Research Article Open Access
A Two Year Retrospective Cross-Sectional Study on Prevalence, associated Factors and Treatment outcome among Patients admitted to Medical Ward (Stroke Unit) at Jimma University Medical Center, Jimma, South West, Ethiopia, 2018.
Hayet Asefa1 Desalew Tilahun Beyene2*
1Bsc Nurse, Studied at Jimma University, Ethiopia
2BAssistant Lecturer, School of Nursing, Jimma University, Ethiopia
*Corresponding author: Desalew Tilahun Beyene, Assistant Lecturer, School of Nursing, Jimma University, Ethiopia E-mail: @
Received: September 17, 2018; Accepted: September 20, 2018; Published: November 26, 2018
Citation: Beyene DT, Asefa H (2018) A Two Year Retrospective Cross-Sectional Study on Prevalence, associated Factors and Treatment outcome among Patients admitted to Medical Ward (Stroke Unit) at Jimma University Medical Center, Jimma, South West, Ethiopia, 2018. Palliat Med Care 5(4): 1-6. DOI: 10.15226/2374-8362/5/4/00170
AbstractTop
Background: Stroke disorder is one of the most common causes of morbidity and mortality worldwide. Although stroke is being recognized as one of the health problems, its prevalence, risk factor, and treatment outcome in the Ethiopian care setup has not been well documented. Therefore, the objective of this study was to assess prevalence, associated factors and treatment outcome among stroke patients admitted to the stroke unit at Jimma University Medical Center, Jimma, and South West Ethiopia.

Objective: To assess the prevalence, associated factors and treatment outcome among stroke patients admitted to the medical ward (stroke unit) at Jimma University Medical Center, Jimma, and South West Ethiopia.

Methods: a Retrospective cross-sectional study of medical records of patients who were admitted to stroke unit from December 1, 2015, to November 31, 2017. Data collection tools were adapted after reviewing relevant literature and collected by data collectors from patients’ chart using the structured checklist. Chi-square was done to know the association between the two variables. Data was cleared and compiled on a master sheet and analyzed manually by using a scientific calculator and presented by using standard tables and diagram.

Result: Among the total sample size of 394 students 367 have participated in the study with a response rate of 93.14%. From a total of study participants, 236(64.31%) had a hemorrhagic stroke while 131(35.69%) had an ischemic stroke and the majority of them had hypertension followed by diabetes mellitus which accounts 123 (29.64%) and 89(21.45%) respectively. Regarding treatment outcome among stroke patients admitted to stroke unit during study period majority of them were died followed by improved which accounts 139(37.87%) and 97(26.43%) respectively.

Conclusion and Recommendation: More than half the study participants 64.31% had a hemorrhagic stroke while 35.69% had an ischemic stroke. There is a significant association between treatment outcome and age and gender i.e., as a p-value of both is 0.00 which is less than 0.05. Therefore, it would recommend that Jimma University Medical Center administration, Jimma University Medical Center staff and other concerned bodies should create proper awareness about risk factors, treatment outcome, and prevention of stroke.

Keywords: Stroke; prevalence; Risk factors; Treatment outcome; JUMC, Ethiopia.
Introduction
Stroke is one of the most common causes of morbidity and mortality worldwide. The latest data from the Global Burden of Diseases Study 2013 (GBD 2013) ranked cerebro vascular disease as the second largest contributor to death and disability-adjusted life years worldwide after ischemic heart disease. There are two main types of stroke hemorrhagic and ischemic stroke. Most of the patients with ischemic stroke present with altered mental status. But, the focal neurologic deficit was the commonest neurologic presentation among patients with intracerebral hemorrhage (1, 2). The prevalence of ischemic stroke is relatively higher than hemorrhagic stroke in most studies from Africa. In Nigeria, the prevalence of hemorrhagic and ischemic stroke in two hospitals was 29.5% and 54.7% respectively. Neurological disorders are increasingly prevalent in Sub-Saharan Africa. The factors that are producing this increased burden include malnutrition, malaria, HIV/AIDS and other causes of encephalitis and meningitis, demographic transitions, increased vehicular traffic, and persistent regional conflicts (3).

Treatments of people with stroke provided by multidisciplinary teams in a stroke unit result in better outcomes. Observational studies and trials of stroke treatment of patients from Europe, Australia, and Argentina have reported considerable variation in the processes of stroke treatment and associated outcomes (4, 5).

