DETERMINING THE RISK FACTORS AMONG STROKE PATIENTS ADMITTED AT

SELECTED HEALTH CARE FACILITIES OF KAKAMEGA COUNTY, KENYA

ABSTRACT

BACKGROUND: The prevalence of stroke is escalating with stroke survivors facing a more

significant threat from long term complications. The burden of dependence associated with this

impairment and prolonged hospitalization threaten to overwhelm health and social care systems.

Therefore, we decided to determine the risk factors among stroke patients admitted at selected

health care facilities of Kakamega County.

METHODOLOGY: The study adopted cross-sectional study design from January 2021 to

January 2022 with a total of 153 stroke patients recruited from selected level four and five

hospitals of Kakamega County. Data was collected through self-administered

questionnaire and analysed using SPSS version 27.0.

RESUSLTS: Men were the dominant participant (71.5%). The patients' average age was

56.3±12.7 years. One out of every five patients smoked, and more than half, 64 (57%), were

from rural areas. People who had hemorrhagic stroke were associated with drinking alcohol more

that of ischemic stroke. When it came to co-morbid conditions, hypertension (40.8%) was the

most frequently detected risk factor. Other common risk factors included atrial fibrillation in 34

(21.9%), diabetes mellitus in 33 (21.2%), and history of heart failure in 30 percent (19.3%) of

those diagnosed. Co-morbid illnesses with the lowest prevalence rates were chronic renal disease

(4%) coronary heart disease (11%) and a history of stroke (9%).

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CONCLUSION: Treatment of stroke patients was sub-optimal and almost half of the patients

had poor treatment outcomes. Availing of thrombolytic therapy, devising appropriate preventive

measures of risk factors, and decreasing preventable complication e.g. aspiration pneumonia

could improve patient outcomes.

Word Count 250 words

KEYWORDS: Stroke, hypertension, risk factors.

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 INTRODUCTION

Stroke is the most prevalent cause of long-term impairment among people and the second largest

cause of mortality globally (1). Roughly 80% of stroke-related fatalities have place in poor

nations (2).Statistics show that stroke case mortality rates are greater in sub-Saharan Africa

(SSA) than in wealthy nations (3).This could be connected to unmanaged risk factors including

hypertension and inadequate access to healthcare. Compared to developed countries, stroke

affects younger people in developing nations (4). Stroke mortality in the US is on the decline

overall, although it is still greater in African Americans than in Whites (5). Several risk factors

for stroke have been identified, such as age, sex, hypertension, hyperlipidemia, cigarette

smoking, alcohol consumption, diabetes mellitus, inadequate fruit and vegetable intake, physical

inactivity, obesity, atrial fibrillation, and other heart disorders (6). Hypertension is the primary

factor globally linked to increased risk of both ischemic and haemorrhagic strokes. It accounts

for 90% of all strokes in the population (7).

The quality of stroke care offered throughout a patient's hospital stay has a significant impact on

outcomes such as functional ability and mortality. Providing treatment for patients with acute

stroke in specialized stroke units has been demonstrated to have a significant impact on

improving the long-term prognosis of stroke (8). The majority of hospitals in sub-Saharan Africa

lack stroke units. The Stroke Quality Enhancement Research Initiative (QUERI) is a national

group focused on improving the quality of stroke care within the US Veterans Health

Administration (VHA). They have developed a chart review methodology to assess evidence-

based quality indicators for stroke care. These indicators are based on existing stroke quality

indicators from the US Joint Commission and other relevant stroke care processes specific to

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VHA medical centers (9).

The quality indicators comprised the documentation of the National Institute of Health Stroke

Scale (NIHSS). Thrombolysis, where necessary, should be administered. Anti-thrombotic

therapy should be initiated by the second day of hospitalization. Lipid management should be

implemented. Deep Vein Thrombosis (DVT) prophylaxis is recommended. Anticoagulation is

necessary for patients with atrial fibrillation. Dysphagia screening should be conducted prior oral

intake, Pressure ulcer evaluation, Fall risk Evaluation, Prompt mobilization, Cessation of

smoking counselling, anti-thrombotic therapy at discharge, Rehabilitation consult and stroke

education at discharge. Most of these quality indicators are easy to assess and include processes

of care that are affordable to implement (e.g. administering aspirin or proper nursing care) hence

are relevant to resource limited settings for monitoring and improving the quality of stroke care.

