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Scovia Nalugo Mbalinda,1 Mark Kaddumukasa,2 Josephine Nambi Najjuma,3 Martin Kaddumukasa,1,4 Jane Nakibuuka,1,4 Christopher J Burant,5 Shirley Moore,6 Carol Blixen,7 Elly T Katabira,1 Martha Sajatovic7 1Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda; 2Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 3Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda; 4Department of Medicine, Mulago Hospital, Kampala, Uganda; 5Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, 44106, USA; 6Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA; 7Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center & Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USACorrespondence: Scovia Nalugo Mbalinda, Department of Nursing, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda, Tel +256782212151, Email snmbalinda@gmail.comPurpose: Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa.Methods and Materials: Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies.Results: Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 − 23% among those with recurrent strokes compared to primary strokes.Conclusion: This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.Keywords: stroke recurrence, sub-Saharan Africa, risk factors, secondary prevention, cardiovascular disease

Martin Kaddumukasa,1 Alyssa M Edwards,2 Josephine Nambi Najjuma,3 Scovia Nalugo Mbalinda,4 Jane Nakibuuka,1 Christopher J Burant,5 Shirley M Moore,6 Carol Blixen,2 Elly T Katabira,1 Martha Sajatovic,2 Mark Kaddumukasa1 1Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 2Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA; 3Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda; 4Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda; 5Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, USA; 6Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USACorrespondence: Martin Kaddumukasa, Email kaddumart@gmail.comAbstract: The study set out to perform a systematic literature review of evidence-based interventions that target the reduction of secondary stroke risk in Africa. The review analyzed longitudinal intervention studies conducted in Sub-Saharan Africa, focusing on adult participants who had suffered a prior stroke. It encompassed publications and peer-reviewed papers sourced from reputable databases, including PubMed, Ovid, Cochrane, and Web of Science. Three randomized clinical trial (RCT) studies were included with sample sizes ranging from 16 to 400 participants, mean age ranged between 50 and 66 years, with 64.5% male participants. All studies applied multidisciplinary team interventions of enhanced patient follow-up involving care givers, nurse educators, physicians, and social workers. Interventions ranged from comprehensive patient education, tracking of medication adherence and enforcing healthy lifestyle behaviors (regular exercise, regular BP checks, and dietary changes). We found a decrease in Systolic Blood Pressure over time in 2 of 3 treatment groups, an improvement in medical adherence in all treatment groups, and a decrease in cholesterol levels in 1 treatment group. Evidence-based interventions involving multidisciplinary teams and comprehensive patient education were found to demonstrate promising results in reducing secondary stroke risk in Africa, leading to significant improvements in medical adherence and reductions in systolic blood pressure in the majority of treatment groups. However, more research is required to confirm the influence of these interventions on cholesterol levels and to establish their lasting advantages in preventing strokes among African communities.Keywords: secondary stroke risk, risk interventions, Sub-Saharan Africa

Carol Blixen,1,2 Jennifer B Levin,2 Kristin A Cassidy,2 Adam T Perzynski,1 Martha Sajatovic2–4 1Center for Health Care Research and Policy, MetroHealth Medical Center, 2Department of Psychiatry, 3Department of Neurology, Neurological Institute, 4Department of Biostatistics & Epidemiology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA Background: Bipolar disorder (BD) is a chronic mental illness associated with reduced quality of life, high rates of suicide, and high financial costs. Evidence indicates that psychosocial stress might play an important role in the onset and course of BD. Objective: The objective of this study was to address the gap between coping theory and the clinical use of coping strategies used to self-manage BD.Methods: In-depth interviews were conducted with a sample of 21 poorly adherent patients with BD. All interviews were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes.Results: Transcript-based analysis generated two major domains of coping strategies used to self-manage BD: 1) problem focused (altering eating habits, managing mood-stabilizing medications, keeping psychiatric appointments, seeking knowledge, self-monitoring, and socializing) and 2) emotion focused (distracting activities, denial, isolation, modifying/avoiding, helping others, and seeking social support). Participants used both types of coping strategies to deal with stressful situations brought about by the internal and external demands associated with self-management of BD.Conclusion: This qualitative study provided a first step in evaluating coping strategies as a possible mediator in the self-management of BD and has implications for health care providers. Being able to characterize an individual’s coping behaviors can help patients modify or replace more maladaptive coping with better coping strategies in the self-management of this chronic mental illness. Keywords: bipolar disorder, coping strategies, self-management

