'Care for Stroke', a web-based, smartphone-enabled educational intervention for management of physical disabilities following stroke: feasibility in the Indian context

A mobile application-based post-stroke care strategy for survivors and their caregivers for prevention and management of post-stroke complications - "Stroke Home Care:" Development and feasibility

Objectives

In developing nations such as India, a disparity exists between the available resources for stroke rehabilitation and the substantial burden of stroke cases. Consequently, the provision of cost-effective and multidisciplinary post-stroke rehabilitation care to stroke survivors becomes of paramount importance. The utilization of mobile applications (apps) for stroke care has been on the rise, offering a personalized and pragmatic solution with the potential for wider reach in settings constrained by limited resources. To address the unmet needs in the prevention and management of post-stroke complications, we conceptualized a strategy known as a mobile application-based post-stroke care strategy for both survivors and their caregivers.

Materials and Methods

The scope of the app's focus was determined based on the incidence of post-stroke complications within a prospective cohort of stroke patients, in conjunction with existing literature. An initial "web-based mobile app" prototype was crafted to align with the identified focus area. Before the development of the final app version, a feasibility study was conducted involving 30 participant dyads (comprising a patient and a caregiver). Content validity was evaluated by a panel of 20 stroke experts encompassing neurologists, nurses, physiotherapists, and psychologists.

Results

The "Stroke Home Care" (SHC) mobile app was conceived as a web-based educational tool aimed at preventing and managing post-stroke complications. It seeks to train caregivers of immobile stroke patients in the administration of preventive and therapeutic care procedures, thereby potentially enhancing survivors' quality of life and alleviating caregivers' burden. The feasibility and validity studies indicated "high satisfaction" levels among most caregivers and experts (>75%), with the remainder expressing "satisfaction" and no "dissatisfaction" regarding app utilities. Stroke experts unanimously deemed the app "appropriate", with consensus on contents, video quality, video length, and voice clarity. Caregivers reported "satisfactory" user experiences, encountering no issues during app installation or operation. Suggestions from both caregivers and experts were integrated into the final app version.

Conclusion

The "SHC" app represents a feasible and well-received innovation tailored for the use by caregivers of stroke survivors. Consequently, the initial feasibility of the developed app serves as a precursor to a randomized controlled clinical trial aimed at substantiating its effectiveness within the post-stroke survivor and caregiver population. Notably, within resource-constrained contexts, this app has the potential to be a pivotal tool for post-stroke care.

Effectiveness of a smartphone-enabled dyadic self-care programme (SDSCP) for stroke survivors and caregivers: study protocol for a randomised controlled trial

INTRODUCTION

The promotion of self-care has begun to serve as a central response strategy to the rising burden of stroke. In fact, stroke self-care can be recognised to be a dyad phenomenon having an effect on the health of stroke survivors and their caregivers. While studies have confirmed the effectiveness of smartphone-based interventions in improving self-care among stroke survivors, there remains a lack of evidence specifically regarding dyadic self-care interventions for both patients and caregivers.

AIM

The present single-blinded, two-arm, randomised controlled trial aims to verify the effectiveness of a smartphone-enabled dyadic self-care programme (SDSCP) for stroke survivors and their caregivers.

METHODS AND ANALYSIS

The estimated sample size is 152 stroke survivor-caregiver dyads. The participants will be randomly classified (1:1) into either a control (N=76) or an experimental group (N=76) through block randomisation. The participants classified into the experimental group will be provided with SDSCP, and during the initial home visit, the research team members will provide instructions to all patients and caregivers on how to download and use the smartphone application. While the participants in the control group will be given the existing stroke standard care. The main outcome measures of stroke survivors will consist of the Self-Care of Stroke Inventory and a short version of the Stroke Specific Quality of Life Scale. The outcome measures of stroke caregivers will primarily cover the Caregiver Contribution to Self-Care of Stroke Inventory and Zarit burden interview. The data of this study will be collected at three time points, including baseline, 1 month and 6 months from the baseline.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Zhengzhou University (ZZUIRB 2021-115) in January 2021. The results achieved in this study will facilitate the clinical practice to improve self-care of stroke survivors and promote dyadic health outcomes for stroke patients and caregivers.

TRIAL REGISTRATION NUMBER

The study was registered with the Chinese Clinical Trial Registry and the registration number is ChiCTR2100053591.

