Stroke Prevalence in Australia
Discuss about the Epidemiology and Principles of Research.
Stroke acts as a significant contributing factor for the total disease burden on a global scale and research indicates it to be preceding coronary heart disease as the cause of death. Further, stroke is a notable reason for disability among individuals. Stroke is defined as the condition in which cell death in brain is due to poor supply of blood. It is the acute loss of brain function due to impairment of blood supply. As per the World Health Organization definition for stroke, it is the “neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours” (1). Medical science classifies stroke into two categories; hemorrhagic, as a result of bleeding, and ischemic, as a result of the absence of blood flow. Signs of such a condition include the restriction to feel or move a side of the body, loss of vision to one side, and difficulties in speaking or understanding. Research indicates that ischemic stroke constitutes almost 80% of the total stroke cases (2).
In Australia, the prevalence of stroke can be estimated on the basis of self-reported data collected from the 1998, 2003 and 2009 Surveys of Disability, Ageing and Carers (SDACs) conducted by the ABS (Australian Bureau of statistics). In the year 2009, approximately 375,759 Australians have had suffered a stroke in their lifetime. Overall, the incidence of stroke was much higher in males as compared to female (1.9% as compared to 1.3%). 70% of people who had suffered a stroke had the age and above (3). In Australia, the burden of stroke mostly affects the disadvantaged populations within the different communities in a disproportionate manner. Those living in the low socioeconomic group have more chances of suffering from a stroke. The trend is further magnified in indigenous population (4). As per the reports of AIHW, the overall stroke incidence is found to be twice among the indigenouspopulation. Disparities in risk factor prevalence among the two groups contribute to this discreet burden of stroke between the country’s populations.
The burden of stroke mortality is compounding, and the direct impact of stroke on the central nervous system is the cause of a wide array of disability. Survival from stroke and the comprehensive rehabilitation process is a major cause off increased cost to the healthcare system. Stroke was the cause of death for 8300 individuals in Australia in the year 2010 and accounted for 6% of all deaths in the country (5). Research indicates that death rates due to stroke increase considerably with age. More females died due to stroke as compared with males. However, age-specific rates were found to be higher in males than females between the ages of 55 and 84. Expanded research on this arena indicates that hemorrhagic stroke is more associated with loss of good health when a comparison is done to ischemic stroke. This can be attributed to the higher case fatality rate among those with younger age. Raw mortality rate defining stroke burden emphasizes that the issue can only be controlled with better management strategies addressing the distinct risk factors.
Burden of Stroke Mortality
The healthcare expenditure for strokes in the country is in millions and accounts for almost 7% of total healthcare expenditure for all cardiovascular diseases. It is to be highlighted in here that healthcare expenditure is not only a result of expenditure incurred due to a residential care facility. The cost of healthcare is also related to admission of hospital-admitted patients, out-of-hospital medical services and pharmaceuticals. Reports of the year 2008–09, the total estimated expenditure on stroke as indicated by research was found to be more for males as compared to females (6).
Research highlights that the complications of suffering stroke are multivariate. The common complications include brain edema, pneumonia, urinary tract infection, seizures, clinical depression, and deep venous thrombosis. The main aim of management guidelines for stroke focuses on improvement in quality of life of patients, through primary, secondary and tertiary care. Management of stroke patients is complex and needs interventions encompassing drug therapies, medical supervision and monitoring (7).
The causal factors and the risk factors for stroke are widely noted across the literature. Causation of stoke has been indicated to be complex, caused due to an imperative association between risk factors. These factors are both modifiable and non-modifiable across a wide range of biomedical and behavioural factors. One must note that broader community-based socioeconomic factors are also involved in this process. The traditionally considered risk factors include tobacco smoking and hypertension which have been noted as synonymous with cardiovascular diseases (8). The non-modifiable risk factors include ethnicity, gender age, inherited disease and weight at birth, while the modifiable risk factors include diabetes mellitus, hypertension, heart diseases, alcohol abuse, dyslipidemia, obesity, metabolic syndrome, peripheral artery disease and drug abuse.
A rich pool of studies highlights hypertension to be the most significant contributor to risk of stroke. The other top risk factors include smoking, obesity, physical activity and diet which make up near about 80% of the total risk for stroke etiologies across the globe. A small pool of evidence indicates that hypertension acts as a more prominent risk factor in individuals for hemorrhagic stroke as compared to ischemic stroke. High blood pressure has been proved to increase the risk for stroke by four times. Alcohol intake has also been indicated to be more related to hemorrhagic stroke. There exists strong evidence that genetic basis of certain individuals acts as a risk factor for stroke. The chances of an individual to suffer a stroke are 2.79 times higher if the person has a parental history of stroke prior to the age of 65 years (9).
