A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study

Weight management personas of breast cancer patients undergoing chemotherapy in China: a multi-method study

BACKGROUND

Mobile health (mHealth) may be an ideal solution for breast cancer (BC) patients in China to access weight management interventions. User retention and engagement are the main challenges faced by mHealth applications. A user persona, which is a user-centered design process, can lead to the development of mHealth that is more acceptable to the needs of target users. This study aimed to investigate the variety of experiences in weight management and the behavioral preferences of BC patients receiving chemotherapy to develop users' personal information and persona development for the design and implementation of mHealth interventions.

METHODS

Sixteen individual semi-structured in-depth interviews were conducted with BC patients receiving chemotherapy. We employed the thematic analysis method to analyze the interview transcripts in NVivo 11 software. The themes obtained from the analysis were used as the subdomains of personas. A proforma was designed to extract each participant's experience in each subdomain. Patients who exhibited similar experience in subdomains were grouped into a persona using affinity diagrams. The personas were named according to their prominent features. A questionnaire survey was conducted to validate the personas and to test whether the personas that were generated from the qualitative interview data were applicable to the Chinese population with BC.

RESULTS

Four themes were identified as subdomains of weight management personas: the perception of weight management while undergoing chemotherapy, symptoms and emotional disturbance, changes in diet and exercise, and health literacy and information seeking. Five personas were ultimately obtained: (1) positive weight controllers, (2) patients who were inactive due to fatigue, (3) young patients who avoided communication, (4) overweight patients with treatment priority, and (5) patients who engaged in irregular exercise. Finally, the quantitative study showed that 51.58% of patients chose one of these five personas to represent themselves in weight management. None of the patient reported selecting options that were not explicitly outlined in the questionnaire and provided personalized descriptions of their weight management characteristics.

CONCLUSIONS

The selected personas were developed from in-depth interviews on biopsychosocial areas. They highlight different weight management patterns in Chinese BC patients and provide implications for both the design of mHealth systems and traditional interventions.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings

Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.

Co-design for stroke intervention development: Results of a scoping review

BACKGROUND

Co-design methodology seeks to actively engage end-users in developing interventions. It is increasingly used to design stroke interventions; however, limited guidance exists, particularly with/for individuals with stroke who have diverse cognitive, physical and functional abilities. Thus, we describe 1) the extent of existing research that has used co-design for stroke intervention development and 2) how co-design has been used to develop stroke interventions among studies that explicitly used co-design, including the rationale, types of co-designed stroke interventions, participants involved, research methodologies/approaches, methods of incorporating end-users in the research, co-design limitations, challenges and potential strategies reported by researchers.

MATERIALS AND METHODS

A scoping review informed by Joanna Briggs Institute and Arksey & O'Malley methodology was conducted by searching nine databases on December 21, 2022, to locate English-language literature that used co-design to develop a stroke intervention. Additional data sources were identified through a hand search. Data sources were de-duplicated, and two research team members reviewed their titles, abstracts and full text to ensure they met the inclusion criteria. Data relating to the research objectives were extracted, analyzed, and reported numerically and descriptively.

RESULTS

Data sources used co-design for stroke intervention development with (n = 89) and without (n = 139) explicitly using the term 'co-design.' Among studies explicitly using co-design, it was commonly used to understand end-user needs and generate new ideas. Many co-designed interventions were technology-based (65%), and 48% were for physical rehabilitation or activity-based. Co-design was commonly conducted with multiple participants (82%; e.g., individuals with stroke, family members/caregivers and clinicians) and used various methods to engage end-users, including focus groups and workshops. Limitations, challenges and potential strategies for recruitment, participant-engagement, contextual and logistical and ethics of co-designed interventions were described.

CONCLUSIONS

Given the increasing popularity of co-design as a methodology for developing stroke interventions internationally, these findings can inform future co-designed studies.

Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review

AIM

Technology including artificial intelligence (AI) may play a key role to strengthen primary health care services in resource-poor settings. This systematic review aims to explore the evidence on the use of AI and digital health in improving primary health care service delivery.

METHODS

Three electronic databases were searched using a comprehensive search strategy without providing any restriction in June 2023. Retrieved articles were screened independently using the "Rayyan" software. Data extraction and quality assessment were conducted independently by two review authors. A narrative synthesis of the included interventions was conducted.

