Oyedunni Arulogun

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol

Background: As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research. Methods: SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. Study Significance: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Randomized controlled trial of a multipronged intervention to improve blood pressure control among stroke survivors in Nigeria

Rationale Stroke is the second-leading cause of death in low- and middle-income countries, but use of evidence-based therapies for stroke prevention in such countries, especially those in Africa, is extremely poor. This study is designed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge. Aim/Hypothesis The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke (THRIVES) significantly improves blood pressure control after stroke. Design This prospective triple-blind randomized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria. The culturally sensitive, system-appropriate intervention comprises patient report cards, phone text messaging, an educational video, and coordination of posthospitalization care. Study Outcomes The primary outcome is improvement of blood pressure control. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers. Discussion We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region.

Stroke genomics in people of African ancestry: charting new paths.

Abstract One in six people worldwide will experience a stroke in his/her lifetime. While people in Africa carry a disproportionately higher burden of poor stroke outcomes, compared to the rest of the world, the exact contribution of genomic factors to this disparity is unknown. Despite noteworthy research into stroke genomics, studies exploring the genetic contribution to stroke among populations of African ancestry in the United States are few. Furthermore, genomics data in populations living in Africa are lacking. The wide genomic variation of African populations offers a unique opportunity to identify genomic variants with causal relationships to stroke across different ethnic groups. The Stroke Investigative Research and Educational Network (SIREN), a component of the Human Health and Heredity in Africa (H3Africa) Consortium, aims to explore genomic and environmental risk factors for stroke in populations of African ancestry in West Africa and the United States. In this article, we review the literature on the genomics of stroke with particular emphasis on populations of African origin.

Community attitudes towards childbearing and abortion among HIV-positive women in Nigeria and Zambia.

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive womans pregnancy – induced abortion or birth – to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

Multilingual Validation of the Questionnaire for Verifying Stroke-Free Status in West Africa

Background and Purpose— The Questionnaire for Verifying Stroke-Free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological, and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages, Yoruba, Hausa and Akan, for ascertainment of stroke-free status of control subjects enrolled in an on-going stroke epidemiological study in West Africa. Methods— Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records, and neuroimaging (gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Results— The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by gold standard, 98% were determined to have had stroke, whereas of 219 without stroke 87% were determined to be stroke-free by QVSFS. Negative predictive value of the QVSFS across the 3 languages was 0.97 (range, 0.93–1.00), sensitivity, specificity, and positive predictive value were 0.98, 0.82, and 0.80, respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen k=0.92. Conclusions— QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.

Community Gate Keepers' Awareness and Perception of Prevention of Mother-To- Child Transmission of HIV Services In Ibadan, Nigeria

Each year, around half a million children aged under 15 become infected with HIV and more than 90% are the result of mother-to-child transmission. Services to prevent mother-to-child HIV transmission (PMTCT) are therefore important entry points for HIV/AIDS prevention, treatment and care services for women, their children and families. The study aimed at identifying level of awareness and knowledge of PMTCT services that can be utilized in improving access. The methodology consisted of 20 individual in-depth interviews spread over Adabeji, Adeoyo/Agbadagbudu, Jakiru/Onipasan and Eleta communities, in Ibadan among household heads, religious and community based leaders. Key factors identified were low knowledge of mother to child transmission, lack of knowledge of the PMTCT services, inadequate community sensitization, inadequate healthcare facilities. The success of PMTCT programmes demands a shift towards a more community-based approach which calls for strong advocacy, enlightenment and community mobilization for improved awareness and utilization of PMTCT services.

Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol.