A retrospective cross-sectional study conducted in the first Hospital of Jilin University, Chang Chun, China on prevalence of stroke and associated risk factors showed that the overall prevalence of stroke in Jilin Province was 7.2% (95% CI 6.3% to 8.2%). Of all stroke cases, 91.7% (95% CI 87.4% to 94.6%) were ischemic stroke and 8.3% (95% CI 5.4% to 12.6%) were hemorrhagic stroke. The prevalence rates of dyslipidemia, smoking, and hypertension were ranked as the top three cerebro vascular risk factors and were 62.1%, 61.8%, and 57.3%, respectively. This study also showed that hypertension, dyslipidemia and lack of exercise were associated with ischemic stroke. However, only hypertension (OR=4.064, 95% CI 1.358 to 12.160) was significantly associated with hemorrhagic stroke (6).

Another retrospective study conducted on assessments of prevalence and risk factor among admitted patients in China showed that when type of stroke was tabulated against mortality, forty-nine (out of 187) (26.2%: 95% CI=19.8;32.6) of the patients with ischemic stroke died while 51/214 (23.8% 95% CI= 18.1;29.6) died among hemorrhagic strokes. No difference in mortality was found between hemorrhagic and ischemic strokes (p=0.584) (7).

A one-year retrospective study conducted on pattern and outcomes of patients with stroke admitted in tertiary hospitals in Zimbabwe showed that form a total of 450 stroke cases, (63% women) were included in the final analysis. The proportion of stroke cases among the admissions was 0.61%. Risk factors were hypertension (58.5%), diabetes (18%) and HIV, (14%)). Inhospital mortality was 24.9%, 95% CI (20.9; 29.0%). Mortality was associated with the place of admission (p< 0.001). Gender and side of stroke were significantly associated (p< 0.001). (8).A prospective hospital-based study conducted at another center in Ethiopia reported ischemic stroke as the commonest type of stroke. The pattern of admissions for neurological diseases among Ethiopian patients at two hospitals in Addis Ababa about three decades ago showed stroke (45%) and bacterial meningitis (12%) as the two most common causes of admissions (9).

A retrospective study conducted on assessment of risk factors and treatment outcome of stroke admissions at St. Paul’s Teaching Hospital showed that hypertension was found to be the most common antecedent risk factor in 92 (56.4%) patients. Diabetes mellitus (DM) was identified as a risk factor in 19 (11.6%) patients and 14 (8.5%) patients had both hypertension and diabetes mellitus. In-hospital case fatality rate of stroke was 30.1%. Most (45.4%) patients were discharged with the significant neurologic deficit. Only 36 (22.1%) patients were discharged with significant neurologic improvement. Among in-hospital deaths, the majority (63.3%) were in those with intracerebral hemorrhage. Of 11 patients who had a previous history of stroke, 7 (63.4%) died in hospital showing a statistically significant association (p=0.049) (10).

A retrospective cross-sectional study of patients admitted with a clinical diagnosis of stroke on characteristics and outcomes of the stroke at Tikur Anbessa Teaching Hospital showed that hemorrhagic stroke was the most common cause of stroke accounting for 57% of all patients. Hypertension was the most frequent risk factor identified followed by cardiac disease, 65.6%, and 22.7% respectively. The overall mortality was44.5%. Altered mental state and non-focal neurologic deficits were the only independent predictors of mortality (11). There is a great need for organized research that is closely linked to assess prevalence, associated risk factor, and treatment outcome of stroke. On the assessment of prevalence, associated risk factor and treatment outcome of stroke study is almost non-exist in our local setting (study areas). Although stroke is being recognized as one of the health problems, its prevalence, risk factor, and treatment outcome in the Ethiopian care setup has not been well documented. Information on stroke and associated risk factors could help in tuning up the service delivery for stroke patients. Therefore, the objective of this study was to assess prevalence, associated factors and treatment outcome among stroke patients admitted to the medical ward at Jimma University Medical Center, Jimma, and South West Ethiopia.
Materials and Methods
The study was conducted at Jimma University Medical Center from December 1, 2015, to November 31, 2017, which is located in Jimma Zone, Oromia region. JUMC is a university teaching hospital and is the only referral hospital for the southwestern of Ethiopia. Jimma is located 357km South West of the capital city of Ethiopia, Addis Ababa. All patients admitted to JUMC were used as a source population with a total sample size of 394.
Study design
Retrospective cross-sectional study design was conducted with the total sample size 394 which was obtained by using single population proportion formula among patients admitted to medical ward from December 1, 2015, to November 31, 2017, in JUMC.
Data Collection Methods
Data was collected by trained data collectors using a checklist sheet from the medical records of those patients who had been admitted to the medical ward over the specified time period based on inclusion criteria patients with neurological problems who are 15years and older. The checklist was developed after a review of different kinds of literature and contained socio demographic data, HIV status, type of stroke, common risk factors, diabetes mellitus, substance use, and atrial fibrillation) and possible treatment outcomes of patients. Before commencing data collection, ethical clearance and approval were obtained from Jimma University, College Health Science and Medicine, Department of Nursing. Oral informed consent was secured from the involved participants for their participation after the nature of the study was fully explained to them. The right to refuse was respected and data was collected respectfully.
Result
Socio-demographic characteristic of the study population
From the total sample size of 394 students, 367 have participated in the study with a response rate of 93.14%. Of these 234(63.8%) were males and 133(36.2%) were females. Fromtotal participants, 143 (38.96%) were Muslims religion followers followed by orthodox 117 (31.88). Oromo were the majored scored from ethnic groups which had 153 (41.69%) followed by Ahmara which accounts 116 (31.61%) as shown in (Table 1) below.
Table 1:Socio-demographic distributions of respondents among stroke patients admitted to Medical wards, in JUMC, Jimma zone Southwest Ethiopia, 2018.

