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. 2026 Apr 17;6(3):e002243. doi: 10.1161/SVIN.125.002243

Transcending Social and Cultural Barriers to Transform Global Stroke Care: An SVIN Mission Thrombectomy Initiative

Fawaz Al-Mufti 1,2, Mohamed Elfil 2, Hazem S Ghaith 3, Aarti Kishore Jain 1,2, Nimrod Gozum 1,2, Eric Feldstein 1, Ankita Jain 1, Eris Spirollari 1, Andre Calixte 4, Priyank Khandelwal 5,✉, Victor C Urrutia 6, Nabeel A Herial 7, Pankajavalli Ramakrishnan 8, Gabor Toth 9, Mohammad El-Ghanem 10, Krishna Amuluru 11, Viktor Szeder 12, Jonathan R Crowe 13, Karol Budohoski 14, Zurab Nadareishvili 15, Kaustubh Limaye 16, Fazeel Siddiqui 17, Hamza Shaikh 18, Nishita Singh 19, Hesham Masoud 20, Sushanth R Aroor 21, Shashvat M Desai 22, Santiago Ortega-Gutierrez 23, Tareq Kass-Hout 24, Dileep R Yavagal 25, Kaiz S Asif 26, on behalf of the Mission Thrombectomy Collaborative
PMCID: PMC13138413  PMID: 42088326

Abstract

Stroke is a leading cause of neurological disability and mortality worldwide, with acute ischemic strokes caused by large-vessel occlusions presenting significant health care challenges. While endovascular thrombectomy has emerged as a gold standard treatment, access to timely stroke care remains severely limited, especially in low- and middle-income countries. This review examines the multifaceted social, cultural, and systemic barriers that impede effective stroke care globally. We performed a comprehensive search of PubMed from 2004 to 2024, using keywords of acute stroke care, low-middle-income countries, social barriers, cultural barriers, and access. There are several recognized obstacles to stroke treatment, especially in the acute settings, including health fatalism, spiritual and religious beliefs that discourage medical intervention, and widespread lack of public awareness about stroke symptoms and urgency. Cultural misconceptions often lead individuals to delay or avoid seeking medical care, with some communities attributing stroke to supernatural forces or divine punishment. Language barriers, insufficient health care infrastructure, and socioeconomic challenges further compound these issues, particularly in regions such as sub-Saharan Africa and parts of Asia. Furthermore, there are critical infrastructural barriers to delivering acute stroke in a timely manner, including limited transportation to health care facilities and inadequate stroke centers in rural areas. A comprehensive strategy to address these challenges should focus on culturally sensitive education, community engagement, and infrastructure development. Recommendations include cooperating with religious and community leaders, developing targeted awareness campaigns, and creating inclusive health care approaches that respect local cultural contexts. Overall, addressing the global stroke burden not only requires technological interventions but also demands a holistic approach that bridges cultural understanding, challenges misconceptions, and empowers communities to recognize and respond to stroke as a critical medical emergency.

Keywords: ischemic stroke, eurologists, patient care, thrombectomy, triage

GRAPHIC ABSTRACT:

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Stroke is a leading cause of neurological disability and the second most common cause of mortality worldwide.1 Acute ischemic stroke accounts for 85% of all stroke cases, with more than a third of these classified as large-vessel occlusions.2 Large-vessel occlusions are responsible for a disproportionate share of both disability (≈60%) and poststroke mortality (nearly 90%).3 In high-income countries, the treatment of acute ischemic stroke due to large-vessel occlusion typically involves 2 primary emergency interventions: intravascular thrombolysis (IVT) with tPA (tissue-type plasminogen activator) and endovascular thrombectomy (EVT).4 In 2015, EVT was established as the gold standard for treating acute ischemic stroke caused by large-vessel occlusion, following randomized controlled trials that demonstrated superior outcomes and greater efficacy of EVT compared with IV tPA alone or other available therapies for eligible patients.4,5 However, access to EVT remains limited, and many patients with acute ischemic stroke in low- and middle-income regions still experience the consequences of lacking timely access to acute stroke interventions.

