Multi-level community interventions for primary stroke prevention: A conceptual approach by the World Stroke Organization

Abstract

The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs). This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy. (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia. (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs. (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.

Stroke prevention and control system in China: CSPPC-Stroke Program

“…Chinese stroke center construction is divided into two levels and four layers. 13 The two levels refer to advanced stroke centers and stroke prevention centers. The advanced level is divided into two layers: demonstration advanced stroke centers and advanced stroke centers.…”

“…11 The current World Stroke Organization policy for primary stroke prevention is based on a motivational population-wide strategy implemented by a fully validated and free mobile tool endorsed by all major international stroke, neurology, and heart organizations: the Stroke Riskometer app. 13 Thus, it is important to adapt these strategies for primary stroke prevention in China in future development of the China Stroke Prevention Program. Lastly, the planned future development of the China Stroke Prevention Program should be outlined.…”

Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments

“…The program is being implemented in Argentina, Bolivia, Brazil, Chile, Colombia, Dominican Republic, Ecuador, Mexico, Panama, and Peru and has been widely discussed at the Global Stroke Alliance platform with support of the Pan-American Health Organization (PAHO, which represents the WHO in the Americas) 10 , the Ministry of Health of Brazil, and the World Stroke Organization to implement the HEARTS program in Brazil, to treat patients with hypertension and diabetes, and to implement a clinical trial to assess the concept of treating patients at middle risk of stroke (systolic blood pressure 121-139 mmHg plus one lifestyle risk factor) in primary care using an antihypertensive plus statin polypill, Stroke Riskometer and working with community health workers. Our goal is to demonstrated a 50% reduction in stroke incidence with this program (the WSO "Cut stroke in half " Initiative) (35).…”

Trends and Challenges of Wearable Multimodal Technologies for Stroke Risk Prediction

“…The Stroke Riskometer is a mobile app endorsed by the World Stroke Organization to evaluates one's risk of stroke over the next 5 to 10 years based on 20 questions. In addition, it provides suggestions to lower the risk of stroke [8,19]. Another stroke risk system is specifically developed for the Chinese population to predict 10-year and lifetime stroke risk (Table 1) [20].…”

“…Also, hyperglycemia, hyperlipidemia, obesity, diabetes, atrial fibrillation, smoking, heavy drinking, sedentary lifestyle, and unhealthy diet are among the well-known risk factors to control [1]. Many available guidelines describe "population-wide" and "high-risk" strategies intended for stroke prevention [6][7][8]. For population-wide strategies, various scoring systems are developed to evaluate the risk of stroke according to specific risk factors, such as health condition, lifestyle, behaviors, and family history of diseases [9].…”