Population-wide strategies are essential because even small changes in the distribution of risk factors would lead to major reductions in stroke/CVD incidence in the population (Figure 6).^43,44 The population-wide prevention strategy was suggested by Sir Geoffrey Rose in 1985 as the most effective strategy for primary CVD prevention.⁴⁴ As this strategy targets several behavioural and lifestyle risk factors (including tobacco use, unhealthy diet, physical inactivity, overweight and the harmful use of alcohol) that are common for a range of major NCDs, such as heart disease, diabetes, cancer, dementia and pulmonary heart disease, this strategy will be positively impacting not only stroke risk but on all these major NCDs. Over the last 15 years, it has been included in all major CVD prevention guidelines,^34,45 often in combination with high-risk approach and with several anecdotal reports of its effectiveness in selected populations.^46–48 Nevertheless, there is still no country in the world where this strategy has been implemented in full at the national level. The major reasons for the lack of implementation of this strategy on a national level include costs (e.g. increasing the availability of facilities for physical activity, healthy food outlets) and the need for policy and legislative changes that are often not supported by major industries (e.g. salt reduction in processed food, reduction of exposure to smoking, alcohol, fast food).²⁴

An additional important benefit of population-wide prevention approaches that target the entire population rather than just those at high risk is that it may be easier and more effective to promote the maintenance of health than to reverse existing damage, therefore, sensitive timepoints at which health changes may be most impactful are likely earlier in life before subclinical risk factors have emerged.

Intensive clinical care for high-risk individuals remains the dominant paradigm in the world for prevention of stroke.⁴⁹ While management strategies for primary stroke prevention in high CVD risk individuals are well established,³⁴ they are under-utilised^34,50–53 and existing methods of primary stroke prevention are not sufficiently effective.^54–56 The healthcare system has been largely unsuccessful in providing relevant meaningful information to assist people in adhering to recommended lifestyle changes and medications.^{34,54,55,57–59} Uptake of primary prevention recommendations is particularly low in people with moderately increased risk of stroke who would benefit from lifestyle modifications.^54,59,60 Inadequate CVD risk factor management^54,55 and lack of effective communication between health professionals and stroke patients/family^54,61–63 are implicated in underutilisation of primary stroke prevention strategies in people with moderately increased risk of stroke.⁶¹

The high-risk prevention strategy implies calculation of absolute risk of CVD over the next 5 or 10 years with the aim of identification of people at high risk of development of acute CVD (heart attack, stroke, acute peripheral artery disease), which usually defined as having a risk of ≥15% over the next 5 years or ≥30% over the next 10 year or having an established CVD (e.g. stroke, ischemic heart disease, transient ischemic attack [TIA], peripheral artery disease).^64,65 Although assessment of people for absolute stroke/CVD risk is important for matching the intensity of preventing efforts with the individual’s absolute risk⁶⁶ and monitoring success or failure in primary stroke/CVD prevention, there several major issues with the high-risk approach for stroke/CVD prevention. Primary stroke/CVD prevention strategy that aims primarily at high-risk individuals fails to engage into active prevention the majority of the population where most strokes and other acute CVD events occur,^67,68 it also lacks personal motivation to control risk factors by people who are at low or moderate risk of CVD events. Other limitations of this strategy include costs associated with laboratory tests and doctors visit to determine the risk, and lack of population-specific algorithms for stroke and CVD prevention.²⁴ There is evidence that even effective population-wide use of high-risk prevention strategies with aggressive pharmacological treatment in individuals with a 10-year Framingham event risk of ≥30% (6% of population) would have reduced major CVD by at most 11%,⁴⁹ and if high-risk strategies are to have a major impact on CVD in the population, they need to be more widely used than previously envisaged.⁴⁹ In addition, the use of high-risk prevention strategies is limited by access to medical professionals,⁶⁹ and even when care is available, the adherence of patients to recommended medications and lifestyle modifications are often poor⁷⁰ due to multiple reasons,⁷¹ including wrong patients’ beliefs⁷² (limited health literacy) and comorbidities.⁷³

