Reducing the risk of recurrent event in Malaysian stroke survivors: a journey of missed opportunities

Introduction: Stroke survivors are at high risk of recurrent cardiovascular events. Despite increasing amount of stroke-related research happening in Malaysia, little is known about risk reduction in stroke survivors. This thesis’ investigates “missed opportunities” relating to implementing risk reduction strategies and the outcomes (Study 1), survivors’ journeys of care (Study 2) and their experiences and challenges (Study 3). This thesis focusses on 5 metabolic and 3 behavioural risk factors within the framework of “addressed”, “actioned” and “achieved”. Methods: Participants admitted to an urban tertiary university-affiliated medical centre with the clinical diagnosis of acute stroke or transient ischaemic attack from January 2016 to March 2017 were interviewed two years later. The study included those 18 years and older who ambulated independently, and excluded those with stroke secondary to other medical comorbidities and/or those with cognitive impairments. Potential participants were screened from emergency department attendees with acute stroke, and all were followed up. Medical record data were integrated with findings from semi-structured interviews. Missed opportunities at discharge and during follow-up included, for example, no prescription for pharmacotherapy or intervention, including counselling, as reported during the interviews and/or recorded in medical records. Purposive sampling based on predefined age categories, was used to recruit participants for Study 3. Individual in-depth interviews were conducted using a semi-structured interview guide, and data analysed using inductive thematic methods to explore the perspectives of stroke survivors. Results: A total of 106 participants consented to participate, with 89 participants fulfilling the inclusion or exclusion criteria. The addressing of metabolic risk factors closely matched guideline recommendations at discharge and continued to be actioned in the community, post-discharge. For example, the prescribing of preventive medication ranged from 94% for antihypertensive to 85% for statins, and this was maintained in the community. However, two years after the index event, only 34% of hypertensive participants achieved blood pressure control, 21% of participants with diabetes had HbA1c ≤6.5% and 25% achieved LDL <1.8mmol/L. Behavioural risk factors were less likely to be addressed. For example, only 27% of smokers were referred to Quit Smoking programs, and two years after the index event, less than 50% of smokers had quit smoking. Additionally, only 50% received counselling on health behaviours relating to physical activity, even though 26% of survivors spent >6 hours per day in sedentary behaviours, and most recorded low daily median steps (<3300 steps). In relation to dietary intake, only 5% consumed the recommended amount of fruits and vegetables, and 35% achieved 5-10% weight reduction. Post-discharge, most survivors were followed in publicly-funded outpatient specialist clinics, primary care clinics or a combination of both, with minimal involvement in privately-funded general practices. Primary care clinics provided shorter intervals between first contact and future follow-ups, and follow-ups were more regular. Early after discharge, the majority of care was provided by outpatient specialist clinics; however, over time, care slowly transitioned to primary care clinics or to shared care between both specialist outpatient and primary care clinics. Themes that emerged from the 23 participants’ interviews acknowledged that stroke recurrence is possible, raised concerns about dependency on prescribed medication and its perceived side effects, and perceived self-efficacy in initiating and maintaining health behaviour changes. Some intended to change and adopt healthy behaviours recommended to them, whilst some did not. Applying the Health Action Process Approach, participants' health behaviour changes occurred across two processes: forming an intention (motivation phase) and acting on the intention (volition phase). Conclusion: There are more missed opportunities in managing risk reduction strategies, particularly those related to behavioural risk factors. Current risk reduction strategies, such as smoking cessation, were less likely to adhere to recommended care. Although most survivors were routinely followed-up, more can be done to ensure all survivors have frequently scheduled follow-ups, especially early post-discharge; because, in the first two years post-event, survivors are at differing stages of adopting recommended health behaviours, and, despite “the best of intentions”, some fail to maintain behaviour changes aimed at reducing their risk of recurrent events.