Technology-EnaSystem-Integratedbled Model of Care Aiming to Improve the Health of Stroke Patients in Resource-Poor Settings in China

Lead Research Organisation: Duke Kunshan University
Department Name: Global Health Research Center

Abstract

Stroke affects 62 million people worldwide and is a leading cause of death in low- and middle-income countries such as China. This serious condition has a high chance of recurrence and is also highly debilitating, leaving many survivors disabled. In family-oriented societies where significant health expenditure is out-of-pocket, a stroke constitutes a major life event that dramatically changes the life not only of the stroke survivors but also of the family caregivers.

In addition, for the large number of stroke patients living in rural areas, the care they receive is inadequate and far below evidence-based standards. To rely on specialists to provide such services is not only unrealistic but also unsustainable. Yet healthcare workers and family caregivers, who live in the same communities as the patients, lack the necessary knowledge, training and tools to provide high-quality care.

To address these problems, we have designed a model of care to train village doctors and family caregivers, equipping them with innovative digital health technology such as smartphone applications and text messaging. After training, they can deliver evidence-based care to the patients in their villages and families to improve their health status.

Based on nearly ten years of previous studies, we will first update, optimise and integrate the training products and component for the model. We will then roll out the intervention in 50 villages in Nanhe County in Hebei Province located in the stroke belt in China. We plan to train 5 physicians and 5 nurses in secondary healthcare facilities, who will in turn train 25 village doctors and 625 family caregivers, to provide services to 625 patients.

The model described and tested in this study has the potential to provide an example based on training, new technology and sharing of tasks by different players in the healthcare systems, to build up the capacities of many healthcare workers and caregivers in a scalable way, and to improve the health of stroke patients.

Technical Summary

Our proposal tackles the high-priority chronic condition of stroke through a system-integrated technology-enabled model of care tailored for resource-poor settings aiming to improve the health of stroke (SINEMA). The principal research question, designed to address system barriers, is "can trained village doctors and family caregivers, equipped with digital health technology, provide evidence-based care to stroke survivors in resource-poor settings in China." The core components of the model are cascade training, digital health technology and task sharing (i.e. delivery of care by village doctors and family caregivers).

In phase 1, we will conduct a barriers analysis to understand the opportunities and constraints experienced by stroke patients and their families in accessing essential care and rehabilitation through qualitative methods. In phase 2, we will assemble and integrate each component of the SINEMA model piloted in previous studies into a holistic model of practical, scalable and seamless essential healthcare delivery for stroke patients. Phase 3 will be a community-based cluster-randomised controlled trial in Nanhe County, Hebei Province, China. Our local collaborators will first select 5 townships and 10 villages in each township to seek group consent. The 50 villages will be randomised either to the SINEMA programme or usual care. Each village will recruit on average 25 stroke patients (total n=1,250). The village doctors and family caregivers in the 25 intervention villages will receive training to provide evidence-based essential medical care and basic rehabilitation to stroke patients for one year. Primary outcome will be systolic blood pressure. Main secondary outcomes will include EQ-5D and Barthel Index.

Process/implementation-related outcomes will be evaluated through qualitative methods such as focus groups and key informant interviews. We will also conduct cost-effectiveness analyses to better aid sound policy-making for future scale-up.

Planned Impact

Our study will not only benefit researchers, practitioners and policymakers in need of innovative models and practical tools and technology, but the impact of our study has the potential to be felt by many patients and their families in China, throughout the healthcare system, and in other low- and middle-income countries (LMICs) searching for effective and low-cost population solutions to the burden of non-communicable disease (NCD).

The most immediate beneficiaries of the proposed research will be the disadvantaged populations where the work is to be conducted - Nanhe County in Hebei Province, China. Villagers living in these rural areas have a huge burden of stroke and very limited access to high-quality healthcare and rehabilitation. The burden is not only health-related (directly affecting patients), but often also emotionally and economically devastates already poor families, dragging them into poverty, and straining caregivers and the community at large. If the model of care we propose here is proven effective, government support would allow for a wider dissemination of the training programme and rapid uptake of the technology - quickly meeting the needs of those in most need of this intervention.

