Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The manuscript is well written. As it is a review, it would be better to outline the steps for search and the articles included in the review, as well as the type of review. It is unclear about whether it is simply a literature review or other types of review. The search strategy would be important to support the comprehensiveness of the results.

A discussion section to discuss the results, limitations, and implications for practice and research would be helpful.

Author Response

1. As it is a review, it would be better to outline the steps for search and the articles included in the review, as well as the type of review. It is unclear about whether it is simply a literature review or other types of review. The search strategy would be important to support the comprehensiveness of the results.
   • RESPONSE: Thank you for your valuable feedback. We appreciate your suggestion to clearly outline the type of review conducted and to detail our search strategy. We have revised the manuscript to address these points. We have specified that the paper is a comprehensive literature review and have included a detailed description of the databases searched, the keywords used, and the inclusion and exclusion criteria. Additionally, we have summarized the search process and the number of articles included in the review. We believe these additions enhance the clarity and comprehensiveness of our review. Please find the detailed revisions in the Methods section of the revised manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is a very good review article on prehospital care in low and middle income countries.  Authors were able to categorize challenges very well.  They also used nice tables and figures to summarize challenges. Authors did not explain the criteria in selecting only some countries for each category i.e  lack of awareness and knowledge, sociodemographic and cultural factors and also healthcare system and infrastructure challenges.  I would recommend to compare same countries for all categories if possible.  I would also explain door to needle time in each country if available. I would recommend to include disparities between rural and urban communities in each country.  Authors made conclusions and some suggestions in a generalized way but would recommend to provide precise conclusions for low to medium countries separately/individually.

Author Response

1. Authors did not explain the criteria in selecting only some countries for each category i.e lack of awareness and knowledge, sociodemographic and cultural factors and also healthcare system and infrastructure challenges.
   • RESPONSE: Thank you for your valuable feedback. You have made a very great point on this criteria. The criteria for selecting countries were based on the eligibility criteria mentioned in the method section and also based on the availability of comprehensive data on prehospital stroke care. We included all papers that reported complete data on the various aspects of prehospital stroke care, such as awareness and knowledge, sociodemographic and cultural factors, and healthcare system and infrastructure challenges. Consequently, the countries included in our review, such as India, Pakistan, Ghana, and Tanzania, were those for which detailed and relevant data were available. This approach ensures that our review captures a wide range of challenges and solutions applicable to different settings. The detailed selection process is explained in the Methods section, as addressed in response to Reviewer 1.

 

2. I would recommend to compare same countries for all categories if possible.
   • RESPONSE: Thank you for your valuable feedback. We appreciate your suggestions for improving our manuscript. We acknowledge the limitation that there are few studies specifically addressing the risk factors for prehospital delay in LMICs. Due to this limitation, it was challenging to conduct a specific review for some countries. We have ensured that we conducted a comprehensive and robust search for relevant papers and have summarized the findings in tables within each sub-section. However, some countries do not publish data on these factors. We believe these factors do exist in practice, but since we are conducting a literature review, we have only included data based on published literature, not opinions. We have added this discussion to the limitations paragraph of our paper. Nevertheless, we have attempted to address some of the aspects of your input that could still be discussed. We have also included data on door-to-needle times and disparities between rural and urban communities where available. Furthermore, we have provided more precise conclusions and suggestions for low- and middle-income countries individually.

 

3. I would also explain door to needle time in each country if available.
   • RESPONSE: Thank you for your valuable feedback. As mentioned above, the data on door-to-needle times for each country were not always available in the literature. This limitation has been recognized and addressed in the limitations paragraph of our paper.

 

4. I would recommend to include disparities between rural and urban communities in each country.
   • RESPONSE: We have incorporated a discussion on the disparities between rural and urban communities in each country. This highlights the differences in access to care and the challenges faced by different populations. These changes can be seen in the revised manuscript.

 

5. Authors made conclusions and some suggestions in a generalized way but would recommend to provide precise conclusions for low to medium countries separately/individually.
   • RESPONSE: While we have provided more precise conclusions and suggestions for low- and middle-income countries, we acknowledge that this is also a limitation due to the lack of specific data for each country. Given the similarities in socioeconomic contexts among LMICs, we believe the conclusions and suggestions presented are the best we can provide based on the available data. This limitation is also discussed in the limitations paragraph of our paper. These changes can be seen in the revised manuscript.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The review entitled “Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries” discusses stroke, as a leading cause of disability and mortality worldwide, with low- and middle-income countries (LMICs) experiencing 88% of stroke fatalities, primarily due to pre-hospital care delays. These delays result from inadequate public understanding of stroke symptoms, sociodemographic and cultural factors, and insufficient healthcare infrastructure. This review examines these issues and proposes innovative solutions like mobile stroke units and community-based educational campaigns, aiming to inform policy reforms and healthcare improvements in LMICs to enhance stroke care and reduce related mortality and disability.

Please see the comments below

1.      Even though this study emphasizes stroke incidence in low and middle-income countries, if the authors can include points to compare how the approach towards stroke (in each aspect discussed) differs from developed countries, they can get a clearer picture of how improvements can be made in each aspect.

2.      In the introduction, the authors could give a brief explanation of the major types of strokes and how they differ.

3.      Whether the authors noticed any difference in explained findings between ischemic and hemorrhagic stroke. 

4.      Please re-write the conclusion in such a way that it reflects the overall content of the manuscript

Author Response

1. Even though this study emphasizes stroke incidence in low and middle-income countries, if the authors can include points to compare how the approach towards stroke (in each aspect discussed) differs from developed countries, they can get a clearer picture of how improvements can be made in each aspect.
   • RESPONSE: Thank you for your insightful feedback and valuable suggestions. We appreciate your input on including comparisons with developed countries to provide a clearer picture of how improvements can be made in each aspect discussed.We have now incorporated a comparative analysis of the approaches towards stroke care between low- and middle-income countries (LMICs) and developed countries into the Conclusion section of our manuscript. This addition highlights key differences and provides insights into potential areas for improvement in LMICs. By examining these differences, LMICs can identify areas for improvement and adopt successful strategies employed in developed countries to enhance prehospital stroke care.

 

2. In the introduction, the authors could give a brief explanation of the major types of strokes and how they differ.

• RESPONSE: Thank you for your insightful feedback. We appreciate your suggestion to include a brief explanation of the major types of strokes and how they differ in the introduction. We have now incorporated this information into the introduction to provide a clearer context for our readers.

 

 

3. Whether the authors noticed any difference in explained findings between ischemic and hemorrhagic stroke.

• RESPONSE: Thank you for your insightful feedback. We appreciate your suggestion to explore whether there are any differences in explained findings between ischemic and hemorrhagic stroke. Our review primarily discusses stroke in general, as this is how most studies address the topic. They often do not provide detailed differentiation between the prehospital management of ischemic and hemorrhagic strokes. In the in-hospital management, the distinction is clear due to the different treatments required for each type, which we have detailed in our manuscript, such as the use of intravenous thrombolytics for acute ischemic stroke. Throughout our manuscript, we have clearly identified sections specific to ischemic or hemorrhagic strokes when applicable. However, it is also important to acknowledge that most studies tend to focus more on ischemic strokes, which is a limitation of our review. We have added this point to the limitations paragraph of our paper..

 

4. Please re-write the conclusion in such a way that it reflects the overall content of the manuscript.

• RESPONSE: Thank you for your constructive feedback. We appreciate your suggestion to rewrite the conclusion so that it reflects the overall content of the manuscript. We have revised the conclusion to better encapsulate the key findings and insights from our study, integrating the various aspects discussed throughout the manuscript.

Author Response File: Author Response.pdf