Evaluation of the feasibility and acceptability of ReWin-A digital therapeutic rehabilitation innovation for people with stroke-related disabilities in India

Background

Developing culturally appropriate, scalable interventions to meet the growing needs for stroke rehabilitation is a significant problem of public health concern. Therefore, systematic development and evaluation of a scalable, inclusive, technology-driven solution for community-based stroke care are of immense public health importance in India. ReWin is a digital therapeutics platform that was developed systematically. This study aimed to evaluate its feasibility and acceptability in an Indian context.

Objectives

Phase-1: To pilot the intervention for identifying operational issues and finalize the intervention. Phase-2: To assess the feasibility and acceptability of ReWin intervention in an Indian context.

Methods

Design: Mixed-methods research design. Setting: Participant's home and rehabilitation centers. Participants were selected from rehabilitation centers in South India. Participants: Ten stroke survivors and their caregivers, as well as four rehabilitation service providers were recruited for phase 1. Thirty stroke survivors who were treated and discharged from the hospital, and their caregivers as well as 10 rehabilitation service providers were recruited for Phase 2. Intervention: ReWin a digital therapeutic platform with the provider and patient app for the rehabilitation of physical disabilities following stroke was piloted. Process: Evaluation of the intervention was completed in two phases. In the first phase, the preliminary intervention was field-tested with 10 stroke survivors and four rehabilitation service providers for 2 weeks. In the second phase, the finalized intervention was provided to a further 30 stroke survivors to be used in their homes with support from their carers as well as to 10 rehabilitation service providers for 4 weeks. Outcome measures: Primary outcomes: (1) operational difficulties in using the ReWin intervention; (2) feasibility and acceptability of the ReWin intervention in an Indian setting.

Results

Field-testing identified operational difficulties related to 1. Therapeutic content; 2. Format; 3. Navigation; 4. Connectivity, 5. Video-streaming, 6. Language; and 7. Comprehensibility of the animated content. The intervention was reviewed, revised and finalized before pilot testing. Findings from the pilot testing showed that the ReWin intervention was feasible and acceptable. About 76% of the participants had used ReWin for more than half of the intervention period of 4 weeks. Ninety percentage of the stroke care providers and about 60% of the stroke survivors and caregivers felt that the content of ReWin was very relevant to the needs of the stroke survivors. Forty percentage of the stroke survivors and caregivers rated ReWin intervention as excellent. Another 45% of the stroke survivors and caregivers as well as 90% of the stroke care providers rated ReWin intervention as very good based on its overall credibility, usability, and user-friendliness.

Conclusions

ReWin has all the essential components to connect care providers and consumers not just for stroke rehabilitation but for several other health conditions with the use of several other technological features that support rehabilitation of persons with disabilities and strengthen rehabilitation in health systems worldwide. It is critical to amalgamate ReWin and other evidence-based interventions for rehabilitation to innovate scalable solutions and promote universal health coverage for stroke care worldwide.

Measurement, determinants, barriers, and interventions for exercise adherence: A scoping review

BACKGROUND

Adherence to exercise interventions is the cornerstone of a successful rehabilitation program. However, there is limited evidence on multifaceted components of exercise adherence. Therefore, we aimed to summarize the existing literature on measurement, determinants, barriers, theoretical frameworks, and evidence-based interventions that support exercise adherence.

METHODS

We conducted a scoping review based on the PRISMA extension for scoping reviews guidelines and searched the literature in PubMed, Cochrane Databases of Systematic Reviews, ScienceDirect, and Web of Science. Two reviewers independently screened articles. The included articles were subjected to data extraction and qualitative synthesis.

RESULTS

A total of 72 articles were included for this review. Data synthesis showed that there are no gold standard methods of measuring exercise adherence; however, questionnaires and daily logs are commonly used tools. The determinants of adherence are personal, disease-related, therapy-related, provider-related, and health system-related. The common barriers to adherence are the absence of a caregiver, low health literacy, poor communication by healthcare providers, cost, and lack of access to health facilities. Few evidence-based interventions used for supporting adherence are behavioral strategies, improving self-efficacy, motivational therapy, and mHealth or multimedia.

CONCLUSION

Non-adherence to exercises is a challenge for healthcare providers. There are no standard guidelines for the evaluation and management of non-adherence to exercises. Future studies should aim at developing objective measures of exercise adherence and investigate the long-term effects of adherence strategies in different disease populations. It is an under-researched area and requires multipronged strategies to improve adherence levels among patients.

