{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,4]],"date-time":"2026-10-04T18:54:37Z","timestamp":1791140077594,"version":"4.1.0"},"reference-count":43,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,6,26]],"date-time":"2025-06-26T00:00:00Z","timestamp":1750896000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"World Bank scholarship through Ministry of Health of Mozambique"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: The burden of stroke is on the rise in low-income countries (LICs). Organized stroke care (OSC) is crucial for improving outcomes in LICs and is the very first step to reducing delays in diagnosis and treatment. We aim to evaluate delay times (DT) in accessing OSC at the national reference hospital of Mozambique, a LIC from southern Africa. Methods: An observational study based on consecutive case series of 59 stroke patients confirmed by computed tomography (CT) scans over a period of 3 months (May\u2013July 2023). The total DT (from stroke onset to inward hospitalization) was the main outcome. Other specific DTs were analyzed including initial symptoms to arrival and admission (DT0), arrival to CT scans (DT1), arrival of laboratory results (DT2), and arrival to inward hospitalization (DT3). Results: The mean age was 61.9 (min 30\u2013max 90) and 45.8% were female. The median total DT was 20 h. The median time DT0 was 10.6 h (interquartile range (IQR): 16.48). The median DT1 and DT2 were 4 h (IQR: 3.5) and 5 h (IQR: 2.6), respectively. The median DT3 was 10 h (IQR: 4). None of the patients were treated under a stroke code. Conclusions: This study reveals an unacceptable prehospital and in-hospital DT. Waiting for the CT scan contributed to a large proportion of the total DT, which among other factors can be explained by the absence of a stroke code and limited imaging capacity. These findings mirror disparities in stroke care seen in other LICs, where late presentation, scarce imaging, and limited specialized protocols are common. The urgent implementation of organized prehospital and in-hospital stroke pathways is needed in Maputo to improve outcomes.<\/jats:p>","DOI":"10.3390\/ijerph22071008","type":"journal-article","created":{"date-parts":[[2025,6,26]],"date-time":"2025-06-26T11:15:23Z","timestamp":1750936523000},"page":"1008","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Delays in the Stroke Care Pathway in a Low-Income Setting: An Audit Study from Mozambique"],"prefix":"10.3390","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0359-9904","authenticated-orcid":false,"given":"Helena","family":"Buque","sequence":"first","affiliation":[{"name":"Neurology Department, Maputo Central Hospital, Maputo 1100, Mozambique"},{"name":"Community Health Department, Faculty of Medicine, Eduardo Mondlane University, Maputo 1100, Mozambique"},{"name":"Ageing and Cerebrovascular Research Group, ABC Research Institute, Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5340-9833","authenticated-orcid":false,"given":"Lee","family":"Smith","sequence":"additional","affiliation":[{"name":"Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge CB1 1PT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dino","family":"Lopes","sequence":"additional","affiliation":[{"name":"Emergency Department, Maputo Central Hospital, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4122-0774","authenticated-orcid":false,"given":"Damiano","family":"Pizzol","sequence":"additional","affiliation":[{"name":"Health Unit, Eni, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elder","family":"Lorenzo","sequence":"additional","affiliation":[{"name":"Neurology Department, Maputo Central Hospital, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nachan","family":"Arroz","sequence":"additional","affiliation":[{"name":"Neurology Department, Maputo Central Hospital, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lazara","family":"Bacallau","sequence":"additional","affiliation":[{"name":"Neurology Department, Maputo Central Hospital, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8378-2014","authenticated-orcid":false,"given":"Mohsin","family":"Sidat","sequence":"additional","affiliation":[{"name":"Community Health Department, Faculty of Medicine, Eduardo Mondlane University, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3734-9172","authenticated-orcid":false,"given":"Evangelina Namburete","family":"Bauaze","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, Catholic University, Beira 821, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1502-3534","authenticated-orcid":false,"given":"Hip\u00f3lito","family":"Nzwalo","sequence":"additional","affiliation":[{"name":"Ageing and Cerebrovascular Research Group, ABC Research Institute, Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1111\/ijs.12153","article-title":"Setting priorities for stroke care and research","volume":"8","author":"Morgenstern","year":"2013","journal-title":"Int. J. Stroke"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"GBD 2016 Lifetime Risk of Stroke Collaborators (2018). Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016. N. Engl. J. Med., 379, 2429\u20132437.","DOI":"10.1056\/NEJMoa1804492"},{"key":"ref_3","unstructured":"Saver, J.L. (2023, July 09). Time Is Brain-Quantified. Available online: http:\/\/www.americanheart.org\/."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"101105","DOI":"10.1016\/j.ienj.2021.101105","article-title":"Actions taken affecting lead time in the care pathway for low-priority patients with a suspected stroke: A critical incident study","volume":"60","author":"Wennman","year":"2022","journal-title":"Int. Emerg. Nurs."