lastly, a state of 'complete' well-being remains impracticable as it is not operational or measurable. 

Regarding this proposal, a health baseline would be one's state before a stroke. The goal of this partnership is to reduce the difference between one’s health baseline and post-stroke state. 

Global Health

Global Health, in relation to this proposal, refers to a multifaceted stroke education project between UK NHS staff and a semi-urban Nepalese community. 

Koplan et al. (2009) define global health as a nonspecific ‘notion, objective or mix of scholarship, research and practice’. To further explain such an enigmatic definition, Koplan et al. (2009) described Global Health's concept to be a combination of nineteenth-century national Public Health and International Health. Modern Global Health encompasses complex intersocietal transactions, often focusing on how the health of one nation affects another's. For example, telestroke is being optimised in developed counties and then used in LMICs to provide remote stroke treatment. Moreover, a shift towards collaborative, research-based Global Health also enables LMICs to affect positive change in developed countries, optimising limited resource management. Koplan et al. (2009) conclude that Global Health will continue to prioritise the ‘burden of illness’, and so these continuing global health partnerships will be necessary to improve global health equity. 

Need

In a seminal book, Bradshaw (1994) defined four characteristics of sociological need: normative (outlined by experts), expressed (proposed by an individual or group), felt (wants and desires) and comparative (a need is desired based on a comparison to a similar population elsewhere).

However, Bradshaw’s definition of need characteristics is not without criticism, both from Bradshaw themselves and contemporary literature. The main limitation is the omission of economic importance within an individual’s health need. Culyer (2001) improved on Bradshaw’s economic limitation by defining health need as 'the ability of people to benefit from healthcare provision’. Moreover, Culyer (2001) explains that health need is only present when there is the capacity for benefit.

Despite Culyer’s (2001) improved definition, some literature argues that the capacity to benefit fosters healthcare inequality by favouring the young, those free from chronic disease and those with high economic potential (Engle, 2011; Palmer and Harmell, 2016). 

This critique demonstrates the requirement for Global Health partnerships to be equitable, rather than attempt to impose a one-size-fits-all equality approach. A sustainable partnership must produce benefit at an acceptable cost to meet health need goals (Chen and Chen, 2005). 

Proposal Principles

Figure 3 highlights the fundamental principles of this Global Health Partnership, based on the literature review.


 

Needs Assessment

A health needs assessment is a strategic tool for reviewing health inequalities, resource allocation and health needs within a population to allow for future development. The National Institute for Clinical Excellence (NICE) outlines a five-step approach to ensuring that healthcare programmes have a suitable framework from which they can evolve (Grant, 2002; Gupta, 2011). This partnership will utilise the NICE five-step approach with information derived from the literature review to demonstrate the needs assessment underpinning this Global Health partnership plan. 

Aims and objectives have been previously stated in this proposal. A critical objective identified from the literature is establishing communication systems between the UK team and a semi-urban community (Tarakeshwar, Nepal). To achieve this, the author of this proposal will approach community stakeholders such as elders, community leaders and similar members who hold leadership roles that suit this project’s needs. A committee will be formed to oversee the delivery of the project. UK and Nepalese media interaction will be minimised to avoid damaging Tarakeshwar community relations.

Figure 5 specifies information to be gathered to allow stakeholders to understand and investigate the impact of physiological effects, socio-demographics, current management options, financial impacts and broader cultural considerations of stroke.


 

Project Training Design 

As highlighted in the literature review, many papers suggested that additional community training was required, but none specified training structures. Based on the author of this proposal’s experience, in conjunction with learnt outcomes from Frendl et al. (2009), the author of this proposal suggests two one-day group training programmes to exhibit high-yield, low-cost results, accompanied by a two-day ‘train the trainer’ programme with volunteer community stakeholders to improve project sustainability. As per NICE’s five-step needs assessment, the project will be designed around findings from the needs assessment, and the partnership committee will review the training structure before implementation. All training content will be evidence-based and recognised in UK NHS practice. 

Finance and Resources

Prominent in THET’s guidelines for Global Heath Partnerships is the need for a high return on investment to enable sustainability; this is practically important for short-term health partnerships.

High project costs are flights, accommodations and food for UK HCPs travelling to Nepal. 

