Care-seeking pathways and time to tertiary hospital presentation for stroke care in Ondo State, Nigeria

Technical Summary: Care-Seeking Pathways and Time to Presentation for Stroke Care at UNIMEDTH, Ondo State, Nigeria

Problem Statement
Stroke care is critically time-sensitive, particularly for intravenous alteplase, which yields optimal functional outcomes when administered within 4.5 hours of symptom onset. In low- and middle-income countries (LMICs), including Nigeria, patients frequently experience significant prehospital delays. While existing literature documents the prevalence of late hospital arrival, it often treats delay as a singular outcome rather than examining the specific sequence of care-seeking behaviors that precede it. In pluralistic health systems like Nigeria, patients often navigate between formal biomedical facilities, informal providers (e.g., patent medicine vendors), and traditional or faith-based healers before reaching tertiary care. This study addresses the gap in understanding how these specific care-seeking pathways and their complexity influence the time elapsed between symptom onset and presentation at a tertiary stroke-capable facility.

Methodology
The study employed a retrospective hospital-based design, analyzing secondary data from the University of Medical Sciences Teaching Hospital (UNIMEDTH) in Ondo State, Nigeria.

• Data Sources: Records were extracted from the UNIMEDTH Stroke Registry, radiology department logs, referral notes, and ambulance records covering a 24-month period.
• Sample: The analysis included 371 unique stroke cases with documented sociodemographic data, recorded symptom onset times, and reconstructable care pathways leading to UNIMEDTH.
• Variables:
  • Primary Outcome: Time-to-presentation (hours from symptom onset to arrival at UNIMEDTH), analyzed as a right-skewed continuous variable using medians and interquartile ranges (IQR).
  • Pathway Classification: First contacts were categorized into three groups: Hospital/Biomedical (including hospitals and home management by medical professionals), Self/Informal (self-medication, chemists/patent medicine vendors), and Traditional/Faith-based (traditional remedies, healers, prayer houses).
  • Pathway Complexity: Defined by the number of documented steps (contacts) before final presentation, ranging from one-step (direct) to four-step pathways.
• Statistical Analysis: Frequencies and percentages described pathway patterns. Non-parametric tests (Mann-Whitney U and Kruskal-Wallis) were used to compare median presentation times across different first-contact categories and pathway complexities.

Key Results

• Overall Delay: The median time from symptom onset to tertiary presentation was 24 hours (IQR 9–72). Only 14.6% of patients presented within the critical 4-hour window; 85.4% presented after 4 hours.
• First Contact Patterns: Direct presentation to UNIMEDTH was rare (8.1%). The majority of patients (68.2%) first sought care outside a hospital facility.
  • Self/Informal Care was the most common first contact (41.2%), with chemists/patent medicine vendors being the single most frequent specific point of contact (22.4%).
  • Traditional/Faith-based Care accounted for 27.8% of first contacts.
  • Hospital/Biomedical Care accounted for 31.0%, with "management at home by a doctor/nurse" being the most frequent specific biomedical contact (9.2%).
• Pathway Complexity: There were 44 distinct documented pathway sequences. The most common sequence was moving from a chemist/patent medicine vendor directly to UNIMEDTH (10.2%). Nearly 60% of pathways were concentrated in the top 10 sequences, while 41.5% were distributed across 34 other unique routes.
• Impact on Time to Presentation:
  • First Contact Location: Patients whose first contact was a hospital facility had a median presentation time of 3 hours (IQR 2–6), compared to 48 hours (IQR 24–72) for those whose first contact was non-hospital (p < 0.001).
  • Contact Category: Median times increased progressively: Hospital/Biomedical (6 hours) < Self/Informal (24 hours) < Traditional/Faith-based (48 hours).
  • Complexity: A clear gradient was observed: One-step pathways had a median time of 2 hours, two-step pathways 23 hours, and three- and four-step pathways 48 hours (p < 0.001).

Key Contributions
The study shifts the analytical focus from individual "delay" to the structural "pathway" of care. It demonstrates that delayed tertiary arrival is not merely a failure of patient recognition but is embedded in the sequence of provider transitions.

1. Identification of Critical Nodes: The study identifies patent medicine vendors and chemists as the most common initial entry points into the health system for stroke patients in this setting, suggesting they are pivotal nodes for potential intervention.
2. Quantification of Pathway Cost: It provides empirical evidence that multi-step pathways and initial contact with non-biomedical providers are strongly associated with significantly longer times to definitive care.
3. Contextual Interpretation: Using Andersen's Behavioral Model and Kleinman's Explanatory Model, the paper interprets these pathways not as irrational choices but as logical responses to accessibility, trust, and cultural interpretations of symptoms within a pluralistic health system.

Significance and Claims
The authors claim that reducing stroke-related delays in this setting requires moving beyond community awareness campaigns alone. The findings suggest that interventions must address the "interface" between the community and the formal health system. Specifically, the paper argues for:

• Integrated Referral Systems: Establishing urgent referral linkages that connect patent medicine vendors, traditional healers, and faith-based providers directly to tertiary stroke services.
• Provider Training: Equipping first-contact providers outside hospitals (especially chemists) with stroke recognition skills and protocols for immediate referral rather than treatment or observation.
• System Redesign: Recognizing that delayed arrival is partly a system-level failure of coordination between diverse care providers, necessitating a strategy that combines public education with structural improvements in emergency transport and inter-facility communication.

The study concludes that while the median delay of 24 hours aligns with broader African trends, the specific mechanism of delay in Ondo State is the traversal of multiple, often non-biomedical, care steps before reaching a capable facility. Addressing this requires a coordinated approach involving all sectors of the health ecosystem.