Globally, stroke remains the third leading cause of death and the fourth leading cause of disability-adjusted life years, accounting for 93.8 million prevalent cases and 11.9 million incident cases (GBD 2019 Stroke Collaborators, 2021; Gnonlonfoun et al., 2014). Recent global stroke statistics show a consistent increase in stroke burden in low- and middle-income countries (LMICs). The current annual incidence rate has reached 316 per 100,000 individuals, with a prevalence of up to 1,460 per 100,000 persons (Akinyemi et al., 2021). This is one of the highest incidence rates globally compared to 118.7 per 100,000 persons in high-income countries (HICs) (Prendes et al., 2024). The increased stroke burden in Africa is due to multiple factors, such as in utero and early-life under-nutrition, increased cardio-metabolic risks, changes in dietary habits, and increased exposure to particulate air pollution (Akinyemi et al., 2021). The outcomes of stroke are often either death or survival with long-term disability associated with poor quality of life (Hankey et al., 2007; Ramos-Lima et al., 2018; Ganesh et al., 2017). Moreover, evidence suggests a higher risk of recurrent stroke among survivors (Oza et al., 2017; Dabilgou et al., 2021). Common predictors of mortality and disability among stroke survivors in Africa include older age (>65 years), HIV infection, stroke subtype, smoking, alcohol use, and poor observance of treatment for diabetes mellitus and hypertension (Sarfo et al., 2018; Sarfo and Ovbiagele, 2022).

In Africa, data from several studies demonstrate a 3-year fatality rate of over 80% (Akinyemi et al., 2021; Walker et al., 2016), which is similar to rates from a large population-based study conducted in Tanzania over a decade ago, which reported a 3-year fatality rate of 60% (Walker et al., 2016). In recent years, efforts to improve stroke services across sub-Saharan Africa (SSA), including Tanzania, have made significant progress. These initiatives include establishing stroke units, expanding stroke registries, introducing neuro-endovascular services such as mechanical thrombectomy, developing national stroke programs, and increasing stroke awareness and education campaigns, which are important endeavors with the potential to improve stroke outcomes and reduce mortality (Gebreyohanns et al., 2022; Roushdy et al., 2025; Sheriff et al., 2025; Matuja et al., 2025). Currently, data on the long-term post-stroke outcomes in Tanzania are limited. This study aimed to investigate the long-term outcomes among adults with stroke admitted at a large tertiary academic hospital in northwestern Tanzania.

We collected baseline and follow-up data on 301 adult stroke survivors for up to 3 years after discharge from a large tertiary academic hospital in urban northwestern Tanzania. We found a high case fatality rate that increased cumulatively over the 3-year period, strong associations between fatality and demographic and clinical characteristics, and poor adherence to secondary preventive measures following hospital discharge.

The case fatality rate of our cohort at 1 year was 42.9%, with a steep increase to 96.4% at 3 years. These findings are similar to studies conducted in SSA, where the 3-year case fatality rate was 84.3% (Akinyemi et al., 2021), including a recent study conducted along the coastal region of Tanzania that reported a 1-year fatality of 40.8% (Tessua et al., 2021). In contrast, studies from HICs, such as France and Poland (Warsaw), have reported 1-year case fatality rates of 26.8 and 33.1%, respectively (Gabet et al., 2019; Sienkiewicz-Jarosz et al., 2011). Several factors may account for these differences, including limited access to health insurance coverage. In our study, lack of health insurance was strongly associated with fatality. This finding aligns with data from HICs, where uninsured individuals under the age of 65 face a three-fold higher risk of stroke-related mortality compared to those with insurance (McManus et al., 2015). Moreover, individuals with both basic and supplemental private insurance experience even lower mortality rates. In Tanzania, where only 32% of the population has health insurance (Kitole et al., 2023; M. B., 2024), the lack of coverage presents a significant barrier to timely treatment and effective healthcare. Insurance coverage plays a crucial role not only in facilitating access to acute stroke care but also in enabling ongoing primary and secondary prevention, including early detection and treatment of modifiable stroke risk factors (Smolderen et al., 2010; Ayanian et al., 2000).