Functional requirements of a mobile-based application for stroke self-management: A Delphi study

This study aimed to determine the functional requirements of a self-management mobile application for stroke survivors. For extracting the initial functional requirements, a literature review as well as interviews with 17 patients and caregivers were done. The results were analyzed using the content analysis method. The initial extracted requirements were then provided to the specialists by the Delphi technique to determine the final functional requirements. Content validity ratio (CVR) and content validity index (CVI) were calculated according to the Lawshe model. Criteria for item approval included CVR > 0.49 and CVI > 0.79. Finally, the approved items were turned into a five-point Likert scale questionnaire and were then provided to 53 experts and items with a mean score higher than 3.75 were approved. Functional requirements including creating a user account, educational material, support services, providing reminders and alerts for drugs administration and physician appointments, and rehabilitation exercises (to improve balance, upper and lower extremities rehabilitation, and activities of daily living (ADLs)) were approved. Most of the approved functional requirements were related to rehabilitation exercises for improving upper limb motor function. The experts did not approve the requirements for using splints and slings or the recommendation to take some medications.

eHealth Delivery of Educational Content Using Selected Visual Methods to Improve Health Literacy on Lifestyle-Related Diseases: Literature Review

BACKGROUND

Lifestyle-related diseases, such as stroke, heart disease, and diabetes, are examples of noncommunicable diseases. Noncommunicable diseases are now the leading cause of death in the world, and their major causes are lifestyle related. The number of eHealth interventions is increasing, which is expected to improve individuals' health literacy on lifestyle-related diseases.

OBJECTIVE

This literature review aims to identify existing literature published in the past decade on eHealth interventions aimed at improving health literacy on lifestyle-related diseases among the general population using selected visual methods, such as educational videos, films, and movies.

METHODS

A systematic literature search of the PubMed database was conducted in April 2019 for papers written in English and published from April 2, 2009, through April 2, 2019. A total of 538 papers were identified and screened in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. Finally, 23 papers were included in this review.

RESULTS

The 23 papers were characterized according to study characteristics (author and year of publication, study design and region where the study was conducted, study objective, service platform, target disease and participant age, research period, outcomes, and research method); the playback time of the educational videos, films, and movies; and the evaluation of the study's impacts on health literacy. A total of 7 studies compared results using statistical methods. Of these, 5 studies reported significant positive effects of the intervention on health literacy and health-related measures (eg, physical activity, body weight). Although most of the studies included educational content aimed at improving health literacy, only 7 studies measured health literacy. In addition, only 5 studies assessed literacy using health literacy measurement tools.

CONCLUSIONS

This review found that the provision of educational content was satisfactory in most eHealth studies using selected visual methods, such as videos, films, and movies. These findings suggest that eHealth interventions influence people's health behaviors and that the need for this intervention is expected to increase. Despite the need to develop eHealth interventions, standardized measurement tools to evaluate health literacy are lacking. Further research is required to clarify acceptable health literacy measurements.

The current status of stroke-related smartphone applications available to adopt in China: A systematic review study

INTRODUCTION

Stroke-related smartphone applications (apps) present enormous potential for stroke management as apps become increasingly prevalent in China. However, there is no comprehensive study reported about the currents status of stroke-related apps available to adopt in Chinese app market. The aim of this study is to assess the current status of stroke-related apps available to adopt in China.

MATERIALS AND METHODS

Using Stroke-related keywords written in either Chinese or English, the top 6 most prevalent apps online stores in China were searched from June to August 2018, including android market, 360 app market, wan dou jia, baidu mobile app, ying yong bao, apple app store. The basic features of selected apps were analyzed based on operating system, cost, target people, engagement, online interaction, release date, size, popularity, and usefulness. The information accountability of selected apps was evaluated with the Silberg scale. The functionality of selected apps targeting stroke patients at home were reviewed by researchers.

RESULTS

Our study showed that the downloads of stroke-related apps from android platform and the engagement of health professionals in apps development were critically insufficient. And most apps didn't offer a platform to facilitate online interaction with health professional. The information accountability of apps also presented a huge room for improvement. The average Silberg score of 127 apps was 3.5 (out of 9) with most apps not disclosing sponsorship, authors' affiliations, credentials, and sources or references of information. Few apps were modified in the past months. What's more, although the apps targeting stroke patients at home have covered 9 functionalities, most apps had only a simple functionality.

CONCLUSION

This study identified areas for improvement concerning information accountability of stroke-related apps available for adoption in China and reviewed functionality of apps targeting stroke patients at home. The findings might guide the development for stroke-related apps in China in the future.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Can Digitization of Health Care Help Low-Resourced Countries Provide Better Community-Based Rehabilitation Services?