RESULTS

A total of 4596 articles were screened, and finally, 48 articles were included from 21 different countries published between 2013 and 2021. The main focus of the included studies was noncommunicable diseases (n = 15), maternal and child health care (n = 11), primary care (n = 8), infectious diseases including tuberculosis, leprosy, and HIV (n = 7), and mental health (n = 6). Included studies considered interventions using AI, and digital health of which mobile-phone-based interventions were prominent. m-health interventions were well adopted and easy to use and improved the record-keeping, service deliver, and patient satisfaction.

CONCLUSION

AI and the application of digital technologies improve primary health care service delivery in resource-poor settings in various ways. However, in most of the cases, the application of AI and digital health is implemented through m-health. There is a great scope to conduct further research exploring the interventions on a large scale.

Capacity Building, Knowledge Enhancement, and Consultative Processes for Development of a Digital Tool (Ni-kshay SETU) to Support the Management of Patients with Tuberculosis: Exploratory Qualitative Study

BACKGROUND

Achieving the target for eliminating tuberculosis (TB) in India by 2025, 5 years ahead of the global target, critically depends on strengthening the capacity of human resources as one of the key components of the health system. Due to the rapid updates of standards and protocols, the human resources for TB health care suffer from a lack of understanding of recent updates and acquiring necessary knowledge.

OBJECTIVE

Despite an increasing focus on the digital revolution in health care, there is no such platform available to deliver the key updates in national TB control programs with easy access. Thus, the aim of this study was to explore the development and evolution of a mobile health tool for capacity building of the Indian health system's workforce to better manage patients with TB.

METHODS

This study involved two phases. The first phase was based on a qualitative investigation, including personal interviews to understand the basic requirements of staff working in the management of patients with TB, followed by participatory consultative meetings with stakeholders to validate and develop the content for the mobile health app. Qualitative information was collected from the Purbi Singhbhum and Ranchi districts of Jharkhand and Gandhinagar, and from the Surat districts of Gujarat State. In the second phase, a participatory design process was undertaken as part of the content creation and validation exercises.

RESULTS

The first phase collected information from 126 health care staff, with a mean age of 38.4 (SD 8.9) years and average work experience of 8.9 years. The assessment revealed that more than two-thirds of participants needed further training and lacked knowledge of the most current updates to TB program guidelines. The consultative process determined the need for a digital solution in easily accessible formats and ready reckoner content to deliver practical solutions to address operational issues for implementation of the program. Ultimately, the digital platform named Ni-kshay SETU (Support to End Tuberculosis) was developed to support the knowledge enhancement of health care workers.

CONCLUSIONS

The development of staff capacity is vital to the success or failure of any program or intervention. Having up-to-date information provides confidence to health care staff when interacting with patients in the community and aids in making quick judgments when handling case scenarios. Ni-kshay SETU represents a novel digital capacity-building platform for enhancing human resource skills in achieving the goal of TB elimination.

Strategies for specialty training of healthcare professionals in low-resource settings: a systematic review on evidence from stroke care

BACKGROUND

The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings.

METHODS

We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion.

RESULTS

A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates.

CONCLUSIONS

The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts.

A smart devices based secondary prevention program for cerebrovascular disease patients

Background

Commercially available health devices are gaining momentum and represent a great opportunity for monitoring patients for prolonged periods. This study aimed at testing the feasibility of a smart device-based secondary prevention program in a cohort of patients with cryptogenic stroke.

Methods

In this proof-of-principle study, patients with non-disabling ischemic stroke and transient ischemic attacks (TIA) in the subacute phase were provided with a smartwatch and smart devices to monitor several parameters - i.e., oxygen saturation, blood pressure, steps a day, heart rate and heart rate variability - for a 4-week period (watch group). This group was compared with a standard-of-care group. Our primary endpoint was the compliance with the use of smart devices that was evaluated as the number of measures performed during the observation period.