BACKGROUND There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa (SSA), where use of evidence-based therapies among patients receiving conventional care is poor. Designs of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors (including local perceptions and public policies) contributing to the likelihood of compliance with recommended therapeutic goals. This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country. METHODS Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital settings in Nigeria. Six adult stroke survivor focus group discussions and six caregiver focus group discussions, each lasting about 120 minutes will be conducted. Each group will comprise 6 to 8 participants. We will also conduct 22 semi-structured key informant interviews (informed by the Theoretical Domains Framework) with several types of providers and hospital administrators. Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals. Transcript data will be analyzed by reviewers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology, and will involve participatory co-analysis with key stakeholders to enhance authenticity and veracity of findings. DISCUSSION On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1, we intend to develop a culturally sensitive, system-appropriate, multipronged intervention whose efficacy to boost adherence to evidence-based stroke-preventive care will be tested in a future randomized trial (phase 2).

Validation of the 8-item questionnaire for verifying stroke free status with and without pictograms in three West African languages

Background The Questionnaire for Verifying Stroke-free Status (QVSFS) has been validated in Western populations as a method for verifying stroke-free status in participants of clinical, epidemiological and genetic studies. This instrument has not been validated in low-income settings where populations have limited knowledge of stroke symptoms and literacy levels are low. Objective To simultaneously validate the 8-item QVSFS in 3 languages spoken in West Africa (Yoruba, Hausa and Akan) for ascertainment of stroke-free status of control subjects in SIREN. Methods Using a cross-sectional study design, 100 participants each from the 3 linguistic groups will be consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status will be determined by neurologists using structured neurological examination, review of case records and neuro-imaging (Gold standard). The relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) will be assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Conclusion The proposed study will provide valuable data on the performance of the QVSFS in resource-limited settings.

Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study

Summary Background Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa. Methods The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs. Findings Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59.0 years (SD 13.8) for cases and 57.8 years (13.7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98.2% (95% CI 97.2–99.0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19.36 (95% CI 12.11–30.93) and 90.8% (95% CI 87.9–93.7) for hypertension, 1.85 (1.44–2.38) and 35.8% (25.3–46.2) for dyslipidaemia, 1.59 (1.19–2.13) and 31.1% (13.3–48.9) for regular meat consumption, 1.48 (1.13–1.94) and 26.5% (12.9–40.2) for elevated waist-to-hip ratio, 2.58 (1.98–3.37) and 22.1% (17.8–26.4) for diabetes, 2.43 (1.81–3.26) and 18.2% (14.1–22.3) for low green leafy vegetable consumption, 1.89 (1.40–2.54) and 11.6% (6.6–16.7) for stress, 2.14 (1.34–3.43) and 5.3% (3.3–7.3) for added salt at the table, 1.65 (1.09–2.49) and 4.3% (0.6–7.9) for cardiac disease, 2.13 (1.12–4.05) and 2.4% (0.7–4.1) for physical inactivity, and 4.42 (1.75–11.16) and 2.3% (1.5–3.1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence. Interpretation Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans. Funding National Institutes of Health.

Exclusive breastfeeding and related antecedent factors among lactating mothers in a rural community in Southwest Nigeria

This study explored the antecedent factors influencing the practice of exclusive breast feeding (EBF) among lactating mothers in Ayete, a rural community in Southwest Nigeria. A three-stage random sampling technique was used to select 410 mothers of newborns and infants less than six months from households. A pretested semi-structured questionnaire which included a 14-point knowledge scale was used for data collection. Data were analyzed using descriptive statistics, Chi-square test and analysis of variance (ANOVA). Mean age was 27.4±5.9 years and 67.1% respondents were aware that EBF should be initiated immediately after birth. Mean knowledge score on EBF was 8.2±2.9. Age, educational level and occupation were significantly associated with knowledge of EBF (p<0.05). Main perceived challenges associated with EBF were loss of essential nutrients by mothers (87.6%) and inducement of hunger (26.2%). Only 10.2% of respondents were practicing EBF as at the time of the study. Reasons for not practicing EBF included baby needs herbs for strength and vitality (31.3%), baby needed water to quench thirst (23.9%) and non-satisfaction with breast milk alone (20.8%). Practice of EBF was significantly more among respondents earning less than N5000.00 monthly (p<0.05). Continuous sensitization activities are needed to promote breast feeding among lactating mothers. Key words: Exclusive breastfeeding, lactating mothers, antecedent factors.