Background: Mood-stabilizing medications are a cornerstone of treatment for people with bipolar disorder, though approximately half of these individuals are poorly adherent with their medication, leading to negative and even severe health consequences. While a variety of approaches can lead to some improvement in medication adherence, there is no single approach that has superior adherence enhancement and limited data on how these approaches can be implemented in clinical settings. Existing data have shown an increasing need for virtual delivery of care and interactive telemedicine interventions may be effective in improving adherence to long-term medication., Methods: Customized adherence enhancement (CAE) is a brief, practical bipolar-specific approach that identifies and targets individual patient adherence barriers for intervention using a flexibly administered modular format that can be delivered via telehealth communications. CAE is comprised of up to four standard treatment modules including Psychoeducation, Communication with Providers, Medication Routines, and Modified Motivational Interviewing. Participants will attend assigned module sessions with an interventionist based on their reasons for non-adherence and will be assessed for adherence, functioning, bipolar symptoms, and health resource use across a 12-month period. Qualitative and quantitative data will also be collected to assess barriers and facilitators to CAE implementation and reach and adoption of CAE among clinicians in the community., Discussion: The proposed study addresses the need for practical adherence interventions that are effective, flexible, and designed to adapt to different settings and patients. By focusing on a high-risk, vulnerable group of people with bipolar disorder, and refining an evidence-based approach that will integrate into workflow of public-sector care and community mental health clinics, there is substantial potential for improving bipolar medication adherence and overall health outcomes on a broad level., Trial Registration: The study was registered on ClinicalTrials.gov NCT04622150 on November 9, 2020., (© 2022. The Author(s).)

Background: Epilepsy is associated with stigma and negatively impacts the lives of people living with epilepsy (PLWE) and their immediate families. More understanding of the stigma and discrimination experienced by PLWE in sub-Saharan Africa is needed., Methods: In a cross-sectional, mixed methods study, forty- eight PLWE who met the study inclusion criteria were enrolled. In depth interviews and focus group discussions were conducted and were audiotaped and transcribed verbatim. Analysis was conducted using a thematic, constant comparative approach with an emphasis on dominant themes. Perceived stigma was measured using the Kilifi epilepsy stigma score. Associations between socio-demographic factors and Kilifi epilepsy stigma score were assessed., Results: The median age of the study participants was 25 years, with median age (IQR) of epilepsy onset of 12 (6-18) years. The prevalence of high-perceived stigma was 31.9% (15/48). Seizure frequency was associated with high levels of perceived stigma (p-value of 0.038). Psychological abuse, rejections at home, places of employment and schools, poor relationships and intimacy and unmet engagements in social activities were cited as the perceived stigmatizing aspects among PLWE., Conclusion: In this Ugandan sample perceived stigma remains unacceptably high and interventions to address it are urgently needed in our settings., (© 2022 Kaddumukasa M et al.)

Background: Many people living with epilepsy (PLWE) reside in rural communities, and epilepsy self-management may help address some of the gaps in epilepsy care for these communities. A prior randomized control trial of a remotely delivered, Web-based group format 12-week self-management program (SMART) conducted in Northeast Ohio, a primarily urban and suburban community, demonstrated improved outcomes in negative health events such as depression symptoms and quality of life. However, there is a paucity of research addressing the needs of PLWE in rural settings., Methods: The present study leverages collaboration between investigators from 2 mid-western US states (Ohio and Iowa) to replicate testing of the SMART intervention and prioritize delivery to PLWE in rural and semi-rural communities. In phase 1, investigators will refine the SMART program using input from community stakeholders. A Community Advisory Board will then be convened to help identify barriers to trial implementation and strategies to overcome barriers. In phase 2, the investigators will conduct a 6-month prospective randomized control trial of the SMART program compared to 6-month waitlist controls, with the primary outcome being changes in negative health events defined as seizure, self-harm attempt, emergency department visit, or hospitalization. Additional outcomes of interest include quality of life and physical and mental health functioning. The study will also assess process measures of program adopters and system end-users to inform future outreach, education, and self-management strategies for PLWE., Discussion: The method of this study employs lived experience of PLWE and those who provide care for PLWE in rural and underserved populations to refine a remotely delivered Web-based self-management program, to improve recruitment and retention, and to deliver the intervention. Pragmatic outcomes important to PLWE, payers, and policymakers will be assessed. This study will provide valuable insights on implementing future successful self-management programs., Trial Registration: ClinicalTrials.gov NCT04705441 . Registered on January 12, 2021., (© 2021. The Author(s).)

