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

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.

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.

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.