Another key beneficiary is the healthcare system itself. The current system has historically had limited means to reach much of the nations' rural population with even basic healthcare, much less for the complex care necessary for stroke. Even with those who are able to get treatment in hospitals, the treatment is expensive and not always guaranteed to be the best possible care, given often-skewed financial and human resources and incentives. This community-based solution addresses key barriers in effective prevention and control of NCD by capacity building (cascade training), digital health technology, and task-sharing and shifting from specialist to secondary care facilities and community-based healthcare workers and family members.

Digital health technology development is an important part of our proposed study. We expect these technological products to have the potential to be commercialised by the industry such as China Mobile co. (Dr Li-Qun Xu) and to be promoted by governments, healthcare professionals and other associations such as the China Medical Association and various specialty associations including neurology (Dr Yilong Wang) and rehabilitation (Dr Ninghua Wang). Leaders in these companies and organisations are members of our steering committee or advisory group.

Another particular strength of the proposed research is the level of engagement of policymakers, with the National Commission on Health and Family Planning (formerly Ministry of Health) supporting and engaging with the project from the start. Policymakers' influence can potentially affect how the healthcare reforms can strengthen primary care and community-based services through our simplified model of training and technology. Lastly, other important beneficiaries are the millions of people living in LMICs who also shoulder a major burden of stroke and other NCDs. Other countries may be empowered with knowledge and tools from our study that they can tailor to their population's needs. China is a member of the Asia Pacific Economic Cooperation. Scale-up and dissemination channels can be established through the Cooperation, specifically its Health Task Force that has direct reach to many national ministries of health. We have also worked and will work with the Director General of Department of International Cooperation at the National Health and Family Planning Commission to reach other nations.

The impact of this research would reverberate throughout the patient population, healthcare system, industry and government. The research is more than an exercise of academic pursuit - it is about helping millions of people sooner rather than later, with a model that is practical and long-term.

Publications

10 25 50
 
Title APP database 
Description This is the database of the APP. It collects data through APP. The APP is designed for and used by village doctors in the intervention group. They visit stroke patients of our study once a month, and record their blood pressure, medication use and other information in the APP. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact It is used by the project manager, county and township managers, for monitoring village doctors' work and quality control. 
 
Title Baseline database (patients and village doctors) 
Description The baseline survey was conducted in Jun-Aug 2017 to 1299 eligible stroke patients in 50 villages in Nanhe, China, and the database was created. The data collection was conducted following a standard protocol by trained staff. For patients, a brief interviewer-administered questionnaire was completed using Qualtrics, an online-survey platform. The questionnaire collected data on demographic information, disease history, medication use and adherence, lifestyle behaviors, and utilization of healthcare services including hospitalization. Patients also had a physical examination comprising of assessment of blood pressure, weight, height, waist circumference and timed up and go test. For village doctors, the y were invited to complete a self-administered knowledge-attitude-practices questionnaire including questions regards their demographic characteristics, clinical practice experience. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact Members in our research group are analyzing the database. The database helps the group understand the current situation of stroke patients and village doctors in rural Hebei, and contribute the design and refinement of the study. 
 
Title Process evaluation database 
Description 3-month and 6-month process evaluation were conducted by trained staffs.Key stakeholders involved in the study including patients, village doctors, doctors at township level, study coordinators, county government officials will be interviewed. 9-month and 12-month process evaluation will also be conducted in the future. All interview records have been or will be transcribed into text. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact This database will contribute to explore the essential components of the intervention, and help to explain the outcomes in the future. 
 