The causal role of certain less well-documented risk factors is also to be discussed in here. Though further studies are needed to address the fact that role is inconclusive, the factors are noteworthy. These factors include an increase of the apoB/apoA1 ratio, psychological stress, sleep-related disorders, poor diet and frequent infection (10). Future characterization of these risk factors through well-designed clinical research studies would certainly add valuable knowledge. This would form the base for well-tailored preventive strategies addressing the high prevalence of stroke.
Complications of Stroke
Model development for stroke causation is to consider the different behavioral risk factors along with the distinct biomedical risk factors in the context of social and environmental influences. It is noteworthy that such overarching influences are applicable to diverse populations of the community (11). Though there are no direct implications in stroke causation, the distal factors have a notable impact on the prevalence of almost all proximal risk factors. The findings of research a relevant study indicate deaths due to stroke is more common among those coming from the lower socioeconomic group. High prevalence of risk factors such as smoking and hypertension among these individuals are noteworthy. Individuals from this socioeconomic class are also associated with lower level of education and unemployment. The researchers contend that the rate of stroke might be underestimated in some epidemiological studies since distance is a crucial factor for poor hospital attendance in areas that are remote (12).
The multifactorial model provided below is a clear representation of a proximal to a distal causal pathway that highlights schematic associations existing between the diverse factors. It is found that proximal factors like hypertension and smoking are inextricably associated with the pathology of stroke. When the perspective is holistic, one can note that the path between proximal and distal factors is distinct. For instance, an individual having low literacy rate is likely to be coming from low socioeconomic status. As a result, the chances of hypertension and habit of smoking are more in this individual. Additional complexities are a result of multiplicative consequence of a wide range of risk factors acting together in amalgamation with each other. For instance, obesity is a prime risk factor for the development of diabetes, while these two overall act as a major risk factors for stroke. The individual’s mental and psychological wellbeing is also to be considered in this regard. The present model of causation encompasses the stroke risk factors identified and brings into limelight the comprehensivecharacters of the stroke causal pathway together with the disease prevention strategies (13).
Healthcare organizations across Australia are coming up with blueprints for improvement of health in the country and reducing the burden of strokes. The overarching aim of the department of health is to bring improvement in the health status of the population and bring it to the best level. Progressively reducing the inequalities in health outcomes related to stroke would be the key objective. Improvement in care, primary and secondary, for stroke, across the continuum of services is to be achieved in the near future by giving equal opportunities to indigenous population (14).
Preventive strategies for curbing the prevalence of stroke would be effective when implemented if they target the population who are at higher risk of suffering the condition- the indigenous population. Approaches to the population, in general, are complementary. The importance of prevention of hypertension through risk factor prevention strategies would be amplified due to the concurrent impact on other health conditions. These include the widely noted influence of tobacco smoking on lung diseases and lack of physical activities on diabetes. Secondary prevention is required in individuals who suffer from the peripheral arterial disease. Reduction in smoking habits among the population would also serve as an important preventive strategy. It is to be mentioned in here that preventive strategies are to be implemented across the life span of an individual. Evidence from other countries indicates that benefits can be achieved in the long term when nutritional interventions are implemented (15).
Causal and Risk Factors for Stroke
The priorities for national action are to be highlighted at this juncture. The government is to come forward to support coordinated approaches to tobacco control, physical activity and nutrition by acting upon present work. The at-risk populations are indigenous Australians, socioeconomically challenged individuals, older Australians, people with mental health disease, people living in rural isolation (16). Tools and information are to be developed and disseminated for supporting general practitioners and consumers to consider the accurate treatment as per the level of risk of suffering stroke. Population-based strategies would include health education imparted to the population across communities on the risk factors for stroke. Primary care units have a key role in this regard. Healthcare professionals are to work in collaboration with each other in the domain of chronic disease management, such as diabetes and mental health conditions. Further, awareness is to be raised among the healthcare providers and consumers regarding the necessity of seeking urgent medical treatment when the early signs and symptoms of stroke are evident. Health workers in remote and rural workers are to be provided with training and education so that they can handle emergency cases efficiently. On the national level, there is also a need of revising the guidelines for stroke management and prevention for incorporating updated developments in the care system for stroke. Increasing the availability of stoke care unit would also be beneficial (17).
