Viewpoint

Enhancing primary stroke prevention: a combination

approach
Kiran Bam, Muideen T Olaiya, Dominique A Cadilhac, Geoffrey A Donnan, Lisa Murphy, Monique F Kilkenny

Stroke can be prevented through effective management of risk factors. However, current primary stroke prevention Lancet Public Health 2022;
approaches are insufficient and often fragmented. Primary stroke prevention strategies are predominantly targeted at 7: e721–24

behavioural (eg, smoking cessation and lifestyle modifications) and pharmacological interventions (ie, prevention Stroke and Ageing Research,
Department of Medicine,
medications). There is also a need to consider interrelating structural factors that support, or hinder, prevention
School of Clinical Sciences at
actions and behaviours of individuals. Without addressing these structural factors, it is impossible to maximise the Monash Health, Monash
benefits of behavioural and pharmacological interventions at the population level. We propose a tripartite approach to University, Melbourne, VIC,
primary stroke prevention, comprising behavioural, pharmacological, and structural interventions, which is Australia (K Bam MPH,
M T Olaiya PhD,
superimposed on the socioecological model. This approach could minimise the current fragmentation and inefficiency
Prof D A Cadilhac PhD,
of primary stroke prevention. M F Kilkenny PhD); The Florey
Institute of Neuroscience and
Introduction conditions (eg, reduction of air pollution). Addressing Mental Health, Heidelberg, VIC,
Australia (Prof D A Cadilhac,
Globally, advancements in behavioural and pharmaco­ these structural factors could improve the uptake of M F Kilkenny); Melbourne Brain
logical interventions have led to a decline in the behavioural and pharmacological interventions for stroke Centre at the Royal Melbourne
incidence of stroke.1 However, incidence continues to prevention.7 Hospital, University of
rise in people aged 70 years or younger in low-income Melbourne, Melbourne, VIC,
Australia (Prof G A Donnan MD);
and middle-income countries.1 Despite the growing Significance of structural interventions in Stroke Services, Stroke
burden of stroke, current interventions for primary primary stroke prevention Foundation, Melbourne, VIC,
stroke prevention are suboptimal and often fragmented.2,3 The consideration of interventions for addressing Australia (L Murphy MBBS)
A 2021 survey further reaffirmed that primary stroke structural factors from a broader policy perspective will Correspondence to:
prevention interventions are insufficiently implemented.4 ensure the prioritisation of primary stroke prevention Assoc Prof Monique Kilkenny,
Stroke and Ageing Research,
To address current gaps in primary stroke prevention, through action and accountability.5 For example, Department of Medicine, School
Owolabi and colleagues3 recommended designing and interventions that improve healthy eating or physical of Clinical Sciences at Monash
implementing primary stroke prevention interventions activity are unlikely to be successful if there is poor access Health, Monash University,
using an integrated approach, comprising individual to healthy foods or few spaces for physical activity. Melbourne, VIC 3168, Australia
monique.kilkenny@monash.
and population-wide measures. They also suggested that Similarly, interventions aimed at improving the edu
such interventions should be facilitated through availability and affordability of essential medicines, or
appropriate health policy and advocacy. reduction of the amounts of salt and sugar in processed
Current strategies for primary stroke prevention often foods, are often driven by policy decisions. However,
comprise behavioural and pharmacological interventions policy decisions are usually intensive of time and
that are implemented at the individual level. Behavioural resources, and require a multidisciplinary team to
interventions include activities aimed at improving implement.7 Although policy support mechanisms are
awareness of risk reduction at an individual level often effective in high-income countries, they are too
(eg, reducing alcohol intake and increasing physical often inadequately monitored in many low-income and
activity). Pharmacological interventions include opti­ middle-income countries. Inadequate monitoring is
mising the use of medications for stroke prevention. mainly due to budget constraints, which limits capacity
The World Stroke Organization has issued a global for planning and coordination.8 Use of affordable digital
policy agenda on the guiding principles for stroke technology could facilitate real-time monitoring and
prevention that includes reducing exposure to stroke risk feedback to individuals, service providers, and policy
factors, implementing and promoting motivational makers.9 Therefore, to address structural and other
mobile technologies, facilitating access to low-dose barriers for primary stroke prevention, policy support
combination medications in one polypill for specific mechanisms should be facilitated as advocated by
groups, and investing in the training and deployment of international organisations, such as the World Stroke
community health workers for implementation.5 Organization. These mechanisms could involve existing
However, when designing and implementing prevention frameworks developed by global stroke experts and
interventions, there is also a need to consider interrelating patient groups to guide policy decisions for stroke
structural factors6 that support, or hinder, prevention prevention.5
actions and behaviours of individuals. These structural
factors can be modifiable or non-modifiable, such as Proposed tripartite combination approach for
socioeconomic and cultural conditions, political will primary stroke prevention
(eg, collaborations, commitments, and funding), There is an urgent need to integrate interventions10 aimed
government priorities or policies, and environmental at addressing structural factors into existing primary