In the wake of globalization, proliferation of digital technologies (DTs) is rapidly changing many activities across sectors, including influencing health to "go digital." Harnessing opportunities of DTs can be a pathway for delivery of health services, such as community-based rehabilitation (CBR) to the vulnerable groups of populations, particularly those in countries with low resources where health systems are weak and experiencing a deficit of trained health workers necessary to effectively deliver a full spectrum of health services. This perspective explored how some DTs can be leveraged in delivery of CBR services in rural and remote areas of countries with low resources. This is described based on information access and exchange, social satisfaction, shortages of rehabilitation workforce, professional development, and capacity building. However, since seizing advantages of DTs can inevitably be associated with spillovers and limitations, including needs prioritization, skills and language limitations, internet addiction and censorship issues, professionalism and ethical dilemmas, and sustainability, if proper measures are not taken, a caution is made. Moreover, as DTs are revolutionizing various activities across sectors, including health, this is not meant as a substitute for traditional health care activities, including those delivered through CBR, but rather to augment their delivery in settings with low resources and elsewhere.

Use of Technology to Promote Child Behavioral Health in the Context of Pediatric Care: A Scoping Review and Applications to Low- and Middle-Income Countries

Background: The burden of mental, neurological, and substance (MNS) disorders is greater in low- and middle-income countries (LMICs). The rapid growth of digital health (i.e., eHealth) approaches offer new solutions for transforming pediatric mental health services and have the potential to address multiple resource and system barriers. However, little work has been done in applying eHealth to promote young children's mental health in LMICs. It is also not clear how eHealth has been and might be applied to translating existing evidence-based practices/strategies (EBPs) to enable broader access to child mental health interventions and services. Methods: A scoping review was conducted to summarize current eHealth applications and evidence in child mental health. The review focuses on 1) providing an overview of existing eHealth applications, research methods, and effectiveness evidence in child mental health promotion (focused on children of 0-12 years of age) across diverse service contexts; and 2) drawing lessons learned from the existing research about eHealth design strategies and usability data in order to inform future eHealth design in LMICs. Results: Thirty-two (32) articles fitting our inclusion criteria were reviewed. The child mental health eHealth studies were grouped into three areas: i) eHealth interventions targeting families that promote child and family wellbeing; ii) eHealth for improving school mental health services (e.g., promote school staff's knowledge and management skills); and iii) eHealth for improving behavioral health care in the pediatric care system (e.g., promote use of integrated patient-portal and electronic decision support systems). Most eHealth studies have reported positive impacts. Although most pediatric eHealth studies were conducted in high-income countries, many eHealth design strategies can be adapted and modified to fit LMIC contexts. Most user-engagement strategies identified from high-income countries are also relevant for populations in LMICs. Conclusions: This review synthesizes patterns of eHealth use across a spectrum of individual/family and system level of eHealth interventions that can be applied to promote child mental health and strengthen mental health service systems. This review also summarizes critical lessons to guide future eHealth design and delivery models in LMICs. However, more research in testing combinations of eHealth strategies in LMICs is needed.

[Use of smartphone apps in secondary stroke prevention]

Modifiable risk factors such as hypertension, obesity or smoking have been reported to explain up to 90% of risk for ischemic stroke. Treatment of these risk factors is known to decrease the risk of recurrent stroke events. We performed a computer-based literature research from June to August 2018 using the electronic database PubMed to investigate the effect of smartphone apps on risk factor control for secondary stroke prevention as well as feasibility and patient satisfaction with mobile health. Studies evaluating interventions by smartphone or tablet devices in stroke patients and reported results regarding risk factors, feasibility or patient satisfaction were considered (n = 10). Identified data showed significant improvement regarding the control of risk factors hypertension and diabetes as well as significant improvements of the lifestyle risk factors physical inactivity and obesity. Stroke patients perceive smartphone apps mostly as useful and are open-minded regarding mHealth, provided that these complement rather than replace personal medical care.

Process of adaptation, development and assessment of acceptability of a health educational intervention to improve referral uptake by people with diabetes in Sri Lanka

BACKGROUND

One major barrier to uptake of diabetic retinopathy (DR) services is lack of knowledge and awareness of DR among the people with diabetes (PwDM). Targeted health education (HE) can be a key element in improving the uptake of eye care services. Such interventions are lacking in Sri Lanka.

