Discussion
heterogenous, stroke
STROKE
We conducted a systematic review of studies examining stroke care education strategies for hospital-based healthcare professionals in low-resource settings, to better understand the reported impacts of these interventions on knowledge, behaviours and outcomes in these environments.A train-the-trainer approach for the implementation of multidisciplinary stroke units was the most used method for education and found to be effective in two studies examined in this review [Locally-created training videos on the Wessex-Ghana website are freely available [Of the care quality improvement initiatives, the study in China by Wang et al. (2018) with the “train-the-trainer” model had the most demonstrated potential [Three studies [On-site workshops were used in Nigeria in a study by Akinyemi et al. (2015) to provide non-specialists with knowledge on stroke and its care [Although data are limited, it seemed that the “train the trainer” approach was most optimal in providing stroke care education. Technology can be useful as well and if resources are limited, basic education should be considered at a minimum. Previous surveys have shown that health professionals in low-resource settings consider education to be helpful and prefer to do so in workshop and conference formats [While our review is comprehensive, there are some major limitations. Firstly, we could not meta analyse results as the studies were too heterogenous in their methodologies and measured outcomes. Secondly, some studies did not evaluate the impact of training interventions directly on patients. Thirdly, there was no clear definition of what constitutes an effective intervention. Fourthly, we were unable to determine if the changes observed in individual studies were due to Hawthorne effects, improvements in data capture over time, or other biases. Fifthly, multiple educational strategies were used in some studies, making it difficult to clearly identify the individual impacts of the educational components. Several of the studies included written care protocols, pathways and road maps along with educational components. It is possible that the provision of these protocols alone would have resulted in the same positive impact on care. Finally, only 8 out of 1,182 articles from our search met inclusion criteria. The majority of articles were excluded for three reasons: did not describe educational approaches (~ 40%), were not specific to stroke training and did not occur in a low-resource setting. The large number excluded could be due to non-specific search criteria which were required due to the lack of systematic indexing and the use of a variety of key words.The quality of evidence of the included articles was generally satisfactory. Randomized control trial methods in future studies can reduce the risk of biases and increase the level of confidence in the results. While randomized control trials remain the gold standard for evaluating effectiveness, they are not the only design nor is it always the most appropriate design (e.g., sometimes it is difficult to randomize individuals in a setting and a cluster design is not feasible). Other robust study designs, such as cohort or case–control studies, can also be considered. These studies could be implemented at an institutional level where one institution provides training and then implementation outcomes are studied (cohort) or different institutions in the same context (geographical area for example) participate with one receiving training and the other acting as a control (case–control). A pragmatic approach to trial design should be considered, that is informed by a multidisciplinary team and with patient input.