Results

In total, 161 patients were recruited, 87 in the WATCH group and 74 in the control group. In the WATCH group, more than 90% of patients recorded the ECG at least once a day. In total, 5,335 ECGs were recorded during the study. The median blood pressure value was 132/78 mmHg and the median oxygen saturation value was 97%. From a clinical standpoint, although not statistically significant, nine atrial fibrillation episodes (10.3%) in the WATCH group vs. 3 (4%) in the control group were detected.

Conclusion

Our study suggests that prevention programs for cerebrovascular disease may benefit from the implementation of new technologies.

An economic evaluation of a primary care-based technology-enabled intervention for stroke secondary prevention and management in rural China: a study protocol

Introduction

Secondary prevention of stroke is a leading challenge globally and only a few strategies have been tested to be effective in supporting stroke survivors. The system-integrated and technology-enabled model of care (SINEMA) intervention, a primary care-based and technology-enabled model of care, has been proven effective in strengthening the secondary prevention of stroke in rural China. The aim of this protocol is to outline the methods for the cost-effectiveness evaluation of the SINEMA intervention to better understand its potential economic benefits.

Methods

The economic evaluation will be a nested study based on the SINEMA trial; a cluster-randomized controlled trial implemented in 50 villages in rural China. The effectiveness of the intervention will be estimated using quality-adjusted life years for the cost-utility analysis and reduction in systolic blood pressure for the cost-effectiveness analysis. Health resource and service use and program costs will be identified, measured, and valued at the individual level based on medication use, hospital visits, and inpatients' records. The economic evaluation will be conducted from the perspective of the healthcare system.

Conclusion

The economic evaluation will be used to establish the value of the SINEMA intervention in the Chinese rural setting, which has great potential to be adapted and implemented in other resource-limited settings.

A framework for design and usability testing of telerehabilitation system for adults with chronic diseases: A panoramic scoping review

Objective

This scoping review aimed to identify the design and usability testing of a telerehabilitation (TR) system, and its characteristics and functionalities that are best-suited for rehabilitating adults with chronic diseases.

Methods

Searches were conducted in PubMed, EBSCO, Web of Science, and Cochrane library for studies published between January 2017 and December 2022. We followed the Joanna Briggs Institute guidelines and the framework by Arksey and O'Malley. Screening was undertaken by two reviewers, and data extraction was undertaken by the first author. Then, the data were further reviewed and discussed thoroughly with the team members.

Results

A total of 31 results were identified, with the core criteria of developing and testing a telerehabilitation system, including a mobile app for cardiovascular diseases, cancer, diabetes, and chronic respiratory disorders. All developed systems resulted from multidisciplinary teams and employed mixed-methods research. We proposed the "input-process-output" framework that identified phases of both system design and usability testing. Through system design, we reported the use of user-centered design, iterative design, users' needs and characteristics, theory underpinning development, and the expert panel in 64%, 75%, 86%, 82%, and 71% of the studies, respectively. We recorded the application of moderated usability testing, unmoderated testing (1), and unmoderated testing (2) in 74%, 63%, and 15% of the studies, respectively. The identified design and testing activities produced a matured system, a high-fidelity prototype, and a released system in 81.5%, 15%, and 3.5%, respectively.

Conclusion

This review provides a framework for TR system design and testing for a wide range of chronic diseases that require prolonged management through remote monitoring using a mobile app. The identified "input-process-output" framework highlights the inputs, design, development, and improvement as components of the system design. It also identifies the "moderated-unmoderated" model for conducting usability testing. This review illustrates characteristics and functionalities of the TR systems and healthcare professional roles.

Educational level differences in the primary and secondary prevention of stroke

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30-79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all P_trend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all P_trend < 0.001) and with the use of lipid-lowering medication for secondary prevention (P_trend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all P_{for interaction} < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

The Implementation of a Primary Care-Based Integrated Mobile Health Intervention for Stroke Management in Rural China: Mixed-Methods Process Evaluation

Background: There is a lack of evidence concerning the effective implementation of strategies for stroke prevention and management, particularly in resource-limited settings. A primary-care-based integrated mobile health intervention (SINEMA intervention) has been implemented and evaluated via a 1-year-long cluster-randomized controlled trial. This study reports the findings from the trial implementation and process evaluation that investigate the implementation of the intervention and inform factors that may influence the wider implementation of the intervention in the future.