Although it is generally agreed that screening for CVD risk can be used as a guide for making clinical decisions on the intensity and effectiveness of preventative interventions,^42,74 just screening of the population for CVD risk in order to provide intensive medical care to high risk individuals continues to be thought of as an important health target by many governments.⁷⁵ This is particularly disappointing because there is compelling evidence from 15 large randomized controlled trials (totalling about 200,000 patients), including Cochrane systematic review and meta-analysis,^76,77 that screening for high CVD risk, even in combination with some counselling,⁷⁷ is not effective for reducing CVD incidence and mortality. The lack of effectiveness of just screening of the population for high CVD risk individuals and ethical concerns about promotion of screening without linkage to diagnosis and management has led some governments to explore additional ways to improve CVD prevention. For example, the use of CVD predicting algorithms in combination with incentivising clinicians for effective CVD prevention is being trialled in the USA,^78–80 and the most recent evidence suggests that incentivising both clinicians and patients works.⁸¹ While shared financial incentives shown to be effective in that trial for reducing LDL-C level (US$512 per patient for physicians and US$355 for each patient enrolled in the trial) may not be feasible in less affluent societies, the findings of the importance of motivating both physicians and their patients for effective CVD prevention should not be underestimated and some other, more affordable incentives can and should be trialled in other populations.

Primary prevention of stroke and other major NCDs is regarded by the UN as the most cost-effective strategy to reduce burden from these diseases.⁸² For example, reducing salt intake by 15% and implementing four key WHO elements of reduction in tobacco use (taxation, enforcement of smoke-free workplaces, packaging/labelling requirements, awareness campaigns) could avert 13.8 deaths over 10 years at a cost of less that US$0.4 per person per year in low-income and lower middle-income countries, and only US$0.50–1.00 per person per year in upper middle-income countries.⁸³

It is essential for high-risk stroke prevention strategies aimed at specific high-risk populations (e.g. people with stroke or TIA, atrial fibrillation, sickle cell disease, etc.) to be accompanied by population-wide prevention strategies aimed at behavioural/lifestyle and environmental risks in which responsibilities are shared between the health sector, non-government organizations and government bodies. While certain governmental bodies have the power to inform or influence lifestyle, socio-economic and environmental factors (including tobacco control, healthy nutrition, bike lanes, availability of fruits and vegetables at corner stores, air pollution) as well as to provide adequate health services to ensure universal implementation of preventative strategies, the health system has the responsibility to identify risk factors and their proper management on an individual level.^84,85 While these integrative, cross-sectoral approaches combined with behavioural modification (including stroke preparedness and lifestyle modifications) and other strategies have been recently identified as the key strategies for stroke and CVD prevention,^26,59,86 the difficult question is – what could make stroke prevention work? How best to combine population-wide and high-risk prevention strategies? Here are our four major suggested strategies to improve primary stroke prevention (Box 2).

The emphasis in primary stroke prevention should be shifted from high stroke/CVD absolute risk approach to a more comprehensive approach that includes primary stroke prevention strategies in people with all levels of risk of CVD events. In addition to more aggressive controlling elevated blood pressure and other metabolic/physiological risk factors (including AF), primary stroke prevention needs to focus on behavioural and lifestyle risk factors (including tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol) allowing an integrative approach to primary prevention of other major NCDs, such as heart disease, diabetes, cancer, dementia and pulmonary heart disease. This cluster of diseases and risk factors are prioritized by the World Health Organization (WHO) in its Global Action Plan on NCDs⁸⁷ and included in the 2011 UN NCD Declaration, and the UN Post-2015 Sustainable Development Goals.¹² In stroke/CVD occurrence predicting algorithms used by health professionals for stroke/CVD prevention educational purposes, categorising people into low, moderate and high absolute risk for the purpose of communicating the risk to the patients should be abandoned as it discourages people with low and moderate risk of CVD to be motivated to reduce their risk and engaged into primary prevention programmes.²⁴ To illustrate increased risk for people with low absolute CVD risk, it was recommended to use a relative risk, relative risk charts, lifetime risk,^24,88,89 and various risk visualization techniques.^89–91 People with 10-year absolute CVD risk less than 30% should be empowered by their health professional (e.g. by showing them not only their absolute but also relative risk and the effect that each risk factor exposure reduction has on their risk) to control their modifiable risk factors, improve CVD health and reduce their risk of stroke/CVD to as low as possible level. In addition to healthy lifestyle modification⁹² and better adherence to the recommended medications,^93,94 multidrug regimens of proven effective and cheap drugs (e.g. polypill)⁹⁵ could lead to cost-effective prevention of stroke in all developing regions, potentially halving the risk of death from CVD and increasing life expectancy.⁹⁶