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METHODOLOGY

Analytic cross-sectional study design using quantitative approach was used. The study was

carried out in level 4 and 5 hospitals of Kakamega County namely; Kakamega CGH, Butere

county hospital, Malava county hospital and Lumakanda county hospital. A total of 153 patients

who had complete medical records, confirmed diagnosis of stroke were recruited from level four

and level five hospitals of Kakamega county as at January 2021 to January 2022. We included

Patients who had complete medical records, confirmed diagnosis of stroke, and admitted in the

medical ward of the selected hospital during the period of January 2021 to January 2022. We

excluded Patients with a diagnosis of transient ischemic attack or hematoma, as well as stroke

cases with incomplete medical records (not include a patient demographic, left against medical

advice, and unidentified stroke sub-type clinically or by neuro-imaging).

The study used a Cluster sampling technique to group the health facilities in their respective

levels of health care. Kakamega County health facilities have been grouped into four cluster

levels, namely Hospitals (level 5 and 4), Health centers (level 3), and Dispensaries (level 2).

Purposive sampling technique to select the health facilities in level five and four facilities. The

hospitals were chosen because had the minimal requirement to admit and manage stroke patients.

The sample size was calculated using the formulae:

n= (z2pq)/δ2

Where

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n = Desired sample size (when population is greater than 10,000)

z = Standard Normal Deviation which was equal to 1.96 corresponding to 95% confidence

interval

p = Prevalence of the issue under study, 50% p = 0.5

q= 1-p

δ= the error of margin, taken as 0.05. Substituting the figures above in the formula.

Thus n= 1.962 x 0.5 x 0.5/0.052

n = 384

The target population was less than 10,000 the sample size was adjusted using the formula.

nf = n/ [1+ (n/N)] Where;

nf – Desired sample size (when the population was less than 10,000).

n – Sample size (when population was more than 10,000) calculated 384.

N – Average number of patients admitted with stroke in a month Thus

nf = n/1 + (n/N)

= 384

n/1 + (384/209)

= 139

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10% of the sample was used to cater for non-responses.

10% of 139 sample size to cover for those who opted out from the study

=14

The sample size was:

139 + 14= 153

Distribution of sample size among the selected hospitals by PPS where Kakamega CGH have

146 average number of patients admitted with stroke in a month, Butere 73, Malava 55 and

Lumakanda 43. Therefore, distribution of sample size among the selected hospitals was

computed as shown below:

Kakamega CGH

146/384x153 =85

Butere

73/384x153=29

Malava

55/384x153=22

Lumakanda

43/384x153=17

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An adaptation of the data collection tool was made after reviewing relevant literature in related

fields. A semi-structured questionnaire was created in order to extract information from the

medical records of eligible patients. The data collection was carried out by two nurses who had

received specialized training. The contents of the data collection tool were cross-checked against

patient medical charts in order to ensure that they were consistent with standard hospital practice

The discharge treatment outcome was classified as either a good treatment outcome or a poor

treatment outcome based on the treating physician's discharge summary notes or a record of

physical disability measurement using the modified Rankin scale, as indicated by the treating

physician (mRs). A positive treatment outcome/improvement was considered if a patient was

discharged with no significant disability (able to carry out all pre-stroke activities without

assistance from other individuals) or if the patient had a record of mRs 2 when the study began.

A poor treatment outcome was defined as a patient who was discharged with moderate to severe

disability (bedridden, incontinent, requiring continuous care, or an mRs score of 3–5) or who

died during their hospital stay (mRs score of 6) as a result of their treatment. The length of a

hospital stay was calculated as the period of time between admission to and discharge or death

from the hospital. There was a checklist used, this was to assess key elements of stroke standard

guideline as documented by health care providers. The checklist included a list of necessary

investigations carried out on admission of stroke patients. A pre-test was done on 14 patients at

Vihiga County Referral Hospital to ensure the validity and reliability of the data collection

instruments. Prior to actual data collection, a pilot study was carried out at Vihiga County

Referral Hospital.