Despite the high prevalence of premorbid hypertension in our cohort (85.4%), only one-third of hypertensive stroke survivors reported the regular use of antihypertensive medications post-discharge. Moreover, follow-up and medication adherence rates were strikingly low: only 28.6% of patients attended follow-up clinic visits, and only 8.6% participated in physiotherapy. Among those with diabetes and hypertension, only 32 and 41%, respectively, adhered to their prescribed medications. These figures are consistent with other studies in SSA (Tessua et al., 2021) but contrast sharply with data from Sweden, where 77% of stroke survivors attended follow-up at 1 year and antihypertensive adherence reached 82.9% (Månsson et al., 2024). Contributing factors to poor follow-up and low adherence in our setting include limited awareness of hypertension as a chronic condition, a lack of understanding among caregivers about the risk of recurrence, the financial burden of medications, and the absence of physical support to access healthcare facilities (Tessua et al., 2021; Mbalinda et al., 2024; Wasserman et al., 2009).

The gap in secondary prevention is particularly concerning in light of the increased burden of recurrent stroke observed in our cohort. Recurrent stroke was a strong independent predictor of fatality, with affected individuals exhibiting a three-fold increase in fatality compared to those experiencing a first-ever stroke. This association has been reported in previous studies and likely reflects the compounded clinical vulnerability and functional decline associated with recurrent events (Aarnio et al., 2014; Khanevski et al., 2019), as well as missed opportunities for long-term risk factor control. These findings reinforce the urgent need for robust secondary prevention strategies in Tanzania, including structured follow-up systems, improved medication adherence support, and expanded health insurance coverage to ensure continuity of care and reduce the burden of recurrent stroke-related mortality.

Another predictor of fatality in this cohort was a higher baseline stroke severity (moderate to severe and severe strokes). These findings are consistent with a study conducted by Mathisen et al., who reported increased long-term mortality among patients presenting with severe strokes (Mathisen et al., 2016). However, other studies suggest that stroke severity primarily affects survival in the acute phases of stroke, with a more limited effect on long-term outcomes (Rutten-Jacobs et al., 2013). This discrepancy highlights the need for further research to better understand the impact of stroke severity on survival beyond the acute phase. Nonetheless, the association between stroke severity and fatality in our cohort highlights the importance of timely and effective acute interventions. Expanding access to acute revascularization therapies, such as intravenous thrombolysis and mechanical thrombectomy, remains a high priority, as these interventions have been shown to significantly improve long-term functional outcomes compared to best medical therapy alone (Lambrinos et al., 2016). Mechanical thrombectomy, in particular, has demonstrated substantial benefits in achieving early reperfusion in patients with large vessel occlusion, thereby enhancing both short- and long-term survival and recovery (Berkhemer et al., 2015). In parallel, the absence of specialized stroke units and high-quality multidisciplinary rehabilitation services in our setting likely contributes to the observed poor outcomes. Strengthening these components of stroke care could play a vital role in reducing post-stroke mortality and promoting functional independence among survivors.

Our study had several strengths. It is the first stroke registry follow-up study with patient-level data up to 3 years and provides information on various factors that influence case fatality and adherence to secondary preventive measures in Tanzania. Data were collected following internationally accepted definitions by well-trained medical doctors. Among patients who completed follow-up, all necessary information as provided in the questionnaire was collected. Furthermore, the study comes at an opportune time, as the government has embarked on creating stroke units with trained multidisciplinary teams, which will help provide information for creating targeted interventions to improve long-term stroke outcomes, including the region's rehabilitation services.

Our study had several limitations. It was conducted at a single center using data from patients registered in the LZSS (Matuja et al., 2024), where approximately 10% of patients with suspected strokes were unable to complete a non-contrast computed tomography head scan. This finding may limit the generalizability of our findings to other settings due to potential selection bias. In addition, a significant proportion of participants were lost to follow-up after discharge or had missing data, a common challenge in longitudinal studies conducted in SSA.

Given the exceptionally high 3-year mortality rate of 96.5% observed in our cohort, future research should prioritize prospective studies that incorporate detailed analyses of the causes of death. Such investigations are critical for understanding the mechanisms underlying poor long-term outcomes following stroke in this setting and for informing targeted interventions aimed at improving survival. Equally important are efforts to strengthen patient follow-up systems, improve the quality and completeness of mortality data, and explore the factors contributing to poor adherence to secondary prevention strategies within this population.

In this prospective study, 9 in 10 adults died within 3 years post-stroke in northwestern Tanzania, driven by factors such as severe stroke, recurrent strokes, and limited access to health insurance. These findings underscore the urgent need to strengthen post-stroke care systems, advocate for universal health coverage, and improve the management of modifiable risk factors to reduce mortality and enhance quality of life. While this study provides valuable insights, challenges such as losing participants to follow-up and missing data highlight the need for better patient tracking, data collection, and targeted interventions to address gaps in secondary prevention and long-term care in resource-limited settings.