Implementing an integrated approach would incorporate community-clinical linkages that coordinate clinical strategies for high-risk individuals with community-based strategies to promote healthy behaviours and reduce health disparities.^97,98 Coordinated interventions allow for community-wide prevention and management approaches that link efforts improving health across the care continuum and bridging across settings and strategies. Community-clinical linkages help ensure that people with or at high risk of chronic diseases have access to community resources and support to prevent, delay or manage chronic conditions once they occur.⁹⁹ These supports include interventions such as clinician referral, community delivery and payment coverage for effective programs that increase the likelihood that people with heart disease, diabetes or pre-diabetes will be able to “follow the doctor’s orders” and take charge of their health.⁹⁹ Examples include clinical strategies to promote individual smoking cessation along with smoke-free laws that reduce secondary exposure, or the use of community health workers and community pharmacists that can extend the work of the clinical provider into the community and broader population.¹⁰⁰ Given the limited resources available for stroke and CVD prevention even in developed countries, it would be logical to place emphasis on effective population-wide interventions to control or reduce exposure to leading risk factors in the region. For example, population-wide efforts to reduce salt intake and smoking through multiple economic (e.g. taxation) and educational policies and programs have been suggested as cost-effective primary stroke and CVD strategies in developing countries.^101–105 With the UN 2011 Declaration of NCDs,¹² all UN-member governments have the mandate, power and responsibility to undertake actions to reduce the burden from NCDs, including stroke. The practical question is where to take resources to enable these actions? We believe that revenue from smoking and salt taxations, as well as taxations from sugar and alcohol, reduced consumption of which on a population level also shown to be beneficial for CVD and overall health,^106,107 can and should be used to fund primary prevention strategies and primary prevention research of stroke and other major NCDs. Such uses of the tax revenue would also be important to unsure public acceptability of these taxes.¹⁰⁸ There is compelling evidence that smoking,^109–111 salt,^83,108 sugar^112–114 and alcohol^115–119 taxation may be valuable strategies to improve health, especially when combined with other preventative interventions in the population, while generating a considerable revenue for governments.^{113,120–122} Given the already immense and fast increasing burden of stroke and other major NCDs across all countries in the world that threatens sustainability of the whole society, not acting now on primary prevention of these diseases is not acceptable. Governments can develop and implement an emergency action plan addressing the primary prevention of NCDs. It is also important to work on the implementation of what has proved working for primary stroke and NCDs prevention over the last decades in many developed countries in a broader way.

The impact of stroke and other non-communicable disorders (NCD) that share the same risk factors with stroke, such as ischemic heart disease (IHD), dementia (cognitive decline) and type II diabetes mellitus, is huge and increasing.^123–125 Collectively, these NCD account for 14.7 million of deaths (28% of deaths from all causes)¹²⁵ and 290.2 million disability-adjusted life-years lost worldwide.¹²⁴ The burden of NCD is likely to burgeon given the aging of the world’s population and the epidemiological transition currently observed in low- to middle-income countries.¹²⁶ In addition, there is low awareness in the population about these NCD and their risk factors, particularly in developing countries. These factors, coupled with underutilization of strategies for primary prevention of NCD on an individual level and the lack of accurate data on the frequency and significance of risk factors in different countries and populations have been implicated in the ever-increasing worldwide burden of the NCD.

Recent advances in mobile (smartphone) technologies and their worldwide use (about 1.7 billion users) offer unique opportunities to utilise these technologies for improving health (including health and stroke awareness) and research capabilities. Empowering people for self-management of their risk factors through mobile health apps is another potential application of these technologies, which may be particularly appealing for less affluent populations and population with limited access to health services (e.g. rural populations). A number of stroke and other NCD Apps are currently available in App Store and Google Play and promising results are emerging from clinical trials of several smartphone-based technologies and Apps for managing particular medical conditions and risk factors (e.g., smoking cessation, depression, weight and asthma management).^127–131