The statistical package for social science (SPSS) version 27 was used to analyse the data. The

socio-demographic variables and clinical results between stroke subtypes were described using

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descriptive statistics such as proportions, means, and standard deviations. The chi-square test or

Fisher's exact test were used to compare categorical variables, and the t-test was used to compare

continuous variables. For multivariate analysis, variables with a p-value of less than 0.25 in

binary logistic regression analysis were selected. The researchers employed multivariable

logistic regression to find independent predictors of poor clinical outcomes in the hospital. It was

determined that predictors with a probability value less than 0.05 and a confidence interval that

did not contain 1 were statistically significant

Ethical approval and permission for the study was obtained from Masinde Muliro University

Institutional Research and Ethics Committee (IERC). Data collection permission for the study

was sought from the County government of Kakamega and the National Commission of Science

Technology and Innovation (NACOSTI). Participation in the study was voluntary, and all

participants taking part in the study signed an informed consent form for participation.

Information on patients remained confidential and was used only for the study. Safety of the

collected data was guaranteed by using a computer with a password known by just the researcher

as well as storage in cupboards under lock and key. Before the study, permission to conduct

research was sought through a letter of approval from the university ethical review board and the

health care facilities involve.

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RESULTS

According to table 1, Men were the dominant participant (71.5%) out of 153 stroke patients who

took part in the study. The patients' average age was 56.3±12.7 years. One out of every five

patients smoked, and more than half, 64 (57%), were from rural areas. People who had

hemorrhagic stroke were associated with drinking alcohol more that of ischemic stroke. When it

came to co-morbid conditions, hypertension (40.8%) was the most frequently detected risk factor

among the stroke cases studied. Other common risk factors included atrial fibrillation in 34

(21.9%), diabetes mellitus in 33 (21.2%), and a history of heart failure in 30 percent (19.3%) of

those diagnosed. In Table 4.1, the co-morbid illnesses with the lowest prevalence rates were

chronic renal disease (4%), coronary heart disease (11%), and a history of stroke (9%).

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DISCUSSION

According to the findings of the current study, males were more likely than females to suffer a

stroke than females. The majority of stroke patients, as opposed to those who suffered from

hemorrhagic stroke, presented with ischemic stroke. High blood pressure was shown to be the

most common risk factor in the current investigation. The most prevalent type of stroke subtype

diagnosed in this study was ischemic stroke, which was the most common subtype overall. This

finding is consistent with multiple previous studies, which found that ischemic strokes were

more common than hemorrhagic strokes in the general population. On the other hand, there have

been studies conducted in Ethiopia that have found an equal prevalence of both stroke subtypes

as well as a high prevalence of hemorrhagic stroke in the population. This variation could be

related to disparities in stroke diagnosis (clinical versus neuroimaging), differences in socio-

economics and risk factors at the population level, or a combination of these factors. The

prevalence of hemorrhagic stroke is increasing in Sub-Saharan Africa, despite the fact that

ischemic stroke continues to be the most common type of stroke presentation in the region.

Hemorrhagic stroke is associated with a significant risk of fatality. People in most of Sub-

Saharan Africa have different risk factors for stroke (like high blood pressure), environmental

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factors, study design (community-based vs. institutionalized), and clinical diagnosis that aren't

the same.

In the current investigation, hypertension was shown to be the most common concomitant illness

among those who had suffered a stroke (42.2%). Compared to other research, this finding was

consistent with the finding that hypertension is the most common risk factor for stroke around

the world. 2 When it comes to stroke patients in Sub-Saharan Africa, hypertension is still

underdiagnosed or poorly managed among those who are receiving treatment, which contributes

to poor treatment outcomes. Because of low awareness, restricted access to healthcare, and a lack

of a healthy lifestyle, it is possible that this tendency may continue. All of these things can help

cut down on the burden of cerebrovascular disease. Preventing, diagnosing, and treating

hypertension, as well as raising public awareness of the condition, can all play a role. The health

seeking behaviors is usually reflected by the value citizens’ place on health. Myths and beliefs

play a key role in the health seeking behaviours of a person. A comparison study indicated more

stroke incidences in urban areas compared to the rural areas. This was associated to the health

seeking behaviours. Many individuals in the urban centers were seeking medical attention in

private pharmacies and hence delaying care (10). In the study, taking herbal medicine, visiting

traditional healers and missing scheduled appointments delayed initiation of treatment. A

minority also engaged in lifestyle practices such as alcohol consumption or cigarette smoking

that may contribute to stroke condition. A previous study in KNH by (10) showed that 18.2%

were cigarettes smokers. Majority of the smokers later suffered stroke.