METHODS

A local context specific HE intervention (HEI) was developed by adopting available resources and incorporating views from PwDM and key stakeholders. Four sessions of participatory workshops with PwDM (20 Sinhala and 13 Tamil speaking) and two stage 12 stakeholder interviews were conducted to both develop and pre-test the material. The products were a video and a leaflet, delivered at a medical clinic to a sample of 45 PwDM identified as having DR. Semi-structured interviews were conducted after 4 weeks, to evaluate the acceptability and comprehension of the HEI. Additionally, nine interviews were conducted with clinical providers to explore process issues related to delivery of the HEI. Data analysis was conducted using thematic analysis.

RESULTS

The lack of knowledge and awareness on DR, and of the importance of regular DR screening and follow up, combined with poor information on referral pathways were key elements identified from the workshops with PwDM. The stakeholders prioritised the importance of using simple language, and the need for emphasis on improving understanding about the asymptomatic phase of DR. The overall acceptability of the HEI material was satisfactory, although there was some difficulty with interpretation of medical images. Overall, although PwDM liked the ideas of the video, the leaflet was seen as a more practical option, given the busy clinic environment. The key issue was both formats required interaction with the provider, in order to support understanding of the messages.

CONCLUSIONS

The process of adapting HE material is not simply translation into the appropriate language. Instead, a tailored approach in a country, context and particular health services setting is needed. This study illustrates the value of using a participatory approach and involving PwDM and stakeholders in the adaptation and pilot testing of a HEI to improve uptake of screening for DR in the context of Sri Lanka.

Participatory design for selection of icons to represent daily activities of living for a vision-based rehabilitation-cum-assistance system for locked-in patients

Purpose: The majority of rehabilitation systems for locked-in patients are used for therapeutic purposes. However, round-the-clock assistance and support are essential after discharge from hospitals or nursing homes. This inspired us to develop a round-the-clock rehabilitation-cum-assistance system operated by eye gazes of locked-in patients. To do this, we aimed to identify the essential daily activities of living for locked-in patients and represent these activities using the most universally acceptable icons/images on the interface for the rehabilitation-cum-assistance system.Method: Activities were selected from available conventions and literature with advice from a local physiotherapy centre. Simple arithmetic averages and weighted averages of recognition rates for different icons representing different daily activities were calculated as per ISO 3864. Universal acceptability of the icons was compared based on responses from 72 locked-in patients across five different age groups. The final icons or images were then selected.Results: Three icons were categorized as identifiable with overall average recognition rates above 66.7%. Icons with average recognition rates 30-60% were considered to have "medium" recognisability and 21 icons were in this category. The average recognition rates of six icons were below 30% and were not acceptable. An overall recognition efficiency of 91% was achieved for participants from all age groups.Conclusions: The most preferred and unambiguous icons or images representing the essential daily activities of living were identified for use on the interface of our rehabilitation-cum-assistance system for round-the-clock operation.Implications for rehabilitationPerforming some of the daily activities by locked-in patients himself/herself is essential for self-independence as well as measures the level of regular improvement.Assistive technologies have huge potential for application for the purpose, especially the vision-based systems.Present technology is useful for development of a vision-based rehabilitation-cum-assistance system for 24 × 7 assistance for the locked-in patients.A new approach for real-time, user-based field evaluation of icons representing daily activities of living using statistical method of averaging of the recognition rates.

Significant others' perspectives on person-centred information and communication technology in stroke rehabilitation - a grounded theory study

Aim: The aim of this study was to explore significant others' perspectives on how information and communication technology can support the rehabilitation process after stroke and facilitate participation in everyday life.Method: Thirteen significant others were included in the study, and to capture their perspectives, two focus groups, and five individual interviews were carried out in Denmark and Sweden 6-12 months after the stroke incident. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis.Results: Five subcategories were identified from the analysis of the interviews: (1) Information and communication technology providing a sense of security, (2) Information and communication technology as a social mediator, (3) Information and communication technology as a compensator for deficits, (4) Information and communication technology as a way to reach information, and (5) Information and communication technology as a possibility to supplement the rehabilitation process. From these categories, one core category emerged: The potential of information and communication technology to facilitate participation in everyday life and thereby reduce the strains that significant others experience after stroke.Conclusion: Information and communication technology has the potential to facilitate participation in everyday life after stroke. It is important, therefore, to start using information and communication technology in the rehabilitation process after stroke, to bring meaning to everyday life and to support both the stroke survivors and their significant others.IMPLICATIONS FOR REHABILITATIONIntegration of information and communication technology in the rehabilitation process after stroke can accommodate several of the significant others´ needs.Educating stroke survivors to use information and communication technology as part of the rehabilitation process offloads their significant others.Integration of information and communication technology in the rehabilitation process after stroke can bring new meaning in everyday life and can facilitate both independence and participation in everyday life.