Primary stroke prevention should capitalize on information technology to advance prevention approaches and techniques. Electronic health information can be useful to support patients, providers and population health, such as through improved public health surveillance activities.¹³² Importantly, accumulating evidence demonstrates the feasibility and effectiveness of use of mobile technologies for improving healthy lifestyle^133–139 and some medical conditions predisposing to stroke.^140–145 Supported by WHO,¹⁴⁶ these technologies are evolving fast¹⁴⁷ and have shown unprecedented uptake amongst lay consumers and professionals.¹⁴⁸ Use of widely accessible, affordable and validated technological advances,¹⁴⁷ such as the Stroke Riskometer™ app,^24,149 to recognize a person’s own risk and risk factors, to educate about warning signs of stroke that can communicate risk and the importance of addressing risk factors that speak to a various levels of health literacy and in multiple languages, to motivate the person to control their risk factors, to provide targeted advice on how to lower the risk, and to measure effectiveness of primary prevention of NCDs, is another important approach for stroke prevention that should be incorporated into the health system and used by both health professionals and lay people. Not downplaying their significance for developed countries, such mobile technologies are particularly useful for developing countries where availability/affordability of and access to health professionals are limited. Such self-care programs are also seen by the WHO¹⁵⁰ as a vital form of prevention in those at high risk and in improving outcomes in people with NCDs.

As there are significant disparities in the risk^151–155 and burden of stroke among various race/ethnic groups^151–155 and many life style habits are set early in life, culturally appropriate education about healthy lifestyle should be incorporated into standard education curricula and started early in life with reinforcement across the lifespan. There is evidence suggesting effectiveness of school-based stroke education of middle school children,¹⁵⁶ and it may be possible that trained children and community leaders can be effective healthy lifestyle educators for other children. In addition to health being a physical manifestation, stroke knowledge is also a socio-cultural construct that can limit the utility of universal primary prevention strategies for at-risk groups.^8–10 Therefore, it is essential to understand the views, values, norms and beliefs of peoples of varies race/ethnicity who are at risk of stroke, what is more likely to work for them in order to learn and understand stroke and its associated risk factors, and how they will use this information to modify what they do in their daily life. Evidence suggests that even if an intervention is effective, adherence to its recommendations remains poor unless it is meaningful, acceptable and takes into account the factors that make up the patients’ health care environment.¹⁵⁷ In addition, it has been shown that people’s beliefs are important predictors of the extent to which they will engage in behaviours to reduce risk of secondary stroke.⁷¹ Therefore it is crucial that stroke prevention strategies take these factors into account to have optimal impact. This information may also be used to inform culturally appropriate preventative strategies of other major NCD that share common risk factors with stroke, such as CVD, dementia and diabetes.

Linguistic and cultural (subcultural) differences between people of different race/ethnicity in relation to social, family values and sex and gender roles should be taken into consideration when developing culturally competent health education programs.¹⁵⁸ For example, healthy diet recommendations that are successful for stroke and CVD prevention in people of Caucasian ethnicity may not be successful for Pacific or Asian people because their food habits and traditions are very different. There are also racial/ethnic differences in the relative significance of various determinants of stroke occurrence¹⁵² that should also be taken into account when developing culturally specific health education programs. Generic guidelines for making a health education programme more culturally appropriate have been suggested.¹⁵⁸ Development of consensus statements and national stroke prevention guidelines by recognised experts from the region to address local (cultural) issues on the basis of the best available evidence along with the effective strategies to improve stroke awareness (including campaigns to remove stigma associated with stroke) should also be encouraged.¹⁰¹ Mother’s health and lifestyle, normal birth weight, adequate nutrition from the first days of life and thereafter are all-important determinants of health, including risk of stroke and other major NCDs, later in the life. Healthy lifestyle habits, adequate physical activity and maintaining a healthy weight should be formed at a young age,¹⁵⁹ reinforced throughout the lifespan (for healthy diet habits, probably during the first year of life),¹⁶⁰ and can be successfully incorporated in preschool, school, day-care and other interventions in early life settings.¹⁶¹

Recent studies in other countries have shown that knowledge of stroke risk factors and warning signs is deficient in older adults (65+),^162,163 minority ethnic groups,^163–166 people with low levels of education¹⁶³ and rural dwellers.¹⁶⁷ Consistent, culturally sensitive and motivational stroke education campaigns throughout the year (not only at national or World Stroke Awareness day) should be given a priority. As such campaigns are unlikely to be funded by the industry, but there are opportunities for the public sector to promote stroke awareness educational campaigns (along side of other educational campaigns). There is compelling evidence that increasing population/country-specific knowledge about stroke warning signs and risk factors can reduce stroke burden in the population.^168–173