Description Beijing Tiantan Hospital 
Organisation Beijing Tiantan Hospital
Country China 
Sector Hospitals 
PI Contribution We coordinated and assisted with designing the content of the intervention and training.
Collaborator Contribution They designed the content of the intervention, such as steps of follow-up and medication prescription. They also designed the content of training session for village and township doctors.
Impact The content of intervention and training, and the Manual of Operation for village and township doctors.
Start Year 2016
 
Description China Mobile 
Organisation China Mobile
Country China 
Sector Public 
PI Contribution We cooperated with China Mobile to develop the APP of our study: 1) We provided the idea and details of designing the APP, such as modules and indicators. 2) We answer their questions during the development of the APP. 3) We monitored the process and did the quality control. 4) We came out the data management and security plan, and build the security network. 5) We coordinated the testing of the demo APP.
Collaborator Contribution They developed the APP based on our requirements and assisted with building the security network. Also, they develop the demo APP and tested it.
Impact We have developed a demo APP. Disciplines involved: global health, information technology
Start Year 2016
 
Title software copyright (SINEMA APP) 
Description We designed the APP to support village doctors's monthly follow-up, and managers' quality control and monitoring. This APP is designed to standardize the flow of the monthly follow-up visit. With the assistance of SINEMA APP, during each monthly follow-up visit, village doctors will collect information about participants' health conditions, medication use, blood pressure level, etc.; and provide health education to participants on medication adherence and physical activity. 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted 2017
Licensed No
Impact The quality and frequency of monthly follow-up visits have been improved, which may contribute to improvement of patients' health outcomes.
 
Title SINEMA APP 
Description Village doctors in the intervention arm are provided with the SINEMA APP, designed for this study to standardize the flow of the monthly follow-up visit. With the assistance of SINEMA APP, during each monthly follow-up visit, village doctors will collect information about participants' health conditions, medication use, blood pressure level, etc.; and provide health education to participants on medication adherence and physical activity. 
Type Of Technology Software 
Year Produced 2017 
Impact Support villages doctors' monthly follow-up visits to patients. In addition, the project manager, county and township managers can use the APP to monitor village doctors' work. 
 
Description Academic conference CCUGH 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This is the Second Annual Conference of the Chinese Consortium of University for Global Health, with the topic of "Advancing the Health Sustainable Development Goals in China and Globally: Working Together to Meet Challenges". It brings together more than 400 speakers and audiences from academia, government, funding agencies, private sectors and health related organizations from China, other low- and middle-income countries and high-income countries, to explore solutions in achieving the health SDGs through partnerships and collaboration in China and beyond.The objectives of the conference are to gather participants and key stakeholders engaging in health development from China and around the world to discuss key issues and challenges and how research, particularly policy-oriented research can help identify gaps and generate evidence and knowledge for informed policy -making to achieve the health-related Sustainable Development Goals in China and other developing countries. The conference will cover several key areas of the health SDGs including child and maternal nutrition and health; non-communicable diseases (NCDs), emerging infectious diseases; environmental health and climate changes, and health system strengthening, among which NCDs is one of the most popular sub-themes.
Year(s) Of Engagement Activity 2016
 
Description Academic conference Hunan 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact About 300 professionals and students attended the conference, which discussed theories and studies about behavior health. We gave oral presentation about the message-based intervention design of the SINEMA study and shared the experiences with other researchers on the design of the intervention.
Year(s) Of Engagement Activity 2017
 
Description Academic conference ISRD&ATS 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The ISRD&ATS 2017 was held in Shanghai on Nov 17-19. It brought together 76 academic, clinical and industrial specialists and more than 1200 audience from all over the world. It focused on smart and digital health applied in different fields of disease screening, examination and treatment.
Year(s) Of Engagement Activity 2017
 
Description Academic conference in Singapore 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This is CVCT ASIA 2016 2nd Singapore Cardiovascular Clinical Trialists Forum. It brings together top cardiovascular trialists, investigators, statisticians, industry R&D experts, regulators and practitioners across Asia Pacific. During the scientific sessions, workshops and networking events, participants will brainstorm on current issues in cardiovascular drug, device and biomarker development; and trial design, conduct, ethics, interpretation, approvability and implementation in Asia.
Year(s) Of Engagement Activity 2016