Combined action observation and motor imagery therapy: a novel method for post-stroke motor rehabilitation

Cerebral vascular accidents (strokes) are a leading cause of motor deficiency in millions of people worldwide. While a complex range of biological systems is affected following a stroke, in this paper we focus primarily on impairments of the motor system and the recovery of motor skills. We briefly review research that has assessed two types of mental practice, which are currently recommended in stroke rehabilitation. Namely, action observation (AO) therapy and motor imagery (MI) training. We highlight the strengths and limitations in both techniques, before making the case for combined action observation and motor imagery (AO + MI) therapy as a potentially more effective method. This is based on a growing body of multimodal brain imaging research showing advantages for combined AO + MI instructions over the two separate methods of AO and MI. Finally, we offer a series of suggestions and considerations for how combined AO + MI therapy could be employed in neurorehabilitation.

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review

Background

With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems.

Objective

We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature.

Methods

A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools.

Results

The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease–focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories.

Conclusions

In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.

A Systematic Review of Access to Rehabilitation for People with Disabilities in Low- and Middle-Income Countries

Rehabilitation seeks to optimize functioning of people with impairments and includes a range of specific health services—diagnosis, treatment, surgery, assistive devices, and therapy. Evidence on access to rehabilitation services for people with disabilities in low- and middle-income countries (LMICs) is limited. A systematic review was conducted to examine this in depth. In February 2017, six databases were searched for studies measuring access to rehabilitation among people with disabilities in LMICs. Eligible measures of access to rehabilitation included: use of assistive devices, use of specialist health services, and adherence to treatment. Two reviewers independently screened titles, abstracts, and full texts. Data was extracted by one reviewer and checked by a second. Of 13,048 screened studies, 77 were eligible for inclusion. These covered a broad geographic area. 17% of studies measured access to hearing-specific services; 22% vision-specific; 31% physical impairment-specific; and 44% measured access to mental impairment-specific services. A further 35% measured access to services for any disability. A diverse range of measures of disability and access were used across studies making comparability difficult. However, there was some evidence that access to rehabilitation is low among people with disabilities. No clear patterns were seen in access by equity measures such as age, locality, socioeconomic status, or country income group due to the limited number of studies measuring these indicators, and the range of measures used. Access to rehabilitation services was highly variable and poorly measured within the studies in the review, but generally shown to be low. Far better metrics are needed, including through clinical assessment, before we have a true appreciation of the population level need for and coverage of these services.

Use of mobile applications in post-stroke rehabilitation: a systematic review

OBJECTIVE

Information technology and mobile devices are potentially beneficial and useful in the management of patients who have had stroke, including recognition, translation, assessment, and rehabilitation. The objective of this study was to determine the effectiveness of mobile applications in the rehabilitation of stroke survivors.

METHODS

A literature search appraising the effectiveness of mobile applications in the rehabilitation of stroke survivors was performed on PubMed, Embase, Science Citation Index Expanded-SCIE, and EBSCO-CINAHL from their inception until May 28th, 2017. Two reviewers independently screened the literature according to eligibility criteria, evaluated study quality, and collected data from the articles included.

RESULTS

Of the 3574 articles screened, 12 studies met the eligibility criteria of the systematic review. Of these, 2 studies were randomized controlled trials and the remaining 10 were before-after studies, of which only 2 had control groups. The mobile applications encompassed 5 rehabilitation areas, 5 in physical function, 4 in language function, 2 in cognitive function, and 1 risk factor reduction. Of these 12 studies, 9 reported significant improvements in function, while in 3 studies the descriptive statistics indicated favorable changes after intervention.

CONCLUSIONS

Although the use of mobile applications in the rehabilitation of stroke survivors was effective, it is clear from this systematic review that more research is needed to verify their effectiveness.

Protocol for a randomised controlled trial to evaluate the effectiveness of the 'Care for Stroke' intervention in India: a smartphone-enabled, carer-supported, educational intervention for management of disabilities following stroke

INTRODUCTION

The rising prevalence of stroke and stroke-related disability witnessed globally over the past decades may cause an overwhelming demand for rehabilitation services. This situation is of concern for low-income and middle-income countries like India where the resources for rehabilitation are often limited. Recently, a smartphone-enabled carer-supported educational intervention for management of physical disabilities following stroke was developed in India. It was found to be feasible and acceptable, but evidence of effectiveness is lacking. Hence, as a step forward, this study intends to evaluate clinical effectiveness of the intervention through a randomised controlled trial.