Introduction: Stroke burden is rapidly increasing globally. Modifiable risk factors offer an opportunity to intervene, and targeting hypertension is a key actionable target for stroke risk reduction in sub-Saharan Africa. This 3-site planned randomized controlled trial builds on promising preliminary data., Methods: A total of 246 Ugandan adults will be recruited randomized to experimental intervention vs. enhanced treatment control. Intervention participants will receive six weekly group-format stroke risk reduction self-management training sessions, and the controls will receive information on cardiovascular risk. The primary study outcome is systolic B.P. measured at baseline, 13-week, 24 weeks (6 months). Secondary outcomes include other biological and behavioral stroke risk factors., Discussion: The curriculum-guided self-management TargetEd MAnageMent Intervention (TEAM) program is anticipated to reduce the stroke burden in Uganda., Trial Registration: ClinicalTrials.gov identifier: NCT04685408, registered on 28 December 2020., Competing Interests: The authors have declared that no competing interests exist.

Background: The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear., Aim: Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD., Setting: Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania., Methods: 100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification., Results: Moderate-to-high risk alcohol users had worse medication attitudes ( p < 0.01), medication adherence (previous week, p = 0.01; previous month, p < 0.001), and psychiatric symptoms ( p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use ( p = 0.02, 0.02, < 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants., Conclusion: Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances., Competing Interests: Dr Martha Sajatovic has received grants from Nuromate, Otsuka, Alkermes, and the International Society for Bipolar Disorders (ISBD); is a consultant for Alkermes, Otsuka, Janssen, Myriad, Health Analytics, and Frontline Medical Communications; has royalties with Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate; and has been compensated for preparation of the following CME activities: American Physician’s Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts, and Psychopharmacology Institute. The other authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)

Background and Purpose: Epilepsy is often associated with substantial stigma. This study evaluated clinical correlates of stigma in a sample of people living with epilepsy (PLWE) considered high risk due to frequent seizures or other negative health events., Methods: Data were derived from an epilepsy self-management clinical trial. Standardized measures assessed socio-demographics, epilepsy stigma, epilepsy severity, self-efficacy, self-management competency, health literacy, depressive symptoms severity, functional status, social support and quality of life., Results: There were 120 individuals, mean age of 41.73 (SD=17.08), 81 men (66.9%), and 79 (65.3%) African-American. Individual factors correlated with worse stigma w ere indicative of more severe or poorly controlled seizures (frequent seizures, worse seizure severity scores, more antiepileptic drugs), mental health comorbidity (worse depression severity, other comorbidities) and factors related to individual functioning and perceived competency in managing their health (health literacy, health functioning, self-efficacy, quality of life). Multivariable linear regression found that worse quality of life, and having a mental condition were associated with more stigma (β=6.4 and 6.8, respectively), while higher self-efficacy, health literacy and social support were associated with less stigma (β=-0.06, -2.1, and -0.3, respectively). These five variables explained 50% of stigma variation., Conclusions: Stigma burden can be substantial among PLWE and may vary depending on contextual factors such as mental health comorbidity. Care approaches that screen for psychiatric comorbidities, address low health literacy, institute promising self-management programs, and employ effective health communication strategies about epilepsy misconceptions, may reduce epilepsy related burden., Competing Interests: Martha Sajatovic, MD: Research grants within past 3 years: Otsuka, Alkermes, Janssen, International Society for Bipolar Disorders, Reuter Foundation, Woodruff Foundation, Reinberger Foundation, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC); Consultant: Alkermes, Bracket, Otsuka, Janssen, Neurocrine, Health Analytics, Frontline Medical Communications; Royalties: Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate; CME activities: American Physician's Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts., (Copyright © 2020 Korean Neurological Association.)

