FACULTY OF PUBLIC HEALTH
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Item Randomized trial of an intervention to improve blood pressure control in stroke survivors(American Heart Association, Inc., 2020) Owolabi M. O.; Gebregziabher M.; Akinyemi R. O.; Akinyemi J. O.; Akpa O.; Olaniyan O.; Salako B. L.; Arulogun O.; Tagge R.; Uvere E.; Fakunle A.; Ovbiagele B.BACKGROUND: We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke. METHODS AND RESULTS: Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mmHg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mmHg, P=0.82). In an exploratory analysis of subjects with baseline BP >140/90 mmHg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mmHg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mmHg at 12 months. CONCLUSIONS: THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivorsItem Prevalence and correlates of intimate partner violence, before and during pregnancy among attendees of maternal and child health services, Enugu, Nigeria: mixed method approach, January 2015(African Field Epidemiology Network, 2019) Ezeudu C. C.; Akpa O.; Waziri N. E.; Oladimeji A.; Adedire E.; Saude I.; Nguku P.; Nsubuga P.; Fawole O. I.Introduction: Intimate Partner Violence (IPV) is an under-reported public health problem. This study determined the prevalence of IPV and types of IPV, complications and factors associated with IPV among women accessing health services. Methods: we conducted a cross-sectional survey of 702 women accessing maternal and child health services in Enugu State, Nigeria using multi-stage sampling technique. Quantitative data was collected using semi-structured questionnaire, qualitative data by key informant interview (KII). We analysed data using descriptive statistics, bivariate and multivariate logistic regression analysis. The level of statistical significance was set at p-value < 0.05. Qualitative data was analysed using thematic content analysis. Results: mean age of respondents was 27.71 ± 5.14 years and 654 (93.2%) were married. Prevalence of IPV, a year before last pregnancy, was 307 (43.7%) and during last pregnancy was 261 (37.2%). Frequent involvement in physical fights with other men, controlling behaviour and younger aged partners (< 40 years) were independent predictors of IPV experience both before and during pregnancy. Independent predictors of IPV experience before and during pregnancy were younger aged partners (< 40 years). [Adjusted Odds Ratio AOR 1.72; 95% confidence interval (CI) = 1.17, 2.53], partner having controlling behaviour AOR 2.24; 95% C.I=1.51-3.32) and Partner's frequent involvement in physical fights (AOR 2.29; 95% C.I = 1.43-3.66). Having a male child and married/ cohabiting were protective against violence. KII revealed poverty, lack of education and infidelity as common triggers of IPV. Conclusion: the prevalence of IPV and types of IPV was high and the predisposing factors of IPV in Enugu were multifactorial. Couple counselling sessions that focus on non-violence conflict resolution techniques is crucial to end IPV.Item Differential impact of risk factors on stroke occurrence among men versus women in West Africa The SIREN Study(American Heart Association, Inc., 2019) Akpalu A.; Gebregziabher M.; Ovbiagele B.; Sarfo F.; Iheonye H.; Akinyemi R.; Akpa O.; Tiwari H. K.; Arnett D.; Wahab K.; Lackland D.; Abiodun A.; Ogbole G.; Jenkins C.; Arulogun O.; Akpalu J.; Obiako R.; Olowoyo P.; Fawale M.; Komolafe M.; Osaigbovo G.; Obiabo Y.; Chukwuonye I.; Owolabi L.; Adebayo P.; Sunmonu T.; Owolabi M.Background and Purpose—The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods—SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results—Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49–71.77) versus 16.1 0(9.19–28.19)], dyslipidemia [2.08 (1.42–3.06) versus 1.83 (1.29–2.59)], diabetes mellitus [3.18 (2.11–4.78) versus 2.19 (1.53–3.15)], stress [2.34 (1.48–3.67) versus 1.61 (1.07–2.43)], and low consumption of green leafy vegetables [2.92 (1.89–4.50) versus 2.00 (1.33–3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%–99.6%) among females with 9 factors accounting for 97.2% (94.9%–98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions—Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.Item Echocardiographic abnormalities and determinants of 1-month outcome of stroke among West Africans in the SIREN Study(American Heart Association, 2019) Adeoye A. M.; Ovbiagele B.; Akinyemi J. O.; Ogah O. S.; Akinyemi R.; Gebregziabher M.; Wahab K.; Fakunle A. G.; Akintunde A.; Adebayo O.; Aje A.; Tiwari H. K; Arnett D.; Agyekum F.; Appiah L. T.; Amusa G.; Olunuga T. O.; Akpa O.; Sarfo F. S.; Akpalu A.; Jenkins C.; Lackland D.Background-—Little is known about the relationship between echocardiographic abnormalities and outcome among patients with acute stroke. We investigated the pattern and association of baseline echocardiographic variables with 1-month disability and mortality among patients with stroke in the SIREN (Stroke Investigative Research and Education Network) study. Methods and Results-—We enrolled and followed up consecutive 1020 adult patients with acute stroke with baseline transthoracic echocardiography from west Africa. To explore the relationship between echocardiographic variables and 1-month disability (using modified Rankin scale >3) and fatality, regression models were fitted. Relative risks were computed with 95% CIs. The participants comprised 60% men with a mean age of 59.2_14.6 years. Ischemic stroke was associated with smaller aortic root diameter (30.2 versus 32.5, P=0.018) and septal (16.8 versus 19.1, P<0.001) and posterior wall thickness at systole (18.9 versus 21.5, P=0.004). Over 90% of patients with stroke had abnormal left ventricular (LV) geometry with eccentric hypertrophy predominating (56.1%). Of 13 candidate variables investigated, only baseline abnormal LV geometry (concentric hypertrophy) was weakly associated with 1-month disability (unadjusted relative risk, 1.80; 95% CI, 0.97–5.73). Severe LV systolic dysfunction was significantly associated with increased 1-month mortality (unadjusted relative risk, 3.05; 95% CI, 1.36–6.83). Conclusions-—Nine of 10 patients with acute stroke had abnormal LV geometry and a third had systolic dysfunction. Severe LV systolic dysfunction was significantly associated with 1 month mortality. Larger studies are required to establish the independent effect and unravel predictive accuracy of this associationItem Similar changes in neuropsychological functioning in english and spanish speaking HIV patients(John Wiley & Sons Inc, 2018) Akpa O.; Miyahara S.; Taiwo B.; Evans S.; Berzins B.; Robertson K.Objective: Primary language has been reported to influence the results of neuropsy chological (NP) testing. We sought to determine whether being a primary Spanish versus English speaker affects changes in neuropsychological evaluations in persons living with HIV. Method: Data from 209 (188 English speakers and 21 Spanish speakers) ART-naïve HIV-infected adults were extracted from ACTG A5303, a 48-week randomized clini cal trial of two HIV treatment regimens. Participants’ mean (standard deviation) age and years of education were 35.1 (10.7) and 14.3 (2.7) years respectively. Changes from baseline to week 48 of antiretroviral therapy (ART) in individual, total, and do main z-scores for NP tests and Global Deficit Scores (GDS) were compared between the primary languages using linear regression models, adjusted for baseline scores and years of education. Results: Baseline demographic characteristics were comparable except Spanish speakers had less years of education than the English speakers (p < 0.001). Although differences in some NP measures and domains were detected at baseline, the ad justed changes in individual, total and domain NP z-scores from baseline to 48 weeks of ART were not significantly different between the two primary language groups. The 48-week changes in GDS were also similar. Conclusion: Changes in NP during ART were similar between English and Spanish speaking HIV-infected individuals for all NP measures. This suggests that studies of longitudinal changes in NP can pool participants across these languagesItem Stroke Among Young West Africans Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case–Control Study.