Comportamentos de estilo de vida saudável no contexto da prevenção secundária do acidente vascular cerebral

Abstract

Low- and middle-income countries, such as Brazil, face a high burden of stroke and recurrent stroke but lack interventions aimed at encouraging the adoption of healthy lifestyle behaviors for the secondary prevention of this health condition. Thus, this thesis presents the results of five studies that explored the adoption of healthy lifestyle behaviors for stroke secondary prevention. Recently, an overview of systematic reviews demonstrated the effectiveness of face-to-face behavior change and self-management interventions for stroke secondary prevention. Considering the clinical utility of telehealth in the care of individuals post-stroke, Study 1 aimed to critically assess and consolidate the findings of existing systematic reviews on the effectiveness of behavior change and self-management interventions, implemented via telehealth, in reducing the risk of stroke recurrence, as well as to provide new syntheses of primary studies that applied theoretically informed interventions. Fifteen systematic reviews (Phase 1) and 14 randomized controlled trials (RCT) that applied theoretically informed interventions (Phase 2) showed that telehealth interventions were effective in improving medication adherence, healthy eating, physical activity, and control of blood pressure and cholesterol, with a reduction in systolic blood pressure (SBP). However, a shortage of studies conducted in low- and middle-income countries was identified, and none had been conducted in Brazil. Recognizing the importance of telehealth in providing care to individuals post-stroke and the fact that physical inactivity represents the most prevalent risk factor for recurrent stroke in Brazil, Study 2 was carried out with the objective of developing the protocol for a feasibility study of a theoretically informed intervention, combining the 5As brief intervention (Ask, Advise, Assess, Assist, and Arrange), from the HEARTS Technical Package (a document developed by organizations such as the World Stroke Organization and the World Health Organization), with the use of a physical activity monitor, via telehealth, to increase physical activity levels post-stroke (experimental group, EG), while the control group (CG) did not use the physical activity monitor. Study 3 aimed to present the results of the previous study, confirming feasibility in terms of recruitment, implementation, and measurement, despite follow-up losses. The main costs for conducting the study were related to transportation for in-person assessments. Physical activity levels increased clinically in both groups, with a large within-group effect in the EG (Cohen’s d=1.01) and a moderate effect in the CG (Cohen’s d=0.76). The next phase of the study should enable the conduction of assessments remotely, in order to reduce follow-up losses and transportation costs. The simultaneous management of clustered risk factors is associated with a greater reduction in stroke occurrence, reinforcing the relevance of controlling multiple factors to prevent recurrence. Given the absence of a structured intervention for stroke secondary prevention in Brazil that involves the simultaneous management of multiple risk factors, the Irish intervention “iHELP Stroke: Improving Health and Lifestyle Programme,” aligned with stroke secondary prevention recommendations, appears promising for application in the country. However, socioeconomic, geographic, and cultural differences justify the need for its adaptation to the Brazilian context prior to implementation. Considering the current movement toward shared responsibility and partnership in health research, principles that support the recommendation to include the Patient and Public Involvement (PPI) approach in research, individuals post-stroke were planned to be involved as PPI representatives in the adaptation of the Irish intervention “iHELP Stroke” to the Brazilian context. However, there is a scarcity of studies employing PPI in health research in low- and middle-income countries, such as Brazil. Therefore, a scoping review was conducted to identify how PPI has been implemented and reported in empirical stroke research (Study 4). This review highlighted the limited use of PPI in stroke research and recommended expanding this approach, particularly in low- and middle-income countries. In addition, considering that the implementation of stroke secondary prevention interventions should meet the needs and priorities of individuals post-stroke, it is equally relevant, to support the process of adapting the “iHELP Stroke” intervention to the Brazilian context, to understand the similarities and differences between Irish and Brazilian individuals post-stroke regarding the prioritization of key components to be included in interventions aimed at encouraging the adoption of healthy lifestyle behaviors. In this sense, Study 5 was developed with the objective of understanding the similarities and differences in the way Irish and Brazilian individuals post-stroke, participants of PPI research panels, prioritize key components to be included in interventions to encourage the adoption of healthy lifestyle behaviors. A broad convergence was identified (most components were considered “definitely important” simultaneously in both countries), although differences reinforced the need for adaptations when transferring interventions from high-income to middle-income contexts. Finally, Study 6 aimed to describe the process of adapting the Irish “iHELP Stroke” intervention to the Brazilian context, which included the PPI approach in research with a representative post-stroke as a co-researcher, resulting in “iVIDAVC: intervenção para melhorar a saúde e o estilo de vida pós-AVC”. Linguistic, cultural, and structural adaptations were made. The adapted version demonstrated feasibility, with high acceptability and satisfaction, in addition to good levels of retention and attendance. The next phases of the study should address the following points: testing the program with a greater number of group sessions (in the present study, only a minimum of six sessions were offered), considering the reports that the intervention period was too short; ensuring the continuous participation of invited professionals, as these components exceeded the initially planned time; including at least four participants per group, since the absence of two members in a group of three compromised the group sessions; and improving the evaluation of clinical outcomes, in order to better understand the factors associated with meeting the established behavior change goals. Furthermore, considering the relevance of telehealth in enabling the delivery of interventions to individuals post-stroke in Brazil, it is also important that future studies investigate the feasibility of implementing the “iVIDAVC” intervention in this format. The six studies developed provided results with potential for clinical application to encourage the adoption of healthy lifestyle behaviors post-stroke in Brazil, reinforcing the value of theoretically informed interventions and pointing to directions for future research.