The World Stroke Organization reported in 2022 that more than 85% of stroke-related deaths worldwide occur in low- and middle-income countries. Strokes also happen at a lower average age in these countries than in high-income countries, often during peak working years. Strokes can cause death and disability and create an economic burden in low- and middle-income countries. The occurrence of strokes in impoverished people in developing countries can severely impact them and worsen their lack of essential resources. A stroke is an abrupt death of brain cells caused by a shortage of blood flow and oxygen to the brain. Key factors contribute to the burden of stroke in low- and middle-income countries, and global organizations implement strategies to improve outcomes. 

Hypertension in Low- and Middle-Income Countries

Low- and middle-income countries have a high incidence of hypertension, or high blood pressure, which leads to stroke. The poorest people in developing countries often experience hypertension. The link between poverty and hypertension is counter to the common assumption that people in poverty have low body weight and high physical activity levels. Still, other environmental and lifestyle factors can cause hypertension in poor populations. Hypertension damages blood vessels and can cause them to leak or clog, increasing the chances of a stroke. High blood pressure in developing countries is linked to various factors, including environmental conditions and diets high in salt and low in fruits and vegetables. 

There is less awareness and treatment of hypertension in low- and middle-income countries compared with high-income countries. Research published in 2019 by Pascal Geldsetzer and others showed that 26% of people with hypertension in 44 low- and middle-income countries had never received a blood pressure check. Furthermore, merely one in 10 of the hypertension cases had attained control. People in poverty with hypertension often cannot access quality treatment and heavily depend on good health to support themselves financially. 

Air Pollution and Stroke

Air pollution is a significant contributor to stroke and causes 21% of worldwide stroke deaths, according to a report from Dean Schraufnagel and others in 2019. The World Health Organization (WHO) reported in 2016 that more than 85% of air pollution-caused deaths occur in low- and middle-income countries. Lower-income groups in developing countries often work outdoors and endure more air pollution exposure, creating a relationship between poverty and air pollution. Jun Rentschler and Nadezea Leonova reported research in 2023 showing that more than 700 million people living on less than $2 per day experience unsafe levels of air pollution exposure. Air quality standards are typically less strict in developing countries than in high-income countries. The sources of air pollution include older models of machines and cars, city transportation systems, industrialization and the clearing and burning of land for farming. 

Both short-term and long-term exposure to air pollution increases the risk of stroke. Over the long term, tiny pieces of air pollutants affect internal organ function, leading to increased blood clot formation and a potential stroke. 

Health Care Access and Stroke Outcomes

Health care access affects the outcomes of stroke in low- and middle-income countries. A research study by Peter Langhorne and others published in 2018 showed that people in low- and middle-income countries had reduced access to evaluation and treatment when experiencing a stroke. Poverty is also linked to decreased access to quality care for strokes and other cardiovascular events. 

According to a study by Mohammad Rabhar and others published in 2022, access to health care contributes to the lower average age of stroke in low- and middle-income countries. Health care facilities in these countries do not always start preventative stroke measures, such as treating hypertension and measuring blood lipids. Developing countries often lack the imaging capabilities necessary to diagnose stroke effectively. Improving access to health care before, during and after stroke is a potential strategy to reduce stroke incidence and death in low- and middle-income countries. 

The Fight To Improve Stroke Outcomes in Low- and Middle-Income Countries

With an increased understanding of stroke in developing countries, organizations are acting to reduce the burden. In 2017, the International Society of Hypertension began a global campaign to screen people for hypertension. Over two years, the effort resulted in the blood pressure evaluations of 4.2 million people. 

There are also regional groups fighting stroke, including the Middle East and North Africa Stroke Organization, the African Stroke Organization, the European Stroke Organization and the Asia Pacific Stroke Organization. In 2022, the American Heart Association recognized the Middle East and North Africa Stroke Organization for its efforts to educate citizens and health care professionals about stroke and its advocacy for stroke health services. 

The World Stroke Organization—Lancet Neurology Commission Stroke Collaboration Group published a multi-pronged practical strategy for improving worldwide stroke outcomes in October 2023. The commission outlines a path to improve stroke outcomes in developing countries, including increasing surveillance, and access to preventative health care, acute stroke care and rehabilitation therapies. To encourage research on global stroke prevention and treatment, the World Stroke Organization announced funding for four pilot research projects in 2024, prioritizing projects focused on stroke in low- and middle-income countries. 

Looking Ahead 

Stroke in low- and middle-income countries is a complex and multifaceted issue. People in poverty can experience increased exposure to the risk factors of stroke and have fewer resources to cope with stroke. International organizations continue researching and implementing practical strategies to reduce stroke in impacted countries. Improvements in the prevention and treatment of stroke can potentially improve citizens’ quality of life and economic contributions.

– Kelly Carroll
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