Pre-hospital delay among rural South African stroke survivors is 'a complex interplay of knowledge, cultural causal attributions and systematic healthcare inequalities,' shaped by four primary themes: knowledge of stroke, severity of symptoms, belief systems, and distance to medical health facilities.
Key Findings
Results
Limited knowledge of stroke symptoms was a primary determinant of pre-hospital decision-making delay among rural stroke survivors.
Participants demonstrated gaps in recognizing stroke signs as medical emergencies requiring immediate care.
Poor stroke knowledge contributed to delays in seeking formal medical treatment.
The study identified stroke knowledge as one of four primary themes determining pre-hospital delay.
Community-level education was identified as absent or insufficient in reaching rural populations.
Results
Perceived severity of stroke symptoms influenced whether and when survivors sought medical care.
Symptom severity was identified as one of the four primary thematic determinants of pre-hospital delay.
Survivors' subjective interpretation of symptom seriousness shaped their initial help-seeking decisions.
Less severe or ambiguous presentations appeared to contribute to delayed recognition of stroke as an emergency.
This theme emerged through thematic analysis of semi-structured interviews with ten stroke survivors.
Results
Cultural and traditional belief systems influenced stroke survivors' pre-hospital decision-making pathways.
Belief systems were identified as one of four primary themes determining pre-hospital delay.
Participants attributed stroke causation to cultural or supernatural explanations rather than biomedical ones.
Traditional healers were identified as part of the community's primary networks influencing early responses to stroke.
The authors recommend stroke education efforts extend to 'the traditional healer's office' as a key community network.
Socio-cultural factors were framed as part of a 'complex interplay' alongside cognitive and structural factors.
Results
Structural barriers, particularly distance to medical health facilities, contributed to pre-hospital delays among rural stroke survivors.
Distance to medical facilities was identified as one of four primary thematic determinants of pre-hospital delay.
The study was conducted in rural Limpopo Province, South Africa, a context characterized by healthcare access inequalities.
Structural factors were described as part of 'systematic healthcare inequalities' shaping delay.
Geographic remoteness compounded other delay factors including limited knowledge and cultural beliefs.
Methods
An exploratory qualitative design using snowball sampling and semi-structured interviews was employed with ten stroke survivors in rural Limpopo Province.
Sample size was ten stroke survivors recruited via snowball sampling.
Data were collected through semi-structured interviews.
Thematic analysis was used to analyse the data.
The setting was rural Limpopo Province, South Africa.
The study addressed socio-cultural, cognitive, and structural factors influencing decision-making pathways.
Conclusions
The authors concluded that stroke education efforts must extend beyond hospitals into community primary networks including the home, church, and traditional healer's office.
Current hospital-based education was deemed insufficient for reaching rural populations.
Three specific community networks were identified: 'the home, the church, and the traditional healer's office.'
This recommendation was grounded in the finding that belief systems and limited knowledge are key delay factors.
The approach was framed as necessary to address the complex interplay of factors driving pre-hospital delay.
What This Means
This research suggests that when people in rural South Africa experience a stroke, multiple overlapping factors cause them to delay seeking hospital care. The study interviewed ten stroke survivors in Limpopo Province and found four main reasons for these delays: not recognizing stroke symptoms as a medical emergency, judging symptoms as not severe enough to warrant immediate action, holding traditional or cultural beliefs about what causes stroke (such as supernatural explanations), and living far from medical facilities. These factors did not act alone but combined to create significant gaps in timely treatment-seeking behavior.
The cultural dimension was particularly notable. Many participants interpreted their stroke through a traditional or spiritual lens rather than a biomedical one, which meant their first response was often to seek help from traditional healers or family rather than going directly to a hospital. This is significant because stroke treatment is highly time-sensitive — the sooner treatment begins, the better the outcome — and any delay, regardless of cause, reduces the effectiveness of available therapies.
This research suggests that public health efforts aimed at reducing stroke delays in rural South Africa need to go beyond hospital walls. Rather than focusing only on patients who have already reached healthcare facilities, interventions should be brought into the spaces where communities actually live and make decisions — homes, churches, and traditional healers' practices. Partnering with trusted community figures and institutions, including traditional healers, may be essential for improving stroke awareness and emergency response in these settings.
Mhlari R, Kgopa B, Masola N, Moloantoa-Sewapa T. (2026). Factors influencing pre-hospital decision-making among stroke survivors in the rural area of South Africa: an exploratory study.. Frontiers in public health. https://doi.org/10.3389/fpubh.2026.1848220