},{"key":"ref_5","first-page":"E75","article-title":"Emergency Medical Service Time Intervals for Patients with Suspected Stroke in the United States","volume":"29","author":"Cash","year":"2022","journal-title":"Stroke"},{"key":"ref_6","first-page":"CD000197","article-title":"Organised inpatient (stroke unit) care for stroke: Network meta-analysis","volume":"2020","author":"Langhorne","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e74","DOI":"10.1016\/S2468-2667(21)00230-9","article-title":"Primary stroke prevention worldwide: Translating evidence into action","volume":"7","author":"Owolabi","year":"2022","journal-title":"Lancet Public Health"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e46","DOI":"10.1161\/STR.0000000000000158","article-title":"2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association\/American Stroke Association","volume":"49","author":"Powers","year":"2018","journal-title":"Stroke"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"107639","DOI":"10.1016\/j.jstrokecerebrovasdis.2024.107639","article-title":"Accreditation of Stroke Programs at the MENA + Region; Between Aspiration and Reality","volume":"33","author":"Imam","year":"2024","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Cisse, F.A., Damien, C., Bah, A.K., Tour\u00e9, M.L., Barry, M., Djibo Hamani, A.B., Haba, M., Soumah, F.M., and Naeije, G. (2019). Minimal setting stroke unit in a sub-Saharan African public hospital. Front. Neurol., 10.","DOI":"10.3389\/fneur.2019.00856"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1038\/s41582-021-00542-4","article-title":"Stroke in Africa: Profile, progress, prospects and priorities","volume":"17","author":"Akinyemi","year":"2021","journal-title":"Nat. Rev. Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"215","DOI":"10.7196\/SAMJ.2021.v111i3.15104","article-title":"Shortfall in stroke care: A study of ischaemic stroke care practices in a South African metropole","volume":"111","author":"Mandizvidza","year":"2021","journal-title":"S. Afr. Med. J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1177\/17474930221147164","article-title":"Stroke in Africa: A systematic review and meta-analysis of the incidence and case-fatality rates","volume":"18","author":"Okekunle","year":"2023","journal-title":"Int. J. Stroke"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"140","DOI":"10.11604\/pamj.2022.42.140.35086","article-title":"Stroke units in Nigeria: A report from a Nationwide organizational cross-sectional survey","volume":"42","author":"Arabambi","year":"2022","journal-title":"Pan Afr. Med. J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1186\/s13643-017-0594-4","article-title":"Interventions for acute stroke management in Africa: A systematic review of the evidence","volume":"6","author":"Baatiema","year":"2017","journal-title":"Syst. Rev."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"50","DOI":"10.15406\/jnsk.2022.12.00500","article-title":"Stroke in Maputo central hospital, Mozambique: A cross-sectional study 2014\u20132018","volume":"12","author":"Baduro","year":"2022","journal-title":"J. Neurol. Stroke"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2463","DOI":"10.1161\/STROKEAHA.110.594275","article-title":"An epidemiological study of stroke hospitalizations in maputo, mozambique: A high burden of disease in a resource-poor country","volume":"41","author":"Damasceno","year":"2010","journal-title":"Stroke"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Botelho, A., Rios, J., Fidalgo, A.P., Ferreira, E., and Nzwalo, H. (2022). Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph192316357"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Soto-C\u00e1mara, R., Gonz\u00e1lez-Santos, J., Gonz\u00e1lez-Bernal, J., Mart\u00edn-Santidrian, A., Cubo, E., and Trejo-Gabriel-Gal\u00e1n, J.M. (2019). Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke. J. Clin. Med., 8.","DOI":"10.3390\/jcm8101712"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/WCO.0000000000001332","article-title":"Acute stroke care in low and middle-income countries","volume":"38","author":"Martins","year":"2025","journal-title":"Curr. Opin. Neurol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Kakame, K.T., Nakibuuka, J., Mukiza, N., Andia-Biraro, I., Kaddumukasa, M., Burant, C., Katabira, E., and Sajatovic, M. (2023). Prevalence and factors associated with pre-hospital delay among acute stroke patients at Mulago and Kiruddu national referral hospitals, Kampala: A cross-sectional study. BMC Neurol., 23.","DOI":"10.1186\/s12883-023-03413-1"},{"key":"ref_22","unstructured":"John Oluwole, O., Kunle Salawu, F., and Ogunniyi, A. (2025, February 24). Pre-and Intra-Hospital Delays to Acute Stroke Treatment in a Tertiary Hospital in North-East Nigeria. Available online: www.spss.com."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"365","DOI":"10.36347\/sasjm.2024.v10i05.015","article-title":"Reasons for Delay in Presentation of Acute Stroke Patients in Teritary Health Centre in Abuja","volume":"10","author":"Onwuegbuzie","year":"2024","journal-title":"SAS J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1186\/s12245-025-00839-x","article-title":"Predictors of pre-hospital delay among stroke patients in Yekatit-12 hospital Addis Ababa, Ethiopia: Unmatched case-control study","volume":"18","author":"Mamo","year":"2025","journal-title":"Int. J. Emerg. Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Kaddumukasa, M., Kayima, J., Kaddumukasa, M.N., Ddumba, E., Mugenyi, L., Pundik, S., Furlan, A.J., Sajatovic, M., and Katabira, E. (2015). Knowledge, attitudes and perceptions of stroke: A cross-sectional survey in rural and urban Uganda. BMC Res. Notes, 8.","DOI":"10.1186\/s13104-015-1820-6"},{"key":"ref_26","first-page":"21","article-title":"Factors influencing the longer hospital stays for acute stroke patients in a tertiary hospital in Burkina Faso","volume":"2","author":"Jma","year":"2021","journal-title":"J. Rehabil. Res. Pract."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"S6","DOI":"10.1212\/WNL.0000000000012781","article-title":"Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions","volume":"97","author":"Saini","year":"2021","journal-title":"Neurology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1097\/MCC.0000000000001244","article-title":"Code-ICH: Time is brain","volume":"31","author":"Yakhkind","year":"2025","journal-title":"Curr. Opin. Crit. Care"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"105696","DOI":"10.1016\/j.clineuro.2020.105696","article-title":"Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhage","volume":"191","author":"Martinez","year":"2020","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.afjem.2017.11.001","article-title":"Prospective assessment of patients with stroke in Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia","volume":"8","author":"Zewdie","year":"2017","journal-title":"Afr. J. Emerg. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1052","DOI":"10.1016\/j.jstrokecerebrovasdis.2024.107756","article-title":"Enhancing stroke care in Ghana: A systematic review of stroke rehabilitation services","volume":"33","author":"Kankam","year":"2024","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Baatiema, L., Otim, M., Mnatzaganian, G., Aikins, A.D.G., Coombes, J., and Somerset, S. (2017). Towards best practice in acute stroke care in Ghana: A survey of hospital services. BMC Health Serv. Res., 17.","DOI":"10.1186\/s12913-017-2061-2"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Wiyarta, E., Fisher, M., Kurniawan, M., Hidayat, R., Geraldi, I.P., Khan, Q.A., Widyadharma, I.P.E., Badshah, A., and Pandian, J.D. (2024). Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries. J. Clin. Med., 13.","DOI":"10.3390\/jcm13164780"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"117540","DOI":"10.1016\/j.jns.2021.117540","article-title":"Quantitative and qualitative analyses of herbal medication use among Ghanaian stroke survivors","volume":"427","author":"Sarfo","year":"2021","journal-title":"J. Neurol. Sci."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"998","DOI":"10.1111\/j.1468-1331.2009.02666.x","article-title":"Knowledge and perception of stroke amongst hospital workers in an African community","volume":"16","author":"Akinyemi","year":"2009","journal-title":"Eur. J. Neurol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"20503121231215236","DOI":"10.1177\/20503121231215236","article-title":"Health-seeking behavior among non-communicable disease patients globally, systematic review and meta-analysis","volume":"11","author":"Anagaw","year":"2023","journal-title":"SAGE Open Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"786","DOI":"10.5005\/jp-journals-10071-24584","article-title":"Quality Metrics in Acute Stroke: Time to Own","volume":"27","author":"Ahmed","year":"2023","journal-title":"Indian J. Crit. Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"100025","DOI":"10.1016\/j.clinme.2024.100025","article-title":"The new national clinical guideline for stroke: An opportunity to transform stroke care","volume":"24","author":"Bhalla","year":"2024","journal-title":"Clin. Med."},{"key":"ref_39","unstructured":"(2025, February 23). Chapter 2 Organization of Stroke Services. Available online: www.strokeguideline.org."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1111\/ijs.12371","article-title":"World Stroke Organization Global Stroke Services Guidelines and Action Plan","volume":"9","author":"Lindsay","year":"2014","journal-title":"Int. J. Stroke"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1177\/17474930231210448","article-title":"Global stroke statistics 2023: Availability of reperfusion services around the world","volume":"19","author":"Kim","year":"2024","journal-title":"Int. J. Stroke"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"E344","DOI":"10.1161\/STR.0000000000000211","article-title":"Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke a guideline for healthcare professionals from the American Heart Association\/American Stroke Association","volume":"50","author":"Powers","year":"2019","journal-title":"Stroke"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"107913","DOI":"10.1016\/j.clineuro.2023.107913","article-title":"Severe neurocysticercosis in a quaternary hospital from Mozambique: Case series analysis","volume":"233","author":"Buque","year":"2023","journal-title":"Clin. Neurol. Neurosurg."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/7\/1008\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:59:13Z","timestamp":1760032753000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/7\/1008"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,26]]},"references-count":43,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["ijerph22071008"],"URL":"https:\/\/doi.org\/10.3390\/ijerph22071008","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,26]]}}}