The establishment of comprehensive stroke centers, which can provide timely and intensive patient care with a range of specialized resources, is a hallmark of high-income health care systems. On the other hand, in low- and middle-income countries, addressing the gaps in stroke care often involves optimizing existing resources and creating alternative care models.6,7 As highlighted by a previous study, many of these countries have developed stroke care frameworks that focus on early detection and triage, ensuring that patients are quickly directed to health care facilities and care teams capable of providing the appropriate level of treatment.7 However, access to trained neurologists and accurate stroke diagnosis remains a critical challenge.

In addition to these clinical obstacles, several societal barriers impact access to stroke care. These may include inadequate transportation, insufficient public awareness of stroke symptoms, health or spiritual fatalism, and entrenched traditional medical beliefs.7 Previous studies on chronic and severe health conditions have shown that cultural attitudes toward illness can significantly influence health outcomes and the willingness to seek treatment.8 Hence, understanding the social and cultural factors that prevent individuals from accessing timely stroke care is crucial.

A comprehensive review of the literature was completed using PubMed from 2000 to 2024. Key terms used for the search included acute stroke care, low-middle-income countries, social barriers, cultural barriers, and access. A summary of the literature on cultural and social barriers to acute stroke care, knowledge gaps in understanding of stroke symptoms, health care system challenges, and regional case studies that provide an understanding of regional barriers to acute stroke care is presented. Ultimately, this article examines the available literature to identify and describe different barriers to accessing emergent stroke care.

Fatalistic Beliefs and Cultural Influences on Health-Seeking Behavior

The Impact of Health Fatalism on Decision-Making

A critical factor influencing stroke care in many parts of the world is health fatalism, the belief that serious illnesses, such as stroke, are inevitable and untreatable.9 This fatalistic view prevents many individuals from seeking medical attention or adhering to recommended treatment regimens. Health fatalism not only delays timely intervention but also negatively impacts recovery, which ultimately leads to increasing the risk of recurrence and mortality.9 This belief is widespread not only in stroke but also in the management of other chronic and severe conditions, such as epilepsy, cancer, and diabetes.10,11

Spiritual and Religious Fatalism: A Barrier to Medical Care

In many cultures, particularly in religious communities, spiritual and religious fatalism play key roles in delaying or preventing access to medical care. The belief that illness is a result of divine will, outside human control, leads many individuals to forgo medical treatment.10,12 For example, in Islamic communities, illness might sometimes be perceived as a divine test or punishment, which leads patients to avoid medical intervention, believing that their condition cannot be altered through human action.9 Such spiritual beliefs often result in individuals not following through with necessary medical treatments, including those for stroke, further exacerbating the disease’s adverse outcomes.

Knowledge Gaps: Unawareness of Stroke Symptoms and Urgency

Lack of Public Awareness of Stroke Symptoms

One of the most significant barriers to timely stroke care globally is a lack of public awareness of stroke symptoms. Studies show that many patients, even in high-income countries, fail to recognize the signs of stroke in themselves or others.13,14 For example, rural populations in China often delay seeking care because they do not recognize the seriousness of stroke symptoms. This unawareness leads to delayed hospital arrival and missing critical treatment windows for therapies, namely, IVT and EVT.15

Misunderstandings and Cultural Perceptions of Stroke

In addition to a general lack of awareness, misunderstandings and cultural perceptions about the causes and risks of stroke also play roles in delays. In some cultures, stroke is seen as a consequence of spiritual forces, leading to dismissive attitudes toward seeking professional health care.16 This lack of understanding about stroke as a medical emergency, combined with the absence of knowledge about the time-sensitive nature of treatment, exacerbates delays in care and worsens patient outcomes.

Educational Deficits in Recognizing Stroke Risks and Symptoms

Even in countries where stroke awareness campaigns exist, the effectiveness of these efforts is variable. Regional and linguistic differences in the understanding of stroke risk factors, such as hypertension or diabetes, are implicated in the failure to recognize or take action against preventable stroke risks.17 In South America, for example, many individuals do not recognize hypertension or diabetes as stroke risk factors, often attributing stroke to more culturally specific ideas, such as an unbalanced diet or bad luck.17 Such gaps in knowledge, especially about early intervention and prevention, require more targeted, culturally appropriate educational campaigns to ensure timely medical responses.

Language and Communication Barriers in Stroke Care

Language and communication barriers represent significant obstacles to effective stroke care, potentially compromising patient outcomes and health care access.18 For instance, a meta-analysis of studies conducted in the United States, the United Kingdom, Australia, and Canada demonstrated that limited English proficiency creates profound impediments to medical communication, reducing comprehension of medical instructions and higher risks of medical misunderstandings.19 As a result, the time to treatment with reperfusion therapy, essential for acute stroke care, can be delayed and lead to worse outcomes in this population. This is expected to restrict the ability to achieve favorable clinical outcomes in both hyperacute, acute, and chronic stroke care settings.

Insufficient culturally appropriate health education materials can further exacerbate such a challenge, resulting in reduced stroke awareness among linguistic minority populations and limited understanding of stroke risk factors.20 Health care systems frequently lack comprehensive language support, including professional medical interpretation services and cultural competency training for health care providers.21

To address these complex issues, health care organizations must develop multilingual stroke education resources, implement professional medical interpretation protocols, and enhance health care providers’ cultural competency.22,23 Moreover, increased education of medical multilingualism, such that providers are able to speak on complex medical issues in the native language of their patients, will lead to improved care in diverse populations.24 These interventions are critical for mitigating communication barriers and improving stroke care for linguistically diverse populations.

Health Care System Challenges: Infrastructure, Trust, and Access

Structural Barriers: Inadequate Health Care Infrastructure

In many low- and middle-income countries, health care infrastructure is insufficient to support the needs of patients with stroke. In sub-Saharan Africa, for example, access to advanced neuroimaging technologies, such as computed tomography and magnetic resonance imaging, is often limited, and many hospitals lack the capacity to provide effective stroke care, such as IVT or EVT.25,26 Even when neuroimaging equipment is available, the lack of trained neurointerventionalists and stroke specialists in many regions contributes to suboptimal care.27

Socioeconomic and Infrastructure Challenges in Stroke Care

Limitations related to socioeconomic factors and inadequate infrastructure critically hinder stroke care accessibility and quality, creating complex barriers for vulnerable populations.28 Poverty dramatically restricts stroke prevention and treatment, with patients often unable to afford regular health screenings, preventive medications, or specialized stroke rehabilitation services.29,30

Geographic and infrastructural challenges further compound these difficulties. Rural and remote communities experience significantly reduced health care accessibility, characterized by insufficient medical facilities and prolonged emergency response times. Such disparity in stroke care has been demonstrated in multiple countries, including China, the United States, Colombia, Poland, Germany, and Canada.31–37 These disparities are particularly pronounced in underserved regions, where specialized stroke treatment centers are minimal or absent.

Public health awareness deficits contribute to these challenges, resulting in delayed recognition of stroke symptoms and limited community-level preventive strategies.38 The interconnected nature of socioeconomic barriers creates a complex ecosystem that significantly influences stroke care access and poststroke outcomes.

Addressing these multifaceted challenges requires comprehensive strategies, including targeted financial assistance programs, mobile health care units, and extensive public stroke awareness campaigns. Such interventions are crucial for mitigating the profound impact of socioeconomic disparities on stroke care.

Transportation and Geographic Barriers to Timely Treatment

Even when medical infrastructure exists, transportation remains a key challenge in many regions. In many parts of Africa, <2% of patients with stroke reach a hospital via ambulance, significantly reducing the chances of receiving timely care.25 Similarly, rural areas in Latin America and parts of Asia face long distances to stroke centers, making rapid transport to facilities that can provide life-saving treatments nearly impossible. Addressing transportation gaps by improving public health systems and building stroke care facilities in underserved areas is critical.

Social Support Systems in Stroke Care

Social support systems play a vital role in stroke recovery, with cultural dynamics significantly influencing patient rehabilitation and long-term outcomes.39 Cultural expectations and social structures introduce nuanced dynamics into health care support mechanisms, creating complex support networks and potential challenges.

Limited support systems can lead to significant psychological and emotional challenges. Patients experiencing reduced social support often encounter increased psychological distress, decreased adherence to rehabilitation protocols, and higher risks of depression and anxiety.40,41 These emotional barriers can substantially impact physical rehabilitation and overall health outcomes.

