Understanding the Drivers and Cost Impact of Traditional Medicine Use for Stroke Rehabilitation in India: Insights from the ATTEND Trial

Shiva Raj Mishra^{1

2}, Jeyaraj D Pandian³, Sanjith Aaron⁴, Madhusudhan Byadarahalli Kempegowda⁵, Nomal Chandra Borah⁶, Anne Forster⁷, Dorcas B C Gandhi³, D S Halprashant⁸, Maree L Hackett⁹, Lisa A Harvey¹⁰, Stephen Jan⁹, Subhash Kaul¹¹, Dheeraj Khurana¹², Peter Langhorne¹³, Laurent Billot^{9

14}, Lydia John¹⁵, Pallab K Maulik^{16

17}, Gudlavalleti V S Murthy¹⁸, Vivek Nambiar¹⁹, Padma Srivastava²⁰, Jayanta Roy²¹, Sureshbabu Sachin²², P N Sylaja²³, P Vijaya²⁴, Marion Walker¹⁷, Craig S Anderson^{9

25}, Angela Webster^{26

27}, Clara Chow²⁶, Richard I Lindley^{26

9}

Affiliations

¹ Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia, shivarajmishra@gmail.com.
² NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia, shivarajmishra@gmail.com.
³ Christian Medical College and Hospital Ludhiana, Ludhiana, India.
⁴ Christian Medical College and Hospital, Vellore, India.
⁵ Global Hospital, Bengaluru, India.
⁶ Guwahati Neurological Research Centre, Guwahati, India.
⁷ School of Medicine, University of Leeds, Leeds, UK.
⁸ Global Hospital, Chennai, India.
⁹ George Institute for Global Health, Sydney, New South Wales, Australia.
¹⁰ Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.
¹¹ Nizam's Institute of Medical Sciences, Hyderabad, India.
¹² Post Graduate Institute of Medical Education and Research, Chandigarh, India.
¹³ School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
¹⁴ Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
¹⁵ Baptist Christian Hospital, Tezpur, India.
¹⁶ George Institute for Global Health, New Delhi, India.
¹⁷ Amrita Institute of Medical Sciences and Research Centre, Kochi, India.
¹⁸ All India Institute of Medical Sciences, Delhi, India.
¹⁹ Apollo Gleneagles, Kolkata, India.
²⁰ St. Stephen Hospital, New Delhi, India.
²¹ Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
²² Lalitha Hospital, Guntur, India.
²³ Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK.
²⁴ Indian Institute of Public Health-Hyderabad, Hyderabad, India.
²⁵ Institute for Technology and Science for Brain-inspired Research, Fudan University, Shanghai, China.
²⁶ Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.
²⁷ NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.

PMID: 41379724
DOI: 10.1159/000549284

Understanding the Drivers and Cost Impact of Traditional Medicine Use for Stroke Rehabilitation in India: Insights from the ATTEND Trial

Shiva Raj Mishra et al. Cerebrovasc Dis. 2025.

. 2025 Dec 11:1-12.

doi: 10.1159/000549284. Online ahead of print.

Authors

Affiliations

¹ Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia, shivarajmishra@gmail.com.
² NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia, shivarajmishra@gmail.com.
³ Christian Medical College and Hospital Ludhiana, Ludhiana, India.
⁴ Christian Medical College and Hospital, Vellore, India.
⁵ Global Hospital, Bengaluru, India.
⁶ Guwahati Neurological Research Centre, Guwahati, India.
⁷ School of Medicine, University of Leeds, Leeds, UK.
⁸ Global Hospital, Chennai, India.
⁹ George Institute for Global Health, Sydney, New South Wales, Australia.
¹⁰ Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.
¹¹ Nizam's Institute of Medical Sciences, Hyderabad, India.
¹² Post Graduate Institute of Medical Education and Research, Chandigarh, India.
¹³ School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
¹⁴ Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
¹⁵ Baptist Christian Hospital, Tezpur, India.
¹⁶ George Institute for Global Health, New Delhi, India.
¹⁷ Amrita Institute of Medical Sciences and Research Centre, Kochi, India.
¹⁸ All India Institute of Medical Sciences, Delhi, India.
¹⁹ Apollo Gleneagles, Kolkata, India.
²⁰ St. Stephen Hospital, New Delhi, India.
²¹ Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
²² Lalitha Hospital, Guntur, India.
²³ Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK.
²⁴ Indian Institute of Public Health-Hyderabad, Hyderabad, India.
²⁵ Institute for Technology and Science for Brain-inspired Research, Fudan University, Shanghai, China.
²⁶ Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.
²⁷ NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.

PMID: 41379724
DOI: 10.1159/000549284

Abstract

Introduction: Traditional medicines are used to meet a variety of health needs by people across India, but few data exist for their use by those affected by stroke. We aimed to assess the prevalence, costs, and drivers of traditional medicines used by patients with stroke and in relation to defined sociodemographic characteristics.

Methods: This study presents a post hoc analysis of the Family-led Rehabilitation after Stroke in India (ATTEND), a multicentre, prospective, randomised, open blinded endpoint (PROBE) trial conducted at 14 hospitals in India. Data were obtained on the use of non-modern medical treatments and associated financial implications. Multivariable logistic regression was used to identify the predictors of traditional medicine use and reported as adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Financial impacts and their 95% uncertainty intervals were estimated for all new stroke cases in 2022 (80 INR = 1 USD).

Results: Of 1,250 randomised participants, 968 had sufficient data for analysis (age 57.7 [±13.6] years). The overall prevalence of traditional medicine use was 21.1%. Lower use of traditional medicine was associated with high school/college education (aOR: 0.55, 95% CI: 0.30, 0.98) and mild neurological severity (National Institutes of Health Stroke Scale [NIHSS] score <5; aOR: 0.32; 95% CI: 0.14, 0.72). There was no significant association with age (aOR: 1.76; 95% CI: 0.85, 3.64), unemployment (aOR: 2.16, 95% CI: 0.99, 4.74), pre-stroke dependency (aOR: 1.96, 95% CI: 0.46, 8.36), and living accommodation (aOR: 1.13, 95% CI: 0.53, 2.41). We calculated that traditional medicine costs USD 67 million annually: a higher cost burden among men (USD 36 million) compared to women (USD 31 million; 80 INR = 1 USD).

Conclusions: Our study indicates that 1 in five patients used traditional medicine following acute stroke in India, with significant financial bearings on individuals and their families. There is greater use in those with more severe strokes and with lower education. More evidence is required on the efficacy of traditional medicines and their role in the healthcare system.

Keywords: Cross-sectional study; India; Rehabilitation; Stroke; Traditional medicine.

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Understanding the Drivers and Cost Impact of Traditional Medicine Use for Stroke Rehabilitation in India: Insights from the ATTEND Trial

Affiliations

Understanding the Drivers and Cost Impact of Traditional Medicine Use for Stroke Rehabilitation in India: Insights from the ATTEND Trial

Authors

Affiliations

Abstract

LinkOut - more resources

Full Text Sources