Methods: We developed an evaluation framework by employing both the RE-AIM framework and the MRC process evaluation framework to describe the implementation indicators, related enablers and barriers, and illustrate some potential impact pathways that may influence the effectiveness of the intervention in the trial. Quantitative data were collected from surveys and extracted from digital health monitoring systems. In addition, we conducted quarterly in-depth interviews with stakeholders in order to understand barriers and enablers of program implementation and effectiveness. Quantitative data analysis and thematic qualitative data analysis were applied, and the findings were synthesized based on the evaluation framework.

Results: The SINEMA intervention was successfully implemented in 25 rural villages, reached 637 patients with stroke in rural Northern China during the 12 months of the trial. Almost 90% of the participants received all follow-up visits per protocol, and about half of the participants received daily voice messages. The majority of the intervention components were adopted by village doctors with some adaptation made. The interaction between human-delivered and technology-enabled components reinforced the program implementation and effectiveness. However, characteristics of the participants, doctor-patient relationships, and the healthcare system context attributed to the variation of program implementation and effectiveness.

Conclusion: A comprehensive evaluation of program implementation demonstrates that the SINEMA program was well implemented in rural China. Findings from this research provide additional information for program adaptation, which shed light on the future program scale-up. The study also demonstrates the feasibility of combining RE-AIM and MRC process evaluation frameworks in process and implementation evaluation in trials.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03185858.

Effectiveness of a primary care-based integrated mobile health intervention for stroke management in rural China (SINEMA): A cluster-randomized controlled trial

BACKGROUND

Managing noncommunicable diseases through primary healthcare has been identified as the key strategy to achieve universal health coverage but is challenging in most low- and middle-income countries. Stroke is the leading cause of death and disability in rural China. This study aims to determine whether a primary care-based integrated mobile health intervention (SINEMA intervention) could improve stroke management in rural China.

METHODS AND FINDINGS

Based on extensive barrier analyses, contextual research, and feasibility studies, we conducted a community-based, two-arm cluster-randomized controlled trial with blinded outcome assessment in Hebei Province, rural Northern China including 1,299 stroke patients (mean age: 65.7 [SD:8.2], 42.6% females, 71.2% received education below primary school) recruited from 50 villages between June 23 and July 21, 2017. Villages were randomly assigned (1:1) to either the intervention or control arm (usual care). In the intervention arm, village doctors who were government-sponsored primary healthcare providers received training, conducted monthly follow-up visits supported by an Android-based mobile application, and received performance-based payments. Participants received monthly doctor visits and automatically dispatched daily voice messages. The primary outcome was the 12-month change in systolic blood pressure (BP). Secondary outcomes were predefined, including diastolic BP, health-related quality of life, physical activity level, self-reported medication adherence (antiplatelet, statin, and antihypertensive), and performance in "timed up and go" test. Analyses were conducted in the intention-to-treat framework at the individual level with clusters and stratified design accounted for by following the prepublished statistical analysis plan. All villages completed the 12-month follow-up, and 611 (intervention) and 615 (control) patients were successfully followed (3.4% lost to follow-up among survivors). The program was implemented with high fidelity, and the annual program delivery cost per capita was US$24.3. There was a significant reduction in systolic BP in the intervention as compared with the control group with an adjusted mean difference: -2.8 mm Hg (95% CI -4.8, -0.9; p = 0.005). The intervention was significantly associated with improvements in 6 out of 7 secondary outcomes in diastolic BP reduction (p < 0.001), health-related quality of life (p = 0.008), physical activity level (p < 0.001), adherence in statin (p = 0.003) and antihypertensive medicines (p = 0.039), and performance in "timed up and go" test (p = 0.022). We observed reductions in all exploratory outcomes, including stroke recurrence (4.4% versus 9.3%; risk ratio [RR] = 0.46, 95% CI 0.32, 0.66; risk difference [RD] = 4.9 percentage points [pp]), hospitalization (4.4% versus 9.3%; RR = 0.45, 95% CI 0.32, 0.62; RD = 4.9 pp), disability (20.9% versus 30.2%; RR = 0.65, 95% CI 0.53, 0.79; RD = 9.3 pp), and death (1.8% versus 3.1%; RR = 0.52, 95% CI 0.28, 0.96; RD = 1.3 pp). Limitations include the relatively short study duration of only 1 year and the generalizability of our findings beyond the study setting.