 HCPs wishing to deliver pre-hospital training on the project will be asked to contribute to flights and in-country costs. NHS staff can take either annual or unpaid leave at the discretion of local human resource managers. A growing body of literature supports HCPs undertaking overseas work to improve professional development. As such, the author of this study will support NHS HCPs in their appeal for a clinical secondment, if applicable (All-Party Parliamentary Group on Global Health, 2013: Yeomans et al., 2017). 

To gain funding, an application for a THET Small Global Health grant will be submitted. Depending on success levels, further financial support is available from THET’s Large Global Health grants to deliver pre-hospital stroke training to a broader community. 

UK Staffing

To be eligible to participate as a trainer in the project, UK staff must be registered HCPs with knowledge, training and practical experience in stroke care. Furthermore, individuals must have previous teaching experience, an interest in Global Health and a demonstrated ability to work in LMICs.

Partnership Benefits

 Integral to the success of the proposal is a mutually beneficial relationship between the UK and Nepal. Projected benefits for the Tarakeshwar community are:

  1. Reduced incidence of stroke
  2. Reduced pre-hospital delay in those presenting with acute stroke
  3. A reduction in stroke-related mortality and morbidity
  4. Community engagement in improving healthcare
  5. Developing a sustainable, measurable teaching programme

Projected benefits for UK HCP staff are:

  1. Improved communication with those for whom English is not their first language
  2. Increased job satisfaction through delivering sustainable, life-improving training
  3. Improved educational skills and abilities
  4. Improved capacity to work within limited-resource settings
  5. Developed understanding of cultural health practices and behaviours

Evaluation

Based on findings from the literature review, the following four areas require evaluation to determine the project’s success:

  1. Community Training
  2. ‘Train the Trainer’ Training
  3. Impact
  4. Sustainability

 

Community Training

Randomised follow-up interviews and questionnaires with individuals who attended the community training day will evaluate the extent to which stroke knowledge has improved within the community. Feedback from UK HCP trainers will also be requested along with recommendations for improvement.

‘Train the Trainer’ Training

Interviews and questionnaires with community stakeholders who received two-day 'stroke trainer' training will evaluate their improvement in knowledge and understanding of stroke management. Feedback from community ‘stroke trainers’ will be requested alongside recommendations for improvement. It is proposed that community ‘stroke trainers’ regularly email the UK with updates on community stroke training; additionally, the author of this project will email clinical updates in stroke care to Nepalese community ‘stroke trainers’. This ensures project sustainability and maintenance of competency for ‘community trainers’.

Impact and Sustainability

A limitation of this study is that there is a lack of baseline stroke incidence and stroke-related mortality and morbidity data for Tarakeshwar, Nepal. It could be reasonably assumed that increased knowledge of stroke risk factors and a greater awareness of stroke management would reduce stroke-related morbidity and mortality. A partnership with Grande International Hospital (the nearest hospital to Tarakeshwar with stroke capacity) could be achieved to address this. This is a consideration for further partnership, should initial project efforts be successful.

Community trainers will continue to provide stroke risk factor and stroke management training within the community; this will enable the initial project's sustainability. Regular support can be provided from the UK via email and at in-person follow-up projects, should it be warranted. 

Conclusion

Stroke is a leading cause of disability-adjusted life years globally. The lack of community stroke knowledge contributes to pre-hospital delay, leading to morbidity and mortality. Many LMICs do not have formal stroke pathways or hospitals with the capacity to treat stroke. Additionally, Nepal's geographic diversity leaves much of the population out of reach of traditional stroke treatment. Training laypeople to understand, recognise and manage stroke has been evidenced to improve outcomes.

This Global Health Partnership will enable UK HCPs to train and empower a semi-urban Nepalese community to improve stroke care, thus dramatically reducing stroke-related disability-adjusted life years. In return, UK HCPs will improve their communication, develop teaching skills, increase cultural understanding and see improved job satisfaction while improving others' lives.

