A loving son sent a text to me saying, “Mrs. Chika, good evening. Thank you so much for reaching out. I appreciate it. Me and my family have been really trying hard to help with my dad’s recovery. Now he needs physical and speech therapy. We are unable to find a speech therapist in Nigeria. My younger brother sent me a video of them feeding him, and I wanted to get your feedback.”

I watched a video of a young-looking man, likely in his late 50s to early 60s, sitting up at the end of his bed. He had an IV catheter on his left hand. It was apparent by the way he held the cup he drank out of that he was using his non-dominant hand. His presentation was a classic presentation of Left Middle Cerebral Artery (LMCA) stroke: right arm paralysis, drooling his sips of drinks, and speech disturbances.

Two weeks later, I received another text from his son: “My dad passed away Sunday night. We kept begging the doctor to put him on a ventilator, because I saw a video indicating that he was in severe respiratory distress. However, when the ventilator finally arrived, it wasn’t working properly. So, we paid for an ambulance to take him to a different hospital, but the ambulance didn’t make it on time.”

It wasn’t the stroke that killed him. Given his presentation on his last day, he likely died from aspiration pneumonia, a known and preventable complication of stroke, often mitigated with speech evaluation and therapy.

Stroke is a global burden and a leading cause of disability and functional dependency in most industrialized nations, with 5.5 million deaths attributable to stroke in 2016. In Africa, stroke has been established as a leading cause of death among non- communicable diseases, though the incidence and prevalence are not well documented in Nigeria or Africa as a whole.

This chart illustrates an example of the difference between the care available in stroke programs in developed nations and some low- and middle-income countries (LMICs).

Based on this, the ideal medical advice is unrealistic: “Don’t have a stroke in LMICs.” Therefore, the best approach is stroke awareness and prevention. Personal values, religious beliefs, and ideology affect health education. For example, a loved one shared this story of a stroke: 

They were jealous of her crops. Her plantains were growing beautifully; she had thanked God so much for blessing her crops. However, one day someone cursed her. As she lifted her left arm with the cutlass in her hand to cut through the branch in her farmland, her left arm went limp…

To assess knowledge of stroke risk factors while raising awareness, we conducted a qualitative survey of 150 participants in a city in Nigeria between July and September of 2019. We used the stroke risk scorecard from the National Stroke Association. In our study:

• Only 17% of participants were able to identify that a stroke is a brain attack
• 66% said stroke was a result of “curse by an enemy or evil spirit.”
• 66% were unaware of their cholesterol level or had high cholesterol
• 56% did not know their blood pressure or had a history of uncontrolled high blood pressure
• Only 6% learned about stroke from doctors and nurses
• 68% based their knowledge of stroke on friends and relatives who had a stroke

Through the study, we provided one-on-one health education to 150 members of the community. The study also provided insight into belief systems that serve as barriers to health promotion and risk factor reduction. Team members who became invested in this project as they saw the impact they made in people’s lives.

Science and spiritual beliefs do not need to be at opposing sides. The question to ask is, how can we provide education about stroke risk factor modification using principles of human factors?

Our next step is to deploy a robust public awareness campaign. The content will be co-designed by members of the sample population. The protocol will involve the community (spiritual and religious centers), primary care providers, policymakers (government), and data scientists.

Understanding of the belief system that may impact health literacy comes first. The program will integrate spiritual beliefs and behaviors into the education content in addition to scientific information. For example, routine health education (reduce sodium intake, exercise, and eat a healthy diet) does not address a curse, one of the most cited causes of stroke among the study participants.

If we wish to help a community, we must first understand the environment that shapes its thinking. If there is a belief system that illness stems from spiritual forces, it would be futile to teach science-based mechanisms alone. Understanding the interrelationships between spiritual values and health education is crucial to success. One must incorporate values, ideology, and behaviors into any educational approach.

Chika Odioemene, RN, ACNP, is the CEO and Founder of Utopian Healthcare.

Lessons from this work will be shared as part of the IHI Africa Forum on Quality and Safety in Healthcare, originally scheduled for May 2020 and now postponed. Sign up to be notified when more information becomes available about new dates for the IHI Africa Forum.