METHODS

The objective of the study is to evaluate whether the 'Care for Stroke' intervention is clinically and cost-effective for the reduction of dependency in activities of daily living among stroke survivors in an Indian setting. This study is designed as a randomised controlled trial comparing people who received the intervention to those receiving standard care. The trial will be pragmatic and outcome assessor-blinded. The primary outcome for the study is dependency in daily living measured by the Modified Rankin Scale (MRS). A total of 266 adult stroke survivors who fulfil the eligibility criteria will be randomised to receive either 'Care for Stroke' intervention or standard treatment and will be followed up for 6 weeks. The main analyses will compare participants allocated to the 'Care for Stroke' intervention versus those allocated to the standard treatment group on an 'intention-to-treat' basis, irrespective of whether the participants received the treatment allocated or not. The dichotomised MRS scores (0-3 and 4-6) in both the groups will be used to calculate the effect estimates with a measure of precision (95% CI) and presented in the results of the trial.

ETHICS AND DISSEMINATION

The Indian Institute of Public Health-Hyderabad/Public Health Foundation of India - Independent Institutional Ethics Committee and the Ethics Committee of the London School of HygieneandTropical Medicine. Dissemination will be through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

Clinical Trial Registry of India CTRI/2017/07/009014.

mHealth applications as an educational and supportive resource for family carers of people with dementia: An integrative review

Family carers encounter several challenges related to caring for people with dementia, and they need support in managing care recipients’ health needs. This study aims to identify, appraise and synthesise the existing evidence on the use of mHealth/smartphone applications as an educational and supportive resource for family carers of people with dementia. An integrative literature review approach was used. Seven databases were searched. The search generated 117 articles, with seven meeting the inclusion criteria. Three categories and their attendant sub-categories emerged from the literature. The categories are ‘carer support’, ‘evaluation strategies’ and ‘barriers and challenges’. mHealth applications appear to be a feasible intervention for family carers of people with dementia despite the limited available research and barriers for their development and implementation. Further research on mHealth applications with strong methodological rigour and more research on mHealth applications as an educational and supportive resource for carers of people with dementia are needed.

Prevalence and causes of musculoskeletal impairment in Fundong District, North-West Cameroon: results of a population-based survey

OBJECTIVES

Epidemiological data on musculoskeletal conditions such as degenerative joint diseases and bone fractures are lacking in low- and middle-income countries. This survey aimed to estimate the prevalence and causes of musculoskeletal impairment in Fundong Health District, North-West Cameroon.

METHODS

Fifty-one clusters of 80 people (all ages) were selected using probability proportionate to size sampling. Households within clusters were selected by compact segment sampling. Six screening questions were asked to identify participants likely to have a musculoskeletal impairment (MSI). Participants screening positive to any screening question underwent a standardised examination by a physiotherapist to assess presence, cause, diagnosis and severity of impairment.

RESULTS

In total, 3567 of 4080 individuals enumerated for the survey were screened (87%). The all-age prevalence of MSI was 11.6% (95% CI: 10.1-13.3). Prevalence increased with age, from 2.9% in children to 41.2% in adults 50 years and above. The majority of MSI cases (70.4%) were classified as mild, 27.2% as moderate and 2.4% as severe. Acquired non-trauma comprised 67% of the diagnoses. The remainder included trauma (14%), neurological (11%), infection (5%) and congenital (3%). The most common individual diagnosis was degenerative joint disease (43%). Over one-third (38%) of individuals with MSI had never received medical care or rehabilitation for their condition.

CONCLUSIONS

This survey contributes to the epidemiological data on MSI in low- and middle-income countries. Nearly half of adults aged over 50 years had an MSI. There is a need to address the treatment and rehabilitative service gap for people with MSI in Cameroon.

Association of quality of life of carers with quality of life and functional independence of stroke survivors

Background:

Stroke has a great impact not only on patients’ but also on their caregivers’ lives. Carers may experience high levels of burden that can result in deterioration of their health status, social life, and well-being. Association between quality of life (QOL) of carers and that of stroke survivors in Indian setting is not much researched.

Aims and Settings:

To find out QOL and mental health of caregivers of individuals with stroke visiting Physiotherapy Department of Tertiary Care Center in Western India.