Appendices

Appendix 1: Search terms 

Key Word Search / Boolean String

(No Limiters Applied)

EBSCOhost

Education & Healthcare

Google Scholar

Stroke

 

3,790,000

Stroke AND Nepal

 

29,300

Stroke AND Nepal AND Knowledge

 

23,500

Stroke AND Nepal AND Knowledge AND Community

 

17,500

Stroke OR Cerebrovascular Accident AND Nepal

 

5,610

Stroke OR CVA OR Cerebrovascular Accident AND Nepal

 

5,740

Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Training

 

6,160

Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Training AND Pre-hospital AND Community

 

217

Paramedic AND Stroke AND Nepal

 

660

Paramedic OR Doctor AND Stroke AND Nepal

 

10,300

Paramedic OR Doctor OR Healthcare Professionals AND Stroke AND Nepal

 

10,900

Paramedic OR Doctor OR Healthcare Professionals AND Stroke AND Nepal AND Training

 

9,230

Paramedic OR Doctor OR Healthcare Professionals AND Stroke AND Nepal AND Training AND Management

 

8,310

Paramedic OR Doctor OR Healthcare Professionals AND Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Training AND Management

 

9.460

Stroke AND Nepal AND Prehospital

 

700

Stroke AND Nepal AND Prehospital AND Delay

 

523

Stroke AND Nepal AND Prehospital AND Training

 

586

Paramedic OR Doctor OR Healthcare Professionals AND Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Prehospital AND Training

 

521

Stroke AND Nepal AND Mortality

 

15,600

Stroke AND Nepal AND Mortality OR Morbidity

 

16,300

Stroke CVA OR Cerebrovascular Accident AND Nepal AND Mortality OR Morbidity

 

2,770

Risk Factors AND Stroke CVA OR Cerebrovascular Accident AND Nepal

 

3,190

Risk Factors AND Stroke CVA OR Cerebrovascular Accident AND Nepal AND Knowledge

 

2,270

Risk Factors AND Stroke CVA OR Cerebrovascular Accident AND Nepal AND Knowledge OR Training

 

2,190

Risk Factors AND Stroke CVA OR Cerebrovascular Accident AND Nepal AND Community AND Knowledge OR Training

 

1,860

Paramedic OR Doctor OR Healthcare Professionals AND Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Training AND Management AND Risk Factors AND Knowledge

 

7,040

 

 = Chosen Boolean string for literature search.

Appendix 2: Prisma diagram

Boolean String Search Term

Paramedic OR Doctor OR Healthcare Professionals AND Stroke OR CVA OR Cerebrovascular Accident AND Nepal AND Prehospital AND Training

Database: EBSCO, MEDLINE, PubMed, Science Direct, CINHAL and Cochrane.

Search Criteria Applied

Full Text – Scholarly (Peer Reviewed Journals) – Published Date (01/01/2011 to 03/01/2021) – English Language Only

 

 

521 Articles Found

Search results were manually reviewed for keyword, significance, and relevance to the topic

 

490 Articles Excluded

 

 

31 Articles Included

 

 

17 Articles Were Not Primary Research Data

4 Articles Were Inaccessible

 

Google Scholar:

Duplicates Not Included

 

3 Articles Included

 

7 Articles Included

 

Health databases + Google Scholar = 10

 

 

10 Final Articles Reviewed

 

Appendix 3: Distribution of studies between themes

Theme

Articles Linked to Theme

1

Layperson knowledge of stroke

  • Vaidya, A., Umesh, R. A., and Krettek, A. (2013) ‘Cardiovascular health knowledge, attitude and practice/behaviour in an urbanising community of Nepal: a population-based cross-sectional study from Jhaukhel-Duwakot Health Demographic Surveillance Site’, BMJ Open, vol. 3, p. 10.
  • Dhungana, R.R., Devkota, S., Khanal, M.K., Gurung, Y., Giri, R.K., Parajuli, R.K., Adhikari, A., Joshi, S., Hada, B. and Shayami, A. (2014) ‘Prevalence of cardiovascular health risk behaviours in a remote rural community of Sindhuli district, Nepal’, BMC Cardiovascular Disorders, vol. 14, no. 1, p. 92.
  • Silwal, S., Khadka, S. and Sah, B.K. (2019) ‘Knowledge on stroke among middle aged adults in a community at Ratuwamai, Morang’, Tribhuvan University Journal, vol. 33, no. 1, pp. 31–42.
  • Thapa, L., Sharma, N., Poudel, R.S., Bhandari, T.R., Bhagat, R., Shrestha, A., Shrestha, S., Khatiwada, D. and Caplan, L.R. (2016) ‘Knowledge, attitude, and practice of stroke among high school students in Nepal’, Journal of Neurosciences in Rural Practice, vol. 7, no. 4, p. 504.
  • Knowledge and attitude regarding risk factors of cardiovascular disease among general people residing in Nepalgunj, Banke, Nepal. DO  - 10.21203/rs.3.rs-34829/v1. 

2

Awareness of early stroke management

  • Nepal, G., Yadav, J.K., Basnet, B., Shrestha, T.M., Kharel, G. and Ojha, R. (2019) ‘Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal’, BMC Neurology, vol. 19, no. 1, p. 155.
  • Chandra, A., Rajbhandari, P. and Pant, B. (2019) ‘Acute stroke management: the plight of Nepal’, Neurology, vol. 92, no. 21, pp.1022–1023.
  • Thapa, L., Shrestha, S., Shrestha, P., Bhattarai, S., Gongal, D.N. and Devkota, U.P. (2016) ‘Feasibility and efficacy of thrombolysis in acute ischemic stroke: a study from National Institute of Neurological and Allied Sciences, Kathmandu, Nepal’, Journal of Neurosciences in Rural Practice, vol. 7, no. 1, p. 55.
  • Phuyal, S., Poudel, R., Shrestha, G.S., Dawadi, K., Rauniyar, V.K., Thapa, L., Adhikari, R.B., Thapa, A., Sedain, G., Acharya, S.P. and Jalan, P. (2020) ‘Endovascular management of acute ischaemic stroke in Nepal’, The Lancet Global Health, vol. 8, no. 5, pp. e635–e636.
  • Ghimire, S., Ghimire, M.R., Gurung, A., Kachapati, A. and Gurung, S. (2019) ‘Telestroke: beliefs, expectations and perceived barriers among community people residing in Siddharthanagar, Bhairahawa, Nepal’, The Stroke Journal, vol. 3, no. 1, pp. 9–14.

 

 

 

Appendix 4: Literature review matrix

Research Title, Authors and Date

Aims and Objectives

Research Methods and Ethical Issues

Population and Sample Size

Strengths and Weaknesses of the Methodology

Main Findings

Implications for Practice

Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal.

Nepal, G., Yadav, J.K., Basnet, B., Shrestha, T.M., Kharel, G. and Ojha, R.

2019.

 

Evaluate the factors contributing to pre-hospital delay of stroke patients in Nepal.

 

 

 

 

 

 

Data collected from both males and females over the age of 18.

 

A Modified Ranking Scale and Institute of Health stroke scale were used to identify the degree of stroke severity and level of disability the patient suffered.

 

Participants were included if they had presented with stroke symptoms pre-hospital, and had a stroke confirmed by neuroimaging in hospital. 

 

Authors have not disclosed patient identities and there are no conflicts of interest. 

 

The study gained ethical approval from the Review Board, Tribhuvan University Institute of Medicine. 

 

Research adhered to tenets of the Declaration of Helsinki, 2008.

 

Informed consent was gained from all participants. Where informed consent was not obtainable from the participant, it was gained from a next of kin. 

228 patients were enrolled into the study between August 2017 and August 2018.

 

The study was conducted in Tribhuvan University Teaching Hospital (TUTH) located in the capital city of Kathmandu, an urban city in Nepal. 

 

 

 

 

 

Strengths: 

Prospective analysis with a large sample size.

 

Only study to investigate pre-hospital delays in Nepal.

 

Weaknesses: 

Based in a single hospital in an urban setting.

 

Urban and remote Nepalese communities have diverse cultures, therefore the experience of those within this study may not have wider application to Nepal as a country.

Of the 228 participants, 48 arrived at hospital within the four-and-a-half-hour time limit for thrombolysis.

 

Factors that were associated with reduced pre-hospital delay include: onset during the day, facial deviation, speech disturbance, bystander identification of stroke, rushing to EDs after immediate onset of symptoms, direct presentation to EDs, participants living less than 20 km from EDs and education above high school.

 

Factors associated with increased pre-hospital delay included: heavy traffic, an income below $1000 (USD) per annum and diabetes mellitus.

