Introduction
: Comprehensive stroke centers require resource‐intensive patient care and supportive divisions. Resource underutilization can include: traditional beliefs about etiology of stroke, transportation barriers, or an inability to recognize early symptoms of stroke. We explore the available literature to determine region‐specific social and cultural barriers to obtaining stroke care.
Methods
: A literature review was performed to identify studies that described stroke care in low‐income and middle‐income countries (LMICs). We used the search term “stroke” along with the following terms: “burden”, “incidence”, “prevalence”, “awareness”, “transportation”, “stroke services”, “rehabilitation” “tissue plasminogen activator”, “acute stroke”, “emergency care”, “infrastructure”, “stroke services”, “quality improvement”, and “stroke units”, between January 1st, 2015 and August 1st, 2021. Forty‐five articles were identified.
Results
: We identified two broad limitations to expanding stroke care across the globe: infrastructure and education/ culture. We subdivided stroke care regionally into Middle East and North Africa (MENA), Europe, Asia, Latin America, and Subsaharan Africa. In MENA, religious health fatalism scores on questionnaires are negatively correlated with adherence to rehabilitative protocols and stroke outcome. Increased faith engagement conversely is strongly correlated with improved psychiatric outcome following stroke, indicating a role in properly educating Middle Eastern citizens regarding stroke etiology and urgency of treatment. In Europe stroke mortality and incidence is greater in rural areas in the region, likely indicating transit‐related difficulties in obtaining stroke care or deficits in education regarding lifestyle‐based measures to reduce vascular disease. Low per capita numbers of stroke‐specific care units in southern and eastern countries indicate a significant care access need in rural and low‐resource regions. For Asia, a lack of major infrastructure obstacles to wider accessibility of EVT, especially among developing countries. Only 6.5% in a nationwide survey in China were aware that there was a therapeutic window for thrombolytic therapy in 2016, increased to 32.8% after a 2 year nationwide campaign. The adept use of social media to target high‐risk populations can improve awareness of therapeutic windows. Ethnic and socioeconomic disparities are especially pronounced in this region. The RESILIENT trial demonstrated the effectiveness of EVT in Brazilian public hospitals, which helped convince the government to change policy and promote the use of EVT. Similar trials could be used to convince other governments to shift policy and promote the use of EVT as standard of care in public hospital systems. Some African communities consider stroke to be an illness of debilitating/ paralytic, ghost, or shivering etiology. Many communities rely on non medical means of care. A survey at Ignance Deen Neurology ward in 2014 revealed that only 2% of stroke patients arrived in an ambulance while 46% came by public transport and 27% arrived by personal car.
Conclusions
: Social and cultural barriers to obtaining stroke care are based on lack of availability and patient trust. Trust in care and compliance with preventive/rehabilitative measures may be helped by connecting NGOs such as Stroke Angels and Mission Thrombectomy 2020 with community‐based/ religious leaders to correct assumptions about origin and treatment. Targeted, culturally‐relevant messaging may help to increase awareness about symptoms, risk factors, and etiology.
Government-business alliances in state capitalist economies: evidence from low-income markets in China