Design and Methodology:

A cross-sectional survey to find QOL and mental health of caregiver of stroke survivors, self-administered screening instrument WHO-QOL BREF, functional independence measurement (FIM) scale, and BRIEF COPE were used for data collection on adult populations.

Statistical Analysis Used:

The statistical analysis was performed by descriptive analysis and correlation.

Result:

Fifty-four stroke patients and their caregivers (all adults) were included in the study. Average FIM score was 83.75 (18.46) while median was 90 (25). FIM score of patients did not much affect QOL of caregivers.

Discussion:

Analysis of QOL data showed that QOL of caregivers was good in all domains, but patient's QOL was good only in social relations. There was no correlation found in QOL of carers and stroke survivors. Nine percent of change in caregivers social relationship scores can be attributed to patients’ sphincter scores.

Conclusion:

QOL of carers and stroke survivors may be independent. Stroke patients in the study required a moderate assistance for their functional independence which does not seem to affect the caregivers QOL significantly.

Rehabilitation Needs of Stroke Survivors After Discharge From Hospital in India

Objective

To assess the rehabilitation needs of stroke survivors in Chennai, India, after discharge from the hospital.

Design

Mixed-methods research design.

Setting

Home-based.

Participants

Stroke survivors (n=50; mean age ± SD, 58.9±10.5y) and primary caregivers of these stroke survivors (n=50; mean age ± SD, 43.1±11.8y) took part in the quantitative survey. A subsample of stroke survivors (n=12), primary caregivers (n=10), and health care professionals (n=8) took part in the qualitative in-depth interviews.

Interventions

Not applicable.

Main Outcome Measure

Rehabilitation needs after hospital discharge.

Results

About 82% of the needs expressed by stroke survivors and 92% of the needs expressed by caregivers indicated that they had a substantial need for information. The proportion of financial needs reported by the stroke survivors and the caregivers was 70% and 75%, respectively. The qualitative data revealed major gaps in access to stroke rehabilitation services. Service providers identified availability and affordability of services as key problems. Stroke survivors and their caregivers identified lack of information about stroke as major barriers to accessibility of stroke rehabilitation services. Caregivers expressed a tremendous need for support to manage family dynamics.

Conclusions

The study highlights a considerable unmet need for poststroke rehabilitation services. Given the lack of rehabilitation resources in India, developing an accessible, innovative, patient-centered, culturally sensitive rehabilitation intervention is of public health importance. It is crucial for low- and middle-income countries like India to develop technology-driven stroke rehabilitation strategies to meet the growing rehabilitation needs of stroke survivors.

Evaluation of the feasibility and acceptability of the 'Care for Stroke' intervention in India, a smartphone-enabled, carer-supported, educational intervention for management of disability following stroke

OBJECTIVES

(1) To identify operational issues encountered by study participants in using the 'Care for Stroke' intervention; (2) to evaluate the feasibility and acceptability of the intervention.

DESIGN

Mixed-methods research design.

SETTING

Participant's home. Participants were selected from a tertiary hospital in Chennai, South India.

PARTICIPANTS

Sixty stroke survivors treated and discharged from the hospital, and their caregivers.

INTERVENTION

'Care for Stroke' is a smartphone-enabled, educational intervention for management of physical disabilities following stroke. It is delivered through a web-based, smartphone-enabled application. It includes inputs from stroke rehabilitation experts in a digitised format.

METHODS

Evaluation of the intervention was completed in two phases. In the first phase, the preliminary intervention was field-tested with 30 stroke survivors for 2 weeks. In the second phase, the finalised intervention was provided to a further 30 stroke survivors to be used in their homes with support from their carers for 4 weeks.

PRIMARY OUTCOMES

(1) operational difficulties in using the intervention; (2) feasibility and acceptability of the intervention in an Indian setting. Disability and dependency were assessed as secondary outcomes.

RESULTS

Field-testing identified operational difficulties related to connectivity, video-streaming, picture clarity, quality of videos, and functionality of the application. The intervention was reviewed, revised and finalised before pilot-testing. Findings from the pilot-testing showed that the 'Care for Stroke' intervention was feasible and acceptable. Over 90% (n=27) of the study participants felt that the intervention was relevant, comprehensible and useful. Over 96% (n=29) of the stroke survivors and all the caregivers (100%, n=30) rated the intervention as excellent and very useful. These findings were supported by qualitative interviews.

CONCLUSIONS

Evaluation indicated that the 'Care for Stroke' intervention was feasible and acceptable in an Indian context. An assessment of effectiveness is now warranted.