Cultural perspectives on caregiving demonstrate remarkable diversity. Different frameworks prioritize family based care or multidisciplinary health care support.42,43 These variations manifest in different acceptable caregiving strategies and expectations surrounding patient and caregiver roles.

Effective interventions must include developing culturally sensitive support group programs, creating family inclusive rehabilitation strategies, and providing comprehensive psychological support for patients and caregivers. These approaches are critical for addressing the complex social dynamics influencing stroke recovery.

Health Care Mistrust: A Legacy of Historical Abuses

Another significant barrier to care is health care mistrust, particularly in communities that have historically been subjected to medical exploitation or neglect. The legacy of such abuses, such as the Tuskegee Syphilis Study in the United States, has fostered deep mistrust of medical institutions, especially among marginalized populations.44 This mistrust often manifests in reluctance to seek emergency care, even when life-saving treatments are available. Rebuilding trust through community engagement, education, and transparency is crucial in addressing this barrier.

Regional Case Studies: Addressing Specific Stroke Care Barriers

Asia: Bridging the Gap in Stroke Care Access

Asia, home to 60% of the world’s population, carries one of the heaviest stroke burdens globally. Epidemiological research on stroke across Asia reveals significant variability in the mortality, incidence, prevalence, and overall burden of the disease. Mortality rates are relatively low in Japan, with 43.3 deaths per 100 000 person-years and, in Singapore, at 47.9 per 100 000 person-years.45 However, these rates are markedly higher in other parts of the region, such as Indonesia, where the stroke mortality rate stands at 193.3 per 100 000 person-years, and Mongolia, which has the highest rate of the region at 222.6 per 100 000 person-years.45 These disparities highlight the diverse health care challenges and risk factors affecting stroke outcomes across different Asian nations. Thus, it can be concluded that the gap between high- and low-income countries regarding access to EVT and stroke care infrastructure is vast. Countries with advanced health care systems, such as Japan and South Korea, have made great strides in providing acute stroke interventions.46,47 However, many developing countries in the region still struggle to establish the infrastructure needed for effective stroke management.48

Neurointerventionists are in short supply, and stroke units and comprehensive triage systems need to be improved, especially in low-income countries. This leads to limited access to time-sensitive treatments such as EVT. In countries such as Indonesia, Kazakhstan, and Bangladesh, a lack of access to IVT is a significant problem. Even where stroke care is available, the cost of treatment can be prohibitively high for many.49

Cultural barriers also present a challenge to stroke care in Asia. In countries such as China, many people have little awareness of the therapeutic window for thrombolytic therapy, a critical factor in improving outcomes.50 For instance, a 2016 survey revealed that only 6.5% of respondents in China knew that there was a time window for IVT although this knowledge increased to 32.8% by 2018, after a national stroke awareness campaign.50

Some cultures still rely heavily on traditional remedies for stroke prevention and rehabilitation. In Cambodia, for example, conventional therapies, such as moxibustion and cupping, are still commonly used in stroke rehabilitation.51 Traditional Thai therapies, including massage, herbal treatment, and physical therapy, have been found to lead to improvements in quality of life.52 While the efficacy of these treatments is still being assessed, early hospital presentation is necessary for the determination of acute treatment and management for long-term symptoms.53 Widespread efforts must be taken to improve health education in these regions, such as the Stroke 1-2-0 campaign in China, which used social media to educate the public about stroke recognition and treatment.54

Africa: Addressing Health Care Disparities and Cultural Barriers to Stroke Care

Africa presents a unique set of challenges in stroke care, shaped by its diverse cultural, economic, and health care contexts. Recent data from Africa indicate that stroke has an annual incidence rate as high as 316 per 100 000 people, a prevalence rate reaching up to 1460 per 100 000, and a 3-year fatality rate exceeding 80%.55 In low- and middle-income countries, particularly in sub-Saharan Africa, the absence of national stroke care plans and limited health care infrastructure severely restricts access to essential stroke treatments.55 A major barrier to health care delivery is the lack of access to electricity, preventing hospitals from providing reliable health care via ventilators and patient monitors, for example, especially in sub-Saharan African countries, such as Nigeria, Kenya, and Ghana.56 Advanced resources such as stroke centers, neuroimaging, and emergency medical services are often scarce or entirely unavailable, limiting the reach and impact of crucial and necessary interventions such as EVT.25,29 In some rural areas, <2% of patients with stroke manage to reach a hospital via ambulance, making it difficult to treat patients within the critical therapeutic window for effective interventions.25

Culturally, stroke is often perceived through a lens of spiritual or supernatural beliefs. In regions such as Ga-Mashie and Gyegyeano in Ghana, stroke is referred to as a ghost illness, with its causes attributed to curses or spiritual forces.16,29 As a result, many patients turn to traditional healers or herbal remedies rather than seeking medical treatment. This cultural perspective can delay the initiation of proper medical care, further complicating stroke outcomes in affected communities. Despite these challenges, there is ongoing progress in building a more structured and accessible stroke care framework in select African nations, offering hope for improving outcomes in the future.

As in many Asian countries, the financial cost for stroke treatment is prohibitive for many citizens and patients in African nations, such as Nigeria, Senegal, and Tanzania.57 Therefore, patients are less likely to present to the hospital for treatment, and many hospitals are not able to provide IVT for patients.57,58 Many of these financial barriers are underscored by a lack of governmental support in the national health care systems; investment in stroke care infrastructure and treatment by African governmental representatives is needed to improve outcomes for this population.57

Last, insufficient numbers of health care personnel negatively impact the ability to provide adequate stroke care in many African nations. Few emergency medical services systems exist in African nations, impacted by the lack of electricity and trained personnel, such that many patients must transport themselves to the nearest health care facility.55,59 As a result, patients with stroke may miss the treatment window for appropriate reperfusion therapies. Furthermore, due to the small number of residency training programs and lack of advanced facilities and treatments, there are very few neurologists in African nations, especially those trained to administer IVT or manage postthrombectomy patients.55 Ultimately, much work needs to be done to improve training of health care providers and patient understanding of the disease to improve stroke care in the continent.

Moving Forward: Strategies for Overcoming Barriers to Stroke Care

Strengthening Health Care Systems and Access

To address the global stroke burden, the health care infrastructure must be expanded, particularly in low-resource settings. Building stroke centers in rural areas, training more neurointerventionalists, and increasing the availability of imaging equipment will be critical steps toward ensuring more patients receive timely and effective care, especially in high-income regions. In low-income countries, financial barriers to stroke treatment must be eliminated, with the aid of government subsidies and private funding for emergency medical systems, reperfusion therapy, and stroke rehabilitation. In addition, enhancing public transportation systems to ensure patients reach health care facilities within the critical treatment window is essential.

Culturally Sensitive Education and Outreach

Educational efforts must be culturally tailored to address specific misconceptions about stroke in different regions. Partnering with religious and community leaders can help bridge the gap between medical recommendations and cultural beliefs, ensuring that communities receive accurate information about stroke symptoms, prevention, and the importance of immediate care.

Conclusions

As the global stroke burden continues to rise, it has become increasingly urgent to enhance stroke prevention, intervention, and care worldwide. This challenge is multifaceted, involving not only the mobilization of significant economic resources but also the need to dismantle a variety of cultural barriers that impede access to timely and effective treatment. These barriers are deeply rooted in diverse spiritual beliefs, misconceptions about the nature and causes of stroke, and the stigma surrounding the use of health care services. In many communities, stroke is misunderstood or misattributed due to factors such as divine will, punishment, or bad luck, which deters individuals from seeking timely medical attention. Moreover, in numerous cultural contexts, there exists a profound sense of shame or fear of social stigma associated with seeking care, especially for conditions perceived as taboo or life-threatening. For many, the very idea that a stroke is a medical emergency, requiring rapid intervention within a critical time window, is not well understood, contributing to delays in diagnosis and treatment that can drastically reduce the likelihood of favorable outcomes.

To effectively combat the growing stroke burden, a comprehensive global strategy is required, one that goes beyond merely increasing health care infrastructure or access to treatments. A successful response must include a coordinated effort to educate and engage communities on a cultural level, addressing both the myths and the fear that often accompany stroke. Programs aimed at raising awareness about the importance of early recognition of stroke symptoms, the timing of treatment, and the life-saving potential of acute interventions such as thrombectomy and thrombolysis must be integral to any national or international stroke strategy.