Background: Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10-24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA., Aims: To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania., Method: In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes., Results: Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context., Conclusions: Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

Objective: The objective of the study was to assess level of knowledge and attitudes of SUDEP among people living with epilepsy (PLWE) and healthcare workers providing epilepsy care in Uganda., Methods: This cross-sectional study of 48 PLWE and 19 epilepsy care providers used a tailored questionnaire to evaluate epilepsy and SUDEP knowledge, frequency of SUDEP discussion, reasons for not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions to being provided information on SUDEP., Results: Median PLWE sample age was 25 (IQR; 19-34) years, 10 (20.8%) were male, median age of onset of epilepsy 12 (IQR; 6-18) years. Half of the PLWE reported that they had never heard of SUDEP. Most PLWE desired detailed information regarding SUDEP and preferred this information during the subsequent visits. Healthcare provider sample mean age was 35.7 (22.8) years, 12 (63.2%) were male and composed of 4 physicians (21.1%). Only 15% (3/20) of providers discussed SUDEP with their patients while 85% (17/20) have never discussed it. The main reasons for not discussing SUDEP were not knowing enough about SUDEP (89.5%) and no adequate support network available (30%). Providers that discussed SUDEP (100%) reported that negative reactions were the most common patient response., Significance: In this Ugandan sample, most PLWE are not aware of SUDEP and epilepsy care providers rarely discuss SUDEP with their patients or patient caregivers. Negative reactions to SUDEP discussions are common but not universal. There is an urgent need for epilepsy educational programs in clinics and targeted communities addressing SUDEP., Competing Interests: The authors declare that they have no competing interests. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines., (© 2019 The Authors. Epilepsia Open published by Wiley Periodicals Inc. on behalf of International League Against Epilepsy.)

Background: Epilepsy is a common neurological disease with substantial impact on the subject and their caretakers. This exploratory study identified barriers to care for persons living with epilepsy (PLWE) to develop a culturally acceptable nurse led self-management intervention for PLWE previously developed in the United States., Methods: The study involving 48 participants (31 PLWE and 17 caregivers) with in depth interviews and focus groups was conducted. We obtained insights into barriers to care in PLWE and their caregivers. Using a thematic analytic procedure emphasizing the dominant themes the qualitative responses were analyzed. Median age of PLWE was 24 years (IQR 19-30), and10 (52.6%) were male. The median age of epilepsy onset was 12 years (IQR 6-18), range of 1-37 years. The median age of caregivers was 50 years (IQR 45-50.5), with a range of 18-78 years. Seventy five percent of caregivers (6/8) were females., Results: Three major areas of perceived barriers involving individual, family or community and provider and healthcare system barriers to epilepsy care emerged. Individual factors like limited epilepsy knowledge and medication non-adherence were reported to be key barriers to epilepsy care. Caregiver burden and lack of family support as well as poor health care access were identified from the family and health care systems., Conclusions: The main barrier to epilepsy care is limited epilepsy knowledge in PLWE and their caregivers. Improving epilepsy care awareness and knowledge within communities and appropriate health care provider service for epilepsy would help reduce epilepsy barriers and improve care.

Objective: This study evaluated the feasibility, acceptability, and preliminary efficacy of psychoeducation plus an automated text messaging intervention (Individualized Texting for Adherence Building-Cardiovascular [iTAB-CV]) to improve adherence to antihypertensives and bipolar disorder medication., Methods: After a psychoeducation program, iTAB-CV was administered for 2 months. In month 1, participants received one educational-motivational and one mood rating text daily. In month 2, medication reminders were added., Results: The sample (N=38) was 74% African American and 53% women, with a mean±SD age of 51.53±9.06. Antihypertensive nonadherence decreased from a mean of 43%±23% to 21%±18% at 12 weeks (χ 2 =34.6, df=3, p<0.001). Systolic blood pressure decreased from a mean of 144.8±15.5 mmHg to 136.0±17.8 mmHg (χ 2 =17.6, df=3, p<.001). Retention was 100%., Conclusions: In this uncontrolled trial, participants were highly engaged and medication adherence and reduced systolic blood pressure were sustained after psychoeducation plus iTAB-CV. Because iTAB-CV is automated and delivered remotely, it has the potential to reach a large and challenging population.

Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden including reduced quality of life and functional impairment. Care for CPD includes psychosocial and pharmacologic interventions (i.e. antipsychotic drugs) and ongoing health monitoring. This is challenging in resource-limited settings where staff are sparse and/or undertrained. Importantly, mental health human resource needs predict continued deficits compounded by increasing disease burden. A U.S. team recently developed and tested a CPD treatment approach that combines the use of long-acting antipsychotic medication (LAI) with a brief and practical customized adherence enhancement behavioral intervention (CAE-L). This report describes the methodological details of an ongoing, first-ever refinement and preliminary testing of CAE-L in poorly adherent patients with CPD in Tanzania. Additional innovative elements include: 1) a manualized curriculum that targets specific barriers and facilitators to medication adherence in Tanzanians with CPD, and 2) targeting known, high-risk individuals with CPD (those who miss ≥20% of prescribed antipsychotic medication). The study procedures are intended to pave the way for implementing a large-scale intervention trial for CPD in the Tanzanian setting. An important component of this project is capacity building to help form the next generation of care providers. Visit exchanges modeled on a successful NIH-funded Medical Education Partnership Initiative (MEPI) template will also use the U.S. and Tanzanian teams to share expertise, problem-solve, and plan iterative refinements of project deliverables. Taken together, this project has potential to advance the care of people with CPD in Tanzania and has high generalizability to Sub-Saharan Africa and other lower-resource settings.