The authors suggest that to reduce pre-hospital delay of stroke patients to EDs, the following implications need to be completed:

 

Community training to improve and spread awareness

 

Establish comprehensive stroke centres

 

Improving emergency services in the pre-hospital setting

 

Establish telestroke facilities

 

Encourage Tenecteplase as an alternative to Alteplase to reduce costs. 

Acute stroke management: the plight of Nepal

Chandra, A., Rajbhandari, P. and Pant, B.

 2019.

 

A study investigating the assessment and management of stroke in Nepal.

An observational study looking at the authors’ institutional experience of stroke assessment within the Nepalese health care system.

 

Patients were admitted due to presenting with stroke complaints, e.g., facial weakness, slurred speech, unilateral limb weakness. 

 

No source of funding reported.

 

Study does not detail if consent was gained from participants.

 

No conflict of interest declared.

300 patients were admitted to an inpatients’ ward in Nepal between early 2016 and February 2018.

 

 

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

Weaknesses: 

Observational study.

 

No evidence of ethical approval documented.

Just over 5% of patients were eligible for thrombolysis, however, the average time from onset of symptoms to thrombolysis was 1.5 hours.

 

15% of patients in the study were not aware of stroke symptoms and didn’t know if they had had a stroke.

 

 

Further public education is required to inform people of stroke presentations and management options.

 

The cost of thrombolysis remains high in Nepal, and international support is required to improve financial barriers.

Feasibility and efficacy of thrombolysis in acute ischemic stroke: a study from National Institute of Neurological and Allied Sciences, Kathmandu, Nepal

Thapa, L.,  Shrestha, S.,  Shrestha, P., Bhattarai, S.,  Gongal, D. N., and Devkota, U.P.

2016.

 

A study investigating the feasibility and efficacy of thrombolysis in Nepal.

This is a retrospective study conducted between July 2012 and August 2015.

 

Patients underwent a clinical examination and computed tomography to diagnose stroke. 

 

Included in the study were ischemic stroke patients who received thrombolysis within three hours of symptom onset. 

 

Recorded characteristics included ‘demographic profiles, clinical profiles, risk factors, type of thrombolytic

used, and outcomes’

 

Outcomes were measured against a modified Rankin Scale and National Institute of Health Stroke Scale.

 

There were no conflicts of interest declared. 

 

Ethical approval was gained from the Institutional Review Board.

 

Informed written consent was gained from all participants. 

496 patients attended a Nepalese emergency department presenting with acute stroke symptoms.

 

 

Strengths: 

Conducted in Nepal.

 

Well-cited and published in a peer-reviewed journal.

 

The study clearly documents the underpinning statistical data to support the claims and hypothesis.

 

Weaknesses: 

Retrospective study methodology.

 

Small study cohort. 

Of the 496 patients, 15 has transient ischemic stroke, 261 has ischemic stroke, 144 had haemorrhagic stroke, 21 had lacunar infarction and 55 had a subarachnoid haemorrhage. 

 

11 patients received thrombolysis, of which 9 were within the three-hour window.

 

Patient age ranged from 27 to 79.

 

Four patients had hypertension. One had previously had a transient ischemic attack. Three had rheumatic heart disease. One had atrial fibrillation. One had undergone surgery for mitral stenosis. Two were alcohol-dependent and one patient was a smoker. 

 

Four patients suffered complications. There were no fatalities because of treatment. 

 

Six patients had good neurological outcomes.

 

This study clearly documents the feasibility and effectiveness of thrombolysis in the management of acute ischemic stroke in Nepal.

 

This study’s findings are translatable to the care of acute ischemic stroke management in developing countries.

Endovascular management of acute ischaemic stroke in Nepal. 

Phuyal, S., Poudel, R., Shrestha, G.S., Dawadi, K., Rauniyar, V.K., Thapa, L., Adhikari, R.B., Thapa, A., Sedain, G., Acharya, S.P. and Jalan, P.

2020.

A review of endovascular acute ischemic stroke management at Grande International Hospital, Nepal.

Data collected from patients with acute ischemic stroke confirmed by radiological imaging.

 

The severity of the stroke was determined using the National Institutes of Health Stroke Scale.

