Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES)

Background

World Health organization (WHO) estimates indicate that death from stroke in low-income and middle-income countries (LMIC) accounted for 86% of stroke deaths worldwide, and the disability adjusted life years lost in these countries are almost seven times the number lost in high-income countries. Most of these LMIC are in Africa. Moreover, it is expected that as deaths from infectious diseases wane, the burden of stroke is likely to increase substantially over the next few decades in LMICs.

Hypertension, the most potent modifiable risk factor for stroke, and once rare in Africa, is emerging as a serious endemic threat (about 37% of the general population in Nigeria, Africa’s most populous country has hypertension). The occurrence of a stroke itself is the strongest predictor of a repeat event (secondary stroke), which carries an even higher risk of death than a first-time stroke.

Given all of the aforementioned, there is an urgent need to craft and validate effective health care delivery programs that can mitigate the devastating consequences of stroke through enhanced control of high blood pressure in LMICs.

Aims

The overall aim of Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) was to determine whether a culturally-sensitive multipronged post-discharge intervention could significantly reduce blood pressure, enhance achievement of guideline recommended targets for risk factor control, and lower recurrent vascular events in Nigeria.

Project plan

THRIVES has unfolded into five distinct phases:

• Pretest qualitative

• Main qualitative (focus group discussions and semi-structured interviews)

• Intervention tailoring and redesign

• Randomized clinical trial

• Translation to institutional/governmental policy

The research objective for the RCT phase was to conduct a randomized clinical trial of the developed THRIVES intervention vs. standard post discharge management in stroke patients discharged from four hospitals in Nigeria. The primary outcome was a significant reduction in systolic blood pressure at one year. Other study objectives evaluated whether the intervention showed a signal of potential efficacy in reducing the rate of subsequent primary vascular events and investigate whether the intervention compared with usual and customary care will reduce functional disability and enhance quality of life at one year. The final objective was to estimate, in a preliminary fashion, the cost-impact and cost-effectiveness of the THRIVES post discharge intervention, compared with usual and customary care. The multi-pronged intervention involved the use of a patient video therapy, patient report card, and text messages. The patient interactive video therapy was adapted and produced in three languages (English, Yoruba and Pidgin English) in tandem with the primary languages of the study population. A THRIVES Task Force evaluated and reviewed all materials produced.

Impact

The project showed that the THRIVES intervention did not significantly reduce blood pressure compared with the control. However, there was a similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension and both groups received text-messages and a modest financial incentive. Further study is required to determine which aspects of the intervention were effective.

Publications and output

GACD have published an end-of-programme report providing a comprehensive summary of the programme and outcomes

Principal investigators

Team members

Funding organisations

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