Variables

Category

Frequency

Percentage (%)

 Age

<25

14

3.82

25-44

40

10.9

45-64

182

49.59

=>65

131

35.69

Total

367

100

Sex

Male

234

63.8

Female

133

36.2

Total

367

100

Marital status

Married

336

91.55

Single

28

7.63

Others (widow, divorce…)

3

0.82

Total

367

100

Religion

Muslim

143

38.96

Orthodox

117

31.88

Protestant

56

15.26

Catholic

37

10.08

Other(Java, Waqeeffata, Adventist)

14

3.82

 Total

367

100

Ethnicity

Oromo

153

41.69

Ahmara

116

31.61

Tigray

37

10.08

Garage

32

8.72

Dawaro

16

4.36

Other(Kaffa,Hadiya, Silte,sumale,  )

13

3.54

Total

367

100

Types of stroke
Concerning types of stroke among stroke patients admitted to stroke unit during the study period, from a total of study participants 236(64.31%) had the hemorrhagic stroke while 131(35.69%) had an ischemic stroke. Regarding association between dependent variables (types of stroke) and independent variables (age and gender) there is statically significant association between types of stroke and age as p-values < 0.05 (0.008) and no association between gender and types of stroke p-value is >0.05(0.714) as displayed in the (Table 2) below.
Risk factors of stroke
Concerning respondent’s risk factors of stroke among study participants majority of them had hypertension followed by diabetes mellitus which accounts 123 (29.64%) and 89(21.45%) respectively as shown in the (Table 3).
Table 2:Distributions of respondents by types of stroke and association with age and gender, among stroke patients admitted to a stroke unit, in JUMC, Jimma zone Southwest Ethiopia, 2018.

Parameter

Type of stroke No (%)

Total

X2

p-value

Ischemic

Hemorrhagic

No

(%)

No

(%)

No

(%)

  Age (years)

<25

5

1.36

9

2.45

14

3.82

1.36

0.008

25-44

11

2.99

29

7.9

40

10.9

45-64

66

17.98

116

31.61

182

49.59

=>65

49

13.35

82

22.34

131

35.69

Total

131

35.69

236

64.31

367

100

Gender

Male

92

25.06

194

52.86

286

77.93

7.02

0.714

Female

39

10.62

42

11.44

81

32.07

Total

131

35.69

236

64.31

367

100

Table 3:Distributions of respondents by risk factors of stroke among stroke patients admitted to a stroke unit, in JUMC, Jimma zone Southwest Ethiopia, 2018.

Risk factor

Number

(%)

Hypertension

123

29.64

Diabetes Mellitus

89

21.45

Previous Stroke

66

15.91

Atrial fibrillation

45

10.84

Transient ischemic attack

43

10.36

Structural heart disease

43

10.36

Others(HIV, RF, CHF)

6

1.44

Total

415

100

Treatment outcome
Regarding treatment outcome among stroke patients admitted to stroke unit during study period majority of them were died followed by improved which accounts 139(37.87%) and 97(26.43%) respectively. From those died majority of them were at age of =>65 followed by age between (45-64) which accounts 77(20.98%) and 51(13.89%) respectively and male by gender 116(31.61%). Regarding the association between dependent (treatment outcome) and independent variables (age and gender), there is a significant association between treatment outcome and age and gender i.e. as a p-value of both is 0.00 which is less than 0.05 as depicted in the (Table 4) below.
Table 4:Distributions of respondents by treatment outcome among stroke patients admitted to medical wards (stroke unit), in JUMC, Jimma zone, Southwest, Ethiopia, 2018.