Objective: To describe the modifiable lifestyle risk factors for stroke among a high risk population for stroke. Africa suffers from rapid population growth, adoption of harmful western diets, and increased prevalence of hypertension and obesity., Results: A total of 440 study participants were screened and 87 individuals with hypertension plus at least one other known stroke risk factor were enrolled. The prevalence of hypertension and diabetes mellitus in the screened population was 19.7 and 1.8%, respectively. Among those with hypertension only 2.3% (2/87) had ever had serum lipid assessment. Seventy-two percent (68/87) had very high serum LDL-cholesterol, while 33.3% (29/87) had low levels of HDL-cholesterol, and 67.8% had mean blood pressures greater than 160/100 mmHg and 40% (35/87) were obese, with a BMI ≥30. Targeting individuals with modifiable stroke risk factors and implementing self-management programs may be a way to reduce stroke burden in Uganda.

Background: Stroke is a neurological condition with rapidly increasing burden in many low- and middle income countries. Africa is particularly hard-hit due to rapid population growth, patterns of industrialization, adoption of harmful western diets, and increased prevalence of risk factors such as hypertension and obesity. Reducing stroke risk factors and teaching people to respond to stroke warning signs can prevent stroke and reduce burden. However, being able to address gaps in knowledge and improving both preventative and early-response care requires a clear understanding of practical and potentially modifiable topics. In this cross sectional study, we assessed the knowledge and attitudes among an urban population residing within the greater Kampala, Uganda., Methods: A population cross sectional survey was conducted in urban Mukono, district, central Uganda. Through the systematic sampling method, data were gathered from 440 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception using a pretested structured questionnaire., Results: A total of 440 study participants were enrolled. The leading risk factors for stroke identified by the participants were stress (75.7%) and hypertension (45.2%) respectively. Only two (0.5%) of the study participants identified cigarette smoking as a stroke risk factor. Individuals with hypertension have poor knowledge regarding stroke in spite their high risk for stroke., Conclusion: Stroke knowledge is poor while, stress and hypertension are the leading perceived risk factors in our settings. While stress is contributing factor, hypertension is likely a more amenable and practical intervention target. Targeting individuals with stroke risk factors to increase stroke knowledge and education is crucial for engagement in healthcare. Implementing a self-management program to support and motivate this high-risk group as well as adopting healthy life-styles may be a way to reduce stroke burden in Uganda., Competing Interests: Competing interests The authors declare that they have no competing interest.

Patients with serious mental illness (SMI) and diabetes often seek care in primary care settings and have worse health outcomes than patients who have either illness alone. Individual, provider, and system-level barriers present challenges to addressing both psychiatric and medical comorbidities. This article describes the feasibility, acceptability, and implementation of Targeted Training and Illness Management (TTIM), a self-management intervention delivered by trained nurse educators and peer educators to groups of individuals with SMI and diabetes to improve self-management of both diseases. TTIM is intended to be delivered in a primary care setting. Findings are intended to support the future development of nurse-led programs within the primary care setting that teach self-management to individuals with concurrent SMI and diabetes. This approach supports both adaptability and flexibility in delivering the intervention. Interventions such as TTIM can provide self-management skills, accommodate people with both SMI and diabetes in primary care settings such as patient-centered medical homes, and address known barriers to access.

The demands of providing care to impaired older adults frequently results in strain and depressive symptomatology. These outcomes of caregiving may be affected by social support such as home health care. Forty-nine caregivers to impaired older adults receiving home health care and 51 caregivers not receiving home health care were interviewed soon after identification by hospital personnel and 3 months later. Strain and depressive symptomatology were not significantly lower and positive caregiving appraisal was not significantly higher for caregivers receiving home health care even when controlling for their pretest measures. Strain and depressive symptomatology were significantly higher for caregivers of cognitively impaired persons. Home health care nurses need to identify those caregivers at greater risk to individualize services.