(American Heart Association, Inc., 2019) Sarfo F. S.; Ovbiagele B.; Gebregziabher M.; Wahab K.; Akinyemi R. O.; Akpalu A.; Akpa O.; Obiako R.; Owolabi L.; Jenkins C.; Owolabi M. O.Background and purpose: Stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries. Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged <50 years old. Methods: The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged ≥18 years with computed tomography/magnetic resonance imaging-confirmed stroke. Controls were age-and gender-matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed. We used conditional logistic regression to estimate odds ratios and population attributable risks with 95% confidence intervals. Results: Five hundred fifteen (24.3%) out of 2118 cases enrolled were <50 years old. Among subjects <50 years old, hemorrhagic stroke proportion was 270 (52.5%) versus 245 (47.5%) for ischemic strokes. Etiologic subtypes of ischemic strokes included large artery atherosclerosis (40.0%), small vessel disease (28.6%), cardioembolism (11.0%), and undetermined (20.4%). Hypertension (91.7%), structural lesions (3.4%), and others (4.9%) were causally associated with hemorrhagic stroke. Six topmost modifiable factors associated with stroke in descending order of population attributable risk (95% confidence interval) were hypertension: 88.7% (82.5%-94.8%), dyslipidemia: 48.2% (30.6%-65.9%), diabetes mellitus: 22.6% (18.7%-26.5%), low green vegetable consumption: 18.2% (-6.8%-43.2%), stress: 14.5% (4.9%-24.1%), and cardiac disease: 8.4% (5.8%-11.1%). Conclusions: The high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.Item Dominant modifiable risk factors for stroke in Ghana and and Nigeria (SIREN): a case-control study(Elsevier Ltd., 2018) Owolabi M. O.; Sarfo F. S.; Akinyemi R. O.; Gebregziabher M.; Akpa O.; Akpalu A.; Wahab K.; Obiako R.; Owolabi L.; Ovbiagele B.Background Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub Saharan Africa. Methods The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population attributable risks (PARs) with 95% CIs. Findings Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59•0 years (SD 13•8) for cases and 57•8 years (13•7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six x (<1%) had discrete ischaemic and haemorrhagic lesions. 98•2% (95% CI 97•2–99•0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19•36 (95% CI 12•11–30•93) and 90•8% (95% CI 87•9–93•7) for hypertension, 1•85 (1•44–2•38) and 35•8% (25•3–46•2) for dyslipidaemia, 1•59 (1•19–2•13) and 31•1% (13•3–48•9) for regular meat consumption, 1•48 (1•13–1•94) and 26•5% (12•9–40•2) for elevated waist-to-hip ratio, 2•58 (1•98–3•37) and 22•1% (17•8–26•4) for diabetes, 2•43 (1•81–3•26) and 18•2% (14•1–22•3) for low green leafy vegetable consumption, 1•89 (1•40–2•54) and 11•6% (6•6–16•7) for stress, 2•14 (1•34–3•43) and 5•3% (3•3–7•3) for added salt at the table, 1•65 (1•09–2•49) and 4•3% (0•6–7•9) for cardiac disease, 2•13 (1•12–4•05) and 2•4% (0•7–4•1) for physical inactivity, and 4•42 (1•75–11•16) and 2•3% (1•5–3•1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence. Interpretation Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans.Item The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches(Wiley Periodicals, Inc., 2017) Owolabi M.; Olowoyo P.; Popoola F.; Lackland D.; Jenkins C.; Arulogun O.; Akinyemi R.; Akinyemi O.; Akpa O.; Olaniyan O.; Uvere E.; Kehinde I.; Selassie A.; Gebregziabher M.; Tagge R.; Ovbiagele B.Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.Item 2017Depression after Stroke in Sub-Saharan Africa: A Systematic Review and Meta-Analysis(Hindawi Behavioural Neurology, 2017) Ojagbemi A.; Akpa O.; Elugbadebo F.; Owolabi M.; Ovbiagele B.Objective. We aimed to conduct a systematic review and meta-analysis of prevalence and characteristics of poststroke depression (PSD) in sub-Saharan Africa (SSA). Methods. We searched Medline, PsycINFO, and African Journals OnLine using keywords for stroke and depression and the .mp. operator for all 54 SSA countries/regions. Further information was retrieved through a manual search of references from relevant published and unpublished articles. We included only peer-reviewed original studies with epidemiological or experimental designs, conducted random-effect meta-analysis, and identified the most commonly associated factors by weight (inverse of variance method). Results. Seventeen studies, comprising 1483 stroke survivors, met the criteria for syntheses. The pooled frequency of clinically diagnosed PSD was 31% (95% CI = 26%–36%), versus 13.9% in healthy control pairs. Prevalence did not vary much across healthcare settings but was affected by methods of depression ascertainment. PSD was significantly associated with low education, cognitive impairment, physical disability, poor quality of life, and divorced marital status. Conclusion. Almost 1 in 3 individuals with stroke in SSA has clinical depression. Despite limitations around quality of identified studies, results of the present systematic review overlap with findings in the global literature and highlight useful targets for the design and trial of tailored intervention for PSD in SSAItem Development and Reliability of a User-Friendly Multicenter Phenotyping Application for Hemorrhagic and Ischemic Stroke(Elsevier Inc., 2017) Owolabi M.; Ogbole G.; Akinyemi R.; Salaam K.; Akpa O.; Mongkolwat P.; Omisore A.; Agunloye A.; Efidi R.; Odo J.; Makanjuola A.; Akpalu A.; Sarfo F.; Owolabi L.; Obiako R.; Wahab K.; Sanya E.; Adebayo P.; Komolafe M.; Adeoye A. M.; Fawale M. B."Background: Annotation and Image Markup on ClearCanvas Enriched Stroke– phenotyping Software (ACCESS) is a novel stand-alone computer software application that allows the creation of simple standardized annotations for reporting brain images of all stroke types. We developed the ACCESS application and determined its inter-rater and intra-rater reliability in the Stroke Investigative Research and Educational Network (SIREN) study to assess its suitability for multicenter studies. Methods: One hundred randomly selected stroke imaging reports from 5 SIREN sites were re-evaluated by 4 trained independent raters to determine the inter-rater reliability of the ACCESS (version 12.0) software for stroke phenotyping. To determine intra-rater reliability, 6 raters reviewed the same cases previously reported by them after a month of interval. Ischemic stroke was classified using the Oxfordshire Community Stroke Project (OCSP), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and Atherosclerosis, Small-vessel disease, Cardiac source, Other cause (ASCO) protocols, while hemorrhagic stroke was classified using the Structural lesion, Medication, Amyloid angiopathy, Systemic disease, Hypertensive angiopathy and Undetermined (SMASH-U) protocol in ACCESS. Agreement among raters was measured with Cohen’s kappa statistics. Results: For primary stroke type, inter-rater agreement was .98 (95% confidence interval [CI], .94-1.00), while intra-rater agreement was 1.00 (95% CI, 1.00). For OCSP subtypes, inter-rater agreement was .97 (95% CI, .92-1.00) for the partial anterior circulation infarcts, .92 (95% CI, .76-1.00) for the total anterior circulation infarcts, and excellent for both lacunar infarcts and posterior circulation infarcts. Intra-rater agreement was .97 (.90-1.00), while inter-rater agreement was .93 (95% CI, .84-1.00) for TOAST subtypes. Inter-rater agreement ranged between .78 (cardioembolic) and .91 (large artery atherosclerotic) for ASCO subtypes and was .80 (95% CI, .56-1.00) for SMASH-U subtypes. Conclusion: The ACCESS application facilitates a con cordant and reproducible classification of stroke subtypes by multiple investigators, making it suitable for clinical use and multicenter research.