Socio-demographic factor

Treatment Outcome

Total

X2

Df

p-value

Dead

Improved

Discharged with Neurologic Deficit

Discharged against Medical Advice

No

(%)

No

(%)

No

(%)

No

(%)

No

(%)

68.1

9

0

Age

<25

2

0.54

6

1.63

2

0.54

4

1.09

14

3.82

25-44

9

2.45

13

3.54

11

2.99

7

1.91

40

10.9

45-64

51

13.89

66

17.98

40

10.89

25

6.81

182

49.59

=>65

77

20.98

12

3.27

33

8.99

9

2.45

131

35.69

Total

139

37.87

97

26.43

86

23.43

45

12.26

367

100

Gender

Male

116

31.61

78

21.25

70

19.07

22

5.99

286

77.93

25.5

3

0

Female

23

6.27

19

5.18

16

4.36

23

6.26

81

32.07

Total

139

37.87

97

26.43

86

23.43

45

12.26

367

100

Discussions
This study revealed that from a total of study participants 236(64.31%) had a hemorrhagic stroke while 131(35.69%) had an ischemic stroke. This finding is higher compared with a retrospective cross-sectional study conducted in the first Hospital of Jilin University, Chang Chun, China on Prevalence of stroke and associated risk factors which showed that the overall prevalence of stroke in Jilin Province was 7.2% (95% CI 6.3% to 8.2%). Of all stroke cases, 91.7% (95% CI 87.4% to 94.6%) were ischemic stroke and 8.3% (95% CI 5.4% to 12.6%) were hemorrhagic stroke (6). The possible explanation for this difference is may be due to a difference in the study area (developed country vs developing country), study year and study period. This study also showed that association between dependent variables (types of stroke) and independent variables (age and gender) there is the statically significant association between types of stroke and age as p-values < 0.05 (0.008) and no association between gender and types of stroke p-value is >0.05(0.714). This finding is the difference when compared with a one-year retrospective study conducted on pattern and outcomes of patients with stroke admitted in tertiary hospitals in Zimbabwe showed mortality was associated with place of admission (p< 0.001). Gender and side of stroke were significantly associated (p< 0.001) (8).This difference may need further investigation to be certain. This study also showed that among study participants the majority of them had hypertension followed by diabetes mellitus which accounts 123 (29.64%) and 89(21.45%) respectively. This finding is lower compared with a retrospective study conducted on an assessment of risk factors and treatment outcome of stroke admissions at St. Paul’s Teaching Hospital which showed that hypertension was found to be the most common antecedent risk factor in 92 (56.4%) patients and higher with respect to Diabetes mellitus which showed that (DM) was identified as a risk factor in 19 (11.6%) patients and 14 (8.5%) patients had both hypertension and diabetes mellitus (10).This difference is may be due to the difference in the study area, study year and study period. This study also showed that the majority of them were died followed by improved which accounts 139(37.87%) and 97(26.43%) respectively. Regarding the association between dependent (treatment outcome) and independent variables (age and gender), there is a significant association between treatment outcome and age and gender i.e. as a p-value of both is 0.00 which is less than 0.05. It is different when compared with another similar study conducted in China which showed that when type of stroke was tabulated against mortality, forty-nine (out of 187) (26.2%: 95% CI=19.8; 32.6) of the patients with ischemic stroke died while 51/214 (23.8% 95% CI= 18.1; 29.6) died among hemorrhagic strokes. No difference in mortality was found between hemorrhagic and ischemic strokes (p=0.584) (7). This difference is may be due to the difference in the study area, study year and study period.
Acknowledgment
We are grateful to Jimma University, College of Health Science, department of nursing and midwifery and Jimma University medical centre. We also thank the study respondents and the University at large for their wholesome effort and contribution in provision of the information. And at last but not least, we would like to thank the survey supervisors and data collectors for their effort to accomplish data collection with due effort and passing all hard time.
Conflict of Interests
All authors declared that they have no conflict of interests.
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