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 Viewpoint

Behavioural interventions Structural interventions

Stroke awareness and public Multicountry collaboration and

education cooperation with commitment
and funding allocation,
particularly for low-income and
Lifestyle modification (eg, middle-income countries
smoking cessation, reducing
alcohol intake, increasing
physical activity, healthy Public–private partnership (eg,
eating) health insurance companies,
private hospitals, and
pharmaceutical companies)
Risk factor screening, use of
digital tools for risk
assessment (eg, Stroke Healthy and safer environment
RiskometerTM) and school (eg, reducing air pollution)
health programmes

H ea l t h po l i c y Quality of care, learning health

Blood pressure measurement system, research, standardised
Population data for monitoring and reporting,
and control
and granular data analysis

Promoting healthy behaviours Behavioural Structural

and treatment support Capacity building and motivation
to staff through incentive
schemes
Nutritional support
Ensuring patient safety and
person-centred services
Motivational counselling
sessions Advocacy and changes in
Pharmacological
policies, plans, and legislation
Use of digital technologies in
providing feedback to patients In divid u al Dealing with culture and social
and providers norms on myths and
misconceptions of stroke

Pharmacological interventions Addressing inequality and

poverty to access and seek
Treatment and medication stroke prevention services
management: polypill strategy,
antihypertensive, antiplatelet,
Task shifting, community
or lipid-lowering therapy
engagement, empowerment,
Venn diagram denotes a combination approach, and mobilisation of stroke
Awareness and knowledge of comprising behavioural, pharmacological, and survivors or at-risk individuals
medications structural interventions

Stacked venn diagram denotes levels of Stewardship at the global,

Treatment adherence and interventions as per the socioecological model at regional, national, and local levels
support the individual, population (society and community), with political commitments
and public policy levels

Figure: Proposed tripartite combination approach for primary stroke prevention

Integrated tripartite combination approach, superimposed on a socioecological model comprising behavioural, pharmacological, and structural interventions for
primary stroke prevention.

stroke prevention interventions. We propose a broader integration will guide the development and imple­
com­ bination of behavioural, pharmacological, and mentation of a tailored, population-wide approach. This
structural interventions for primary stroke pre­ vention holistic, targeted design of interventions has been
(figure). This tripartite approach is superimposed on the proven to be effective in managing communicable
socioecological model, which conceptualises health chronic conditions, such as HIV.11,13 However, such an
broadly, encompassing multiple levels of influence and approach has not been seriously considered for the
interplay across individual, community, sociocultural, and management of non-communicable chronic conditions,
policy contexts.11,12 The tripartite approach enables such as stroke.
interventions aimed at individuals and entire populations
to be facilitated through strong health policy and advocacy.6 Proposed toolbox for implementing and
Consistent with recommendations by Owolabi and monitoring primary stroke prevention
colleagues,3 our approach includes a broad policy Our proposed approach (figure) includes a com­prehensive
structure as a key part of the overall intervention. This toolbox, comprising sets of specific interventions for each

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aspect of primary stroke prevention. Political support and the potential to improve stroke prevention. This approach
ensuing health policy are important drivers of success for could reduce the current fragmentation and inefficiency
this approach. The design should have evaluation and of primary stroke prevention, particularly for low-income
feedback loops to further inform current and future and middle-income countries, and support the periodic
primary stroke prevention strategies. review of combination approaches needed for effective
Implementing behavioural and pharmacological prevention of stroke.
interventions at the individual level will ultimately be Contributors
limited by the community and the policies to which KB was the lead author, responsible for the conceptualisation and
they are subject. At the individual and community writing of the original draft. MTO, DAC, and MFK were responsible for
supervision. MTO, DAC, GAD, and LM were responsible for reviewing
levels, structural interventions must be implemented to and editing the manuscript for intellectual content. All authors reviewed
ensure patient safety (eg, avoiding detrimental errors and approved the final version of the manuscript.
related to diagnosis or prescription of medications),14 Declaration of interests
prevention of adverse events,15 and ultimately improving We declare no competing interests.
the quality of care.16 In addition, public and private Acknowledgments
partnerships (eg, health insurance companies, private KB received the Monash International Tuition Scholarship and
hospitals, and pharmaceutical companies), plus the Monash Graduate Scholarship support from Monash University
active engagement of other stakeholders, are essential (Melbourne, VIC, Australia). DAC received research fellowship
support from the National Health and Medical Research Council of
at the policy level for implementing primary stroke Australia (1154273). MFK received fellowship support from the
prevention interventions. Such partnerships would be National Heart Foundation of Australia (105737). No specific funding
particularly valuable in countries that have mixed was received for this project.
insurance models for health care, and in low-income References
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