The path forward demands an inclusive, culturally sensitive approach that leverages both public health campaigns and community-based interventions, engaging religious leaders, health care workers, and local influencers to challenge misconceptions and reduce the stigma associated with seeking medical care. Only by addressing these cultural and educational gaps can we create a health care environment where patients with stroke are empowered to act quickly, seek care confidently, and access the life-saving treatments they need.

Ultimately, the fight against the increasing global stroke burden is not just a matter of improving health care systems or investing in technology; it is a battle against the cultural inertia that often prevents timely care. To ensure that all patients, regardless of geography or background, have the opportunity to survive and recover from stroke, we must act now to bridge these gaps in understanding and access.

ARTICLE INFORMATION

Acknowledgments

The authors would like to thank and commend the work of the SVIN: Mission Thrombectomy Collaborative, made up of Ameer Hassan, Robin Novakovic, Alicia Castonguay, Brijesh Mehta, Hiroshi Yamagami, Francisco Jose Mont’Alverne, Jin Soo Lee, Syed Zaidi, Mohamad Ezzeldin, Tanzila Shams, Diogo Haussen, David Liebeskind, Vallabh Janardhan, Osama Zaidat, Tiffany Eatz, Sedna Gandhi, and Jacqueline Brenner. The study is in compliance with ethical approval and informed consent for human studies and compliance with ethical standards for animal studies.

Disclosures

Dr Ortega-Gutierrez and Dr Yavagal serve on the editorial board of Stroke: Vascular and Interventional Neurology. Editorial board members are not involved in the handling or final disposition of Submissions.

Funding Statement

This work was supported by the SVIN Mission Thrombectomy Initiative.

Nonstandard Abbreviations and Acronyms

EVT
endovascular thrombectomy
IVT
intravascular thrombolysis
tPA
tissue-type plasminogen activator
*

F. Al-Mufti and M. Elfil contributed equally.

Contributor Information

Fawaz Al-Mufti, Email: fawaz.al-mufti@wmchealth.org.

Mohamed Elfil, Email: Mohamed.Elfil@wmchealth.org.

Hazem S. Ghaith, Email: hazemghaith11@gmail.com.

Aarti Kishore Jain, Email: ajain9@student.nymc.edu.

Nimrod Gozum, Email: ngozum@student.nymc.edu.

Eric Feldstein, Email: efeldstein12@gmail.com.

Ankita Jain, Email: ajain9@student.nymc.edu.

Eris Spirollari, Email: eris.spirollari@wmchealth.org.

Andre Calixte, Email: Andre.Calixte@mountsinai.org.

Victor C. Urrutia, Email: vurruti1@jhmi.edu.

Nabeel A. Herial, Email: nabeel.herial@outlook.com.

Pankajavalli Ramakrishnan, Email: Pankajavalli.Ramakrishnan@WMChealth.org.

Gabor Toth, Email: tothg@ccf.org.

Mohammad El-Ghanem, Email: elghanmh@gmail.com.

Krishna Amuluru, Email: kamuluru@gmail.com.

Viktor Szeder, Email: vszeder@mednet.ucla.edu.

Jonathan R. Crowe, Email: jrc8z@virginia.edu.

Zurab Nadareishvili, Email: nadareiz@gmail.com.

Kaustubh Limaye, Email: limayekaustubh@gmail.com.

Fazeel Siddiqui, Email: fazeelmukhtar@gmail.com.

Hamza Shaikh, Email: hamza.shaikh@gmail.com.

Nishita Singh, Email: nishita.singh@umanitoba.ca.

Hesham Masoud, Email: masoudh@upstate.edu.

Sushanth R. Aroor, Email: sushanth.r.aroor@uth.tmc.edu.

Shashvat M. Desai, Email: drshashvatdesai@gmail.com.

Santiago Ortega-Gutierrez, Email: santy-ortega@uiowa.edu.

Tareq Kass-Hout, Email: kasshouttareq@gmail.com.

Dileep R. Yavagal, Email: dyavagal@med.miami.edu.

Kaiz S. Asif, Email: Kaiz.asif@gmail.com.

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