 

9 of the 22 patients presented within the 4.5-hour window and received bridging intravenous thrombolysis before mechanical thrombectomy commenced.

 

For patients presenting within 6 hours of symptom onset, thrombectomy was only performed if there was an Alberta Stroke Program Early CT Score of greater than 6.

 

In patients presenting with symptoms between 6 and 24 hours old, thrombectomy was only performed if there was a clinical-diffusion mismatch and MRI-based Alberta Stroke Program Early CT score of more than 5.

 

A CT scan was performed within 24–48 hours of thrombectomy and patients were re-assessed at the three-month mark post-thrombectomy. Good functional independence is defined as a modified Rankin Scale score of two or less.

 

Authors have not disclosed any conflicts of interest.

 

The study does not comment on ethical approval.

22 patients were enrolled into the study in March 2019.

 

The review was conducted in Kathmandu, an urban city in Nepal.

 

 

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

 

Weaknesses: 

Retrospective study methodology.

 

Small study cohort. 

 

Supporting data is not presented in the paper.

 

Does not specify participant demographics.

This review observed that primary thrombectomy was performed in 13 cases and thrombectomy with bridging thrombolysis was used alongside intravenous alteplase in nine cases.

 

17 patients had good functional independence at a three-month follow up.

Pre-hospital delay remains a major limiting factor in the treatment of stroke in Nepal. This review proposes mechanical thrombectomy to be a viable treatment option in Nepal that accommodates patients who present too late for thrombolytics.

 

Despite this opportunity, the cost of the procedure remains high and unaffordable for many.

 

Findings were gained from a well-equipped, single tertiary centre in Kathmandu. Translating this research to less well-equipped centres in Nepal may be challenging.

 

 

Cardiovascular health knowledge, attitude and practice/behaviour in an urbanising community of Nepal: a population-based cross-sectional study from Jhaukhel-Duwakot Health Demographic Surveillance Site. 

Vaidya, A., Aryal, U.R, and Krettek, A.

2013

This study investigated and determined the attitude, knowledge, practice and behaviours toward cardiovascular health in residents of a semi-urban Nepalese community.

 

 

Data was collected via in-home interviews. The interview utilised a questionnaire based on the WHO STEPwise approach to surveillance.

 

All responses were recorded and scored.

 

Blood pressure and anthropometric measurements were also taken and recorded.

 

Ethical approval was gained from Nepal Health Research Council.

 

Funding for this study was supported by grants from the ‘Wilhelm & Martina Lundgren’s Foundation (vet1-367/2011 and vet1-379/2012) and the University of Gothenburg, Sweden through a “Global University” grant (A11 0524/09)’.

 

777 participants responded from six randomly selected groups in two urbanising villages near Kathmandu.

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

 

Large study cohort.

 

First study to explore knowledge, behaviour, and attitude towards cardiovascular health in Nepal.

 

A combination of prompted and unprompted questions utilises the benefits of both investigative methods.

 

Weaknesses: 

Retrospective study methodology.

 

High female participant group creates gender bias; thus, results are more likely to represent female Nepalese participants.

 

 

 

Of the 777 participants, 70% were women and 29.9% lacked formal education.

Within the cohort, cardiovascular risk was high; 21.6% were hypertensive, 20.1% were smokers and 43.3% had low physical activity. There was also a low level of knowledge about heart disease; 11% identified being overweight as a risk factor, 29.7% identified hypertension as being a risk factor and 2.2% identified hyperglycaemia as being a risk factor.

 

60% of participants could not identify any heart attack (HA) symptoms, 20% could identify two to four HA symptoms.

 

Overall, the study concluded that 44% of participants had insufficient cardiovascular knowledge. Moreover, less than 20% had highly satisfactory knowledge.

 

The study findings suggest poor knowledge, behaviours, and attitudes towards cardiovascular health in the semi-urban Nepalese communities studied.

 

There is an opportunity for a follow-up study that investigates male vs female knowledge, behaviours, and attitudes.

 

Moreover, further education about cardiovascular health is needed throughout semi-urban Nepal.

 

 

Prevalence of cardiovascular health risk behaviours in a remote rural community of Sindhuli district, Nepal.