Majority have comorbid conditions such as hypertension, diabetes or heart diseases. A very

small proportion presented within the required 12 hours after onset of stroke which could have

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worsened the outcome of clinical management of their condition. In a study to determine the

outcomes of early vs. delayed admissions to a neurological department of Central India Institute

of Medical Sciences, Hundred and four patients admitted in the facility were grouped as an early

referral (within 24 hours from onset of symptoms) and late referrals (after 24 hours from onset of

the symptoms). Long-term outcomes were determined in the delayed and early admission.

Outcomes of Death, dependency, coma, disability, treatment burden depression and recovery in

both groups were analysed. The analysis was performed to determine the mortality rate of stroke

in the hospital for 12 months, and a comparison was drawn. Analysis showed better prognosis

with a high recovery rate of 90 % with a level of improvement in early admissions compared to

delayed admission with a recovery rate of 23% (11). Similarly, the ratio of dependency was

lower in early admission 6% compared to delayed admission 18%. Less than a third in this

study were within acceptable range of BMI. Obesity increases the risk for high blood pressure,

diabetes, stroke and high blood cholesterol. Once considered a problem in developed countries,

obesity is on the rise in developing countries (12). Four million of the Kenyan population is

obese (13). Being obese and overweight increases risk of stroke (13). Obesity has a significant

effect on stroke directly or through predisposing conditions such as diabetes and hypertension

leading to stroke (13).

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LIMITATIONS OF THE STUDY

The county has many health care facilities with many providers of health but the research was

conducted in a few selected hospitals from the county; therefore, the outcome of research cannot

be generalized to a large population. Lack of follow up in prediction of long-term outcome for

stroke patients after discharge. This was a hospital-based study that did not involve follow up to

patients who were discharged to determine the long-term outcomes. The convenient sampling

method that was used in selecting the health care facilities may have brought up a selection bias.

In addition, stroke management performance and stroke outcome were used as a measure of the

actual performance of the care givers, future studies should include other dependent variables

related to stroke management performance

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CONCLUSION

One out of every five patients smoked, and more than half, were from rural areas. Ischemic

stroke, was the most often seen subtype in this investigation. Stroke patients were in their mid-

50s when they were admitted, with a male preponderance. One of the most common comorbid

conditions observed was hypertension (high blood pressure). Both ischemic stroke and

hemorrhagic stroke patients utilized aspirin and atorvastatin as the most prevalent drugs, whereas

ACEIs were the most widely used antihypertensive medications in patients with both forms of

stroke. A considerable number of stroke patients had poor treatment results as a result of their

illness. Older age, heart failure, a lower level of consciousness on admission, and aspiration

pneumonia were all found to be strongly related to a poor prognosis. All of these things could

improve the health of patients: the use of thrombolytic treatment, the development of appropriate

risk factor prevention strategies, and the reduction of preventable complications like aspiration

pneumonia. The stroke Standard guideline for management of CVA is an important factor for

health care workers in obtaining optimal level of performance.

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TABLES

Table 1: Risk factors and socio-behavioral characteristics among stroke patients among

stroke patients admitted at selected health care facilities of Kakamega County, Kenya

Variables Ischemic (n = 112) Hemorrhagic Total (n = 153) p-value

Age (in years) ‡ 57.2±11.5 53.6±13.6 56.3±12.2 0.128

Sex (male), n (%) 79 (70.4) 30 (74.6) 110 (71.5) 0.607
Residence (rural) 64 (57.0) 21 (52.7) 86 (55.9) 0.681
Smoking, n (%) 17 (14.9) 10(25.8) 29 (18.6) 0.172
Alcohol, n (%) 15(11.4) 12 (29.7) 27 (17.3) 0.009†
Co-morbid
Hypertension, n (%) 41 (36.5) 21 (52.7) 65 (40.8) 0.072
conditions
Diabetes, n (%) 20 (17.8) 12 (30.7) 33 (21.2) 0.087
AF, n (%) 23 (20.4) 10(25.8) 34 (21.9) 0.406
Pervious stroke, n 7 (6.1) 2 9 (5.5) 0.615*
Heart failure, n (%) 22 (18.6) 8 (20.9) 30(19.3) 0.734
(%)
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CAD, n (%) 8 (2.0) 5 12 0.734
CKD, n (%) 6 (5.3) 6 (14.6) 14 (8.8) 0.110*
Note; Abbreviations: AF atrial fibrillation, CAD, coronary artery disease, CKD, chronic kidney

disease.

‡Expressed as mean and standard deviations (SD); *Fisher’s exact test, †Statistically significant

at p- value <0.05.

Full word count: 3451

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