In conclusion, stoke suffered by adults in Australia has become an important health concern in the country in the recent past. Though research indicates that the risk factors are almost similar in the country’s indigenous and non-indigenous population, the burden of the disease is not distributed equally. The issue is more prominent in a community where majority of the indigenous populations are experiencing worse health, economic and social outcomes as compared to the non-indigenous counterparts. In addressing the high prevalence rate of stroke among the population and reducing the burden of the disease, there is a vital need of recognizing the multifactorial nature of the health condition. Considering the conventional proximal risk factors would act as a suitable approach for health professionals who are responsible for delivering primary care across communities. Nevertheless, there exists a large scope for addressing the distal community-based factors. Socioeconomic, environmental and psychological factors hold prime importance in this regard. A holistic approach might be beneficial for addressing the morbidity and mortality related to stroke among adults in Australia. Appropriate preventive and management strategies are to e implemented at the earliest for stopping the increasing prevalence of the condition. Collaboration between government and non-government organizations are pivotal in this regard.
References
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jan 1:STR-0000000000000024.
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun 1;47(6):e98-169.
gov.au. 2018 [cited 21 March 2018]. Available from: https://www.aihw.gov.au/getmedia/3d56c949-68a4-46f3-bc7c-c40c89904d38/13994.pdf.aspx?inline=true
Bray J, Finn J, Cameron P, Smith K, Straney L, Nehme Z, Bladin C. Stroke Public Awareness Campaign are Associated With Improved Ambulance Use for Stroke and Tia in Victoria, Australia.
Lynch EA, Cadilhac DA, Luker JA, Hillier SL. Current rehabilitation assessment practices do not identify any unmet rehabilitation needs for patients with stroke in Australia. International Journal of Stroke. 2015 Sep 1;10:42.
Sacks G, Martin J, Veerman L. Australian sugary drinks tax could prevent thousands of heart attacks and strokes and save 1600 lives. Journal of the Home Economics Institute of Australia. 2016;23(1):40.
Sajobi TT, Menon BK, Wang M, Lawal O, Shuaib A, Williams D, Poppe AY, Jovin TG, Casaubon LK, Devlin T, Dowlatshahi D. Early trajectory of stroke severity predicts long-term functional outcomes in ischemic stroke subjects: results from the ESCAPE Trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times). Stroke. 2017 Jan 1;48(1):105-10.
Davis AP, Billings ME, Longstreth Jr WT, Khot SP. AUTHORS RESPOND: Early diagnosis and treatment of obstructive sleep apnea after stroke: Are we neglecting a modifiable stroke risk factor?.
Brown DL, Conley KM, Sánchez BN, Resnicow K, Cowdery JE, Sais E, Murphy J, Skolarus LE, Lisabeth LD, Morgenstern LB. A multicomponent behavioral intervention to reduce stroke risk factor behaviors: the stroke health and risk education cluster-randomized controlled trial. Stroke. 2015 Oct 1;46(10):2861-7.
Lichtman JH, Froelicher ES, Blumenthal JA, Carney RM, Doering LV, Frasure-Smith N, Freedland KE, Jaffe AS, Leifheit-Limson EC, Sheps DS, Vaccarino V. American Heart Association Statistics Committee of the Council on Epidemiology and Prevention and the Council on Cardiovascular and Stroke Nursing. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation. 2014 Mar 25;129(12):1350-69.
Towfighi A, Cheng EM, Ayala-Rivera M, McCreath H, Sanossian N, Dutta T, Mehta B, Bryg R, Rao N, Song S, Razmara A. Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED). BMC neurology. 2017 Dec;17(1):24.
Banerjee TK, Das SK. Fifty years of stroke researches in India. Annals of Indian Academy of Neurology. 2016 Jan;19(1):1.
Multifactorial causation of stroke in Australia: a comparison [Internet]. Msja.anu.edu.au. 2018 [cited 21 March 2018]. Available from: https://msja.anu.edu.au/multifactorial-causation-of-stroke-in-australia-a-comparison.php
Peter J, Justus AH. Knowledge and Practices of Stroke Survivors Regarding Secondary Stroke Prevention, Khomas Region, Namibia. Journal of Medical Biomedical and Applied Sciences. 2016 Feb;3.
Baum F. The new public health. Oxford University Press; 2016.
Brownson RC, Baker EA, Deshpande AD, Gillespie KN. Evidence-based public health. Oxford University Press; 2017.
Rutledge GE, Lane K, Merlo C, Elmi J. Coordinated Approaches to Strengthen State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke. Preventing chronic disease. 2018;15.