CONCLUSIONS

In this study, a primary care-based mobile health intervention integrating provider-centered and patient-facing technology was effective in reducing BP and improving stroke secondary prevention in a resource-limited rural setting in China.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03185858.

Mobile health interventions in developing countries: A systematic review

This study reviews the quality of evidence reported in mobile health intervention literature in the context of developing countries. A systematic search of renowned databases was conducted to find studies related to mobile health applications published between a period of 2013 and 2018. After a methodological screening, a total of 31 studies were included for data extraction and synthesis. The mobile health Evidence Reporting and Assessment checklist developed by the World Health Organization was then used to evaluate the rigor and completeness in evidence reporting. We report several important and interesting findings. First, there is a very low level of familiarity with the mobile health Evidence Reporting and Assessment checklist among the researchers and mobile health intervention designers from developing countries. Second, most studies do not adequately meet the essential criteria of evidence reporting mentioned in the mobile health Evidence Reporting and Assessment checklist. Third, there is a dearth of application of design science-based methods and theory-based frameworks in developing mobile health interventions. Fourth, most of the mobile health interventions are not ready for interoperability and to be integrated into the existing health information systems. Based on these findings, we recommend for robust and inclusive study plans to deliver highly evidence-based reports by mobile health intervention studies that are conducted in the context of developing countries.

Treatment Adherence and Secondary Prevention of Ischemic Stroke Among Discharged Patients Using Mobile Phone- and WeChat-Based Improvement Services: Cohort Study

BACKGROUND

Real-world studies have indicated that adherence is important for guaranteeing medication effectiveness. Few studies have tested the feasibility and efficacy of WeChat-based improvement services, via mobile phone, in secondary prevention-specific follow-up among discharged stroke patients.

OBJECTIVE

We evaluated a quadruple-domain, WeChat-based service for ischemic stroke secondary prevention designed to improve treatment adherence of discharged patients. This service focuses on sending reminders for drug use, blood pressure recording, and glucose recording; it also records medication use. We compared the endpoint event rate between WeChat self-monitoring and traditional monitoring.

METHODS

A cohort study was used to determine the feasibility of a physician-assisted, WeChat-based improvement service and follow-up self-monitoring platform for the secondary prevention of ischemic stroke. The platform was developed by the Peking University Third Hospital based on the information-motivation-behavioral skills model. The overall adherence rate was calculated as the proportion of medication doses verified via uploading. The ischemic endpoint event rate and medication noncompliance rate were compared between traditional prevention monitoring and WeChat self-monitoring. Factors influencing adherence were summarized.

RESULTS

The 1-year follow-up event rate of the WeChat self-monitoring group was 11.9% (12/101), which was less than that of the traditional group (21/157, 13.4%). Compared with the traditional group, the risk ratio of the WeChat group was 0.983 (95% CI 0.895-1.080); this difference was not noted to be significant. The 1-year medication noncompliance ratio tended to be lower in the WeChat monitoring group (3/101, 3.0%) than in the traditional group (11/157, 7.0%; χ²=1.9, df=1, P=.16). Of the platform registry participants, 89.7% (210/234: 167 hospital-based and 43 community-based participants) adhered to inputting information into WeChat for 8-96 weeks. The average adherence time was 16.54 (SD 0.80, range 2-24) months. The average decrease in adherence was 4 participants (1.1%) per month. Being a member of a community-based population was an influencing factor for good adherence at the 2-year follow-up (OR 2.373, 95% CI 1.019-5.527, P=.045), whereas transient ischemic attack was an influencing factor for poor adherence at the 2-year follow-up (OR 0.122, 95% CI 0.016-0.940, P=.04).

CONCLUSIONS

Use of WeChat self-monitoring showed a trend of increasing medication compliance and decreasing ischemic endpoint event rate compared with traditional monitoring. However, there were ceiling effects in the outcomes, and a relatively small sample size was used. Male participants displayed better adherence to WeChat self-monitoring. The community-based population displayed good adherence when using WeChat self-monitoring.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02618265; https://clinicