Interventions for Behaviour Change and Self-Management of Risk in Stroke Secondary Prevention: An Overview of Reviews

Optimised secondary prevention strategies that include lifestyle change are recommended after stroke. While multiple systematic reviews (SRs) address behaviour change interventions, intervention definitions, and associated outcomes differ between reviews. This overview of reviews addresses the pressing need to synthesise high-level evidence for lifestyle-based behavioural and/or self-management interventions to reduce risk in stroke secondary prevention in a structured, consistent way.

Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied to meta-analyses, demonstrating statistically significant effect sizes to establish the certainty of existing evidence. Electronic databases MEDLINE, Embase, Epistemonikos, and the Cochrane Library of Systematic Reviews were systematically searched, current to March 2023.

Fifteen SRs were identified following screening, with moderate overlap of primary studies demonstrated (5.84% degree of corrected covered area). Interventions identified could be broadly categorised as multimodal; behavioural change; self-management; psychological talk therapies, albeit with overlap between some theoretical domains. Seventy-two meta-analyses addressing twenty-one preventive outcomes of interest were reported. Best-evidence synthesis identifies that for primary outcomes of mortality and future cardiovascular events post-stroke, moderate certainty GRADE evidence supports multimodal interventions to reduce cardiac events, with no available evidence for outcomes of mortality (all-cause or cardiovascular) or recurrent stroke events. For secondary outcomes addressing risk-reducing behaviours, best-evidence synthesis identifies moderate certainty GRADE evidence for multimodal lifestyle-based interventions to increase physical activity participation, and low certainty GRADE evidence for behavioural change interventions to improve healthy eating post-stroke. Similarly, low certainty GRADE evidence supports self-management interventions to improve preventive medication adherence. For mood self-management post-stroke, moderate GRADE evidence supports psychological therapies for remission and/or reduction of depression and low/very low certainty GRADE evidence for reduction of psychological distress and anxiety. Best-evidence for outcomes addressing proxy physiological measures identified low GRADE evidence supporting multimodal interventions to improve blood pressure, waist circumference, and LDL cholesterol.

Effective strategies to redress risk-related health behaviours are required in stroke survivors to complement current pharmacological secondary prevention. Inclusion of multimodal interventions and psychological talk therapies in evidence-based stroke secondary prevention programmes is warranted given the moderate GRADE of evidence that supports their role in risk reduction. Given the overlap in primary studies across reviews, often with overlapping theoretical domains between broad intervention categories, further research is required to identify optimal intervention behavioural change theories and techniques employed in behavioural/self-management interventions.