Dhungana, R.R., Devkota, S., Khanal, M.K., Gurung, Y., Giri, R.K., Parajuli, R.K., Adhikari, A., Joshi, S., Hada, B. and Shayami, A.

2014.

This study aimed to identify how prevalent cardiovascular risk behaviours are in a Nepalese outback community.

This study utilised a descriptive cross-sectional methodology.

 

Participants were randomly selected from Tinkanya Village Development Committee (VDC) in Sindhuli between January and March 2014.

 

Data was collected using a WHO-NCD STEPwise approach questionnaire.

 

Verbal consent was given by all participants.

 

Ethical approval was gained from the Institutional Review Board of the Institute of Medicine, Kathmandu.

 

The authors have not declared any conflicts of interest.

A total of 406 participants aged 20 to 50 were included.

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

 

Large study cohort.

 

Weaknesses: 

Retrospective study methodology.

 

High number of female and indigenous participants included in this study; thus, findings are not well generalised to male and non-indigenous people.

 

Of participants, 76.3% had a low socio-economic status.

 

63.1% lacked formal schooling.

 

46.3% were smokers.

 

28.6% had an insufficient vegetable and fruit intake.

 

96.6% undertook insufficient exercise.

 

37.4% were overweight or obese.

 

On average, daily sodium intake per capita was 14.4g (±4.89g).

 

12.3% were hypertensive.

This study identified a high percentage of high-risk health behaviours in a remote rural community of Sindhuli district, Nepal. Further education is needed to reduce non-communicable disease and improve health behaviours. 

 

Telestroke: beliefs, expectations and perceived barriers among community people residing in Siddharthanagar, Bhairahawa, Nepal. 

Ghimire, S., Ghimire, M.R., Gurung, A., Kachapati, A. and Gurung, S.

2019.

This study investigated the beliefs, expectations, and perceived barriers of telestroke among the Siddharthanagar Municipality community.

A cross-sectional study method was utilised.

 

One participant with prior stroke knowledge completed a semi-structured interview.

 

Collected data included socio-demographic as well as beliefs, expectations and perceived barriers regarding telestroke.

 

Ethical approval for this study has not been declared.

 

The authors declared no conflicts of interest.

100 participants residing permanently in Siddharthanagar Municipality were enrolled between March 2018 and August 2018.

 

57% of participants were male and educated to grade 10 (61%).

 

Ages ranged from 16 to 76.

 

98% were aware of the term ‘stroke’.

 

80% had heard of telemedicine or telestroke.

 

Siddharthanagar Municipality is a city in the Outer Terai plains of Nepal.

Strengths: 

Conducted in Nepal.

 

Published in a peer reviewed journal.

 

Weaknesses: 

Sampling bias, as the study was conducted in a single setting using a purposive sampling technique.

 

 

 

 

 

56% of participants felt that telemedicine improved stroke diagnosis and treatment.

 

Perceived barriers to telestroke were:

  1. Technology (45%)
  2. Increased personal work (45%)
  3. Cost (52%)
  4. Management of tissue plasminogen activator side effects (32%)
  5. Safety and confidentiality of data (48%)
  6. Online safety (43%)

 

This study was conducted on both healthcare professionals and non-healthcare professionals. Further research on healthcare professionals’ beliefs, expectations and perceived barriers would be useful. 

Knowledge of stroke among middle-aged adults in a community at Ratuwamai, Morang

Silwal, S., Khadka, S. and Sah, B.K.

2019.

This study objectively assesses stroke knowledge among middle-aged adults in a community at Ratuwamai, Morang.

This study utilised a descriptive, cross-sectional methodology.

 

A non-probability purposive sampling method was used to select participants.

 

The study used a semi-structured interview questionnaire to obtain data.

 

117 participants were included in the study.

 

Participants were 40 to 65 years of age.

 

62.1% were over the age of 50.

 

32.9% of participants had achieved secondary-level education.

 

Ratuwamai is a rural town situated in south-eastern Terai in Morang district, Nepal. 

Strengths: 

Conducted in Nepal.

 

Published in a peer reviewed journal.

 

Weaknesses: 

Sampling bias, as the study only investigated ‘middle-aged’ participants.

 

Study cohort reported an increased income compared to the local average reported in similar studies.

 

 

97.4% of participants correctly stated that a stroke was a brain problem.

 

100% stated that being 45 years of age or older was a high-risk factor.

 

91.5% identified hypertension as a risk factor leading to stroke.

 

96.6% thought that sudden-onset dizziness was a stroke symptom.

 

 

This study claims that a widespread stroke programme is needed to improve knowledge, thus, improving stroke outcomes by reducing pre-hospital stroke delays and improving cardiovascular health behaviours.

Knowledge, attitude, and practice of stroke among high school students in Nepal.  

Thapa, L., Sharma, N., Poudel, R.S., Bhandari, T.R., Bhagat, R., Shrestha, A., Shrestha, S., Khatiwada, D. and Caplan, L.R.

2016.

This study assessed the baseline knowledge, attitudes, and practices of high school students in Nepal with respect to stroke.

Data was collected from 33 private high schools in Bharatpur, Chitwan district, Central Southern Nepal.

 

Students completed a 15-question yes/no self-structured questionnaire.

 

Results were subject to a chi-square test.

 

The authors reported no conflicts of interest.

 

The paper does not comment on ethical approval or participant consent.

 

1,360 students participated in the study. 55.9% were male.

87.3% were Hindu.

10.4% were Buddhist.

1.5% had a family member who has suffered a stroke.

10.4% knew of someone who had suffered a stroke in their neighbourhood.

30.2% personally knew someone who had had a stroke.

 

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

 

First study to investigate stroke awareness among high school students in Nepal.

 

Weaknesses: 

Sampling bias as only investigated ‘high school-age’ participants who came from backgrounds affluent enough to afford private education.

 

Semi-structured questionnaire with closed yes/ no answers fails to allow for exploration of reasoning.

 

Rural schools and government schools not included.

 

39.3% of participants stated that stroke was a brain problem.

 

72% identified unilateral limb weakness or numbness as a sign of stroke.

 

74% stated hypertension to be a high-risk factor.

 

88.9% would take someone with stroke symptoms to hospital.

 

55.5% felt that Ayurvedic treatment would improve stroke outcome.

 

44.8% stated that stroke was detrimental to a happy life.

 

86.3% stated that family care was essential to stroke recovery.

 

Participants that stated at least one stroke risk factor were 2.83% more likely to take someone with stroke symptoms to hospital.

Overall, stroke understanding and recognition in the Nepalese high school students investigated was good, however, stroke misconceptions continue to exist. Further education is needed to ensure adequate stroke knowledge and understanding of stroke management.

Knowledge and attitude regarding risk factors of cardiovascular disease among general people residing in Nepalgunj, Banke, Nepal.

Tharu, R.P. and Rawal, S.

2020.

The aim of this study was to assess the knowledge and attitudes of cardiovascular disease risk factors among individuals residing in Dhamboji-1, Nepalgunj, Banke, Nepal.

A descriptive cross-sectional research design was used.

 

Primary data was collected through a self-administered questionnaire.

 

Non-probability convenience sampling was used to select participants.

 

Data was collected and analysed through both descriptive and inferential statistics (SPSS software version 21).

 

No conflicts of interest are declared.

 

Informed consent was gained from all participants.

 

Ethical approval was granted from Nepalgunj Sub Metropolitan City, Wada Karyalaya, Dhomboji-1.

 

100 participants were selected from Dhamboji-1, Nepalgunj, Banke, Nepal during July 2019. 

 

 

Strengths: 

Conducted in Nepal.

 

Published in a peer-reviewed journal.

 

Findings correlated with similar studies.

 

Study has been well cited in peer-reviewed literature and much of its findings are supported.

 

Weaknesses: 

Cohort limited to 100.

 

Limited to one Nepalese community.

 

Sampling bias present as only those who wanted to take part did so.

Overall, attitudes towards cardiovascular disease risk factors were deemed unfavourable among the participants.

 

However, knowledge of cardiovascular disease risk factors was acceptable.

 

This study concluded that cultural health behaviours among the cohort were poor despite adequate underpinning of health knowledge.

A comprehensive programme of education and training focused on all cardiovascular risk factors required to reduce the burden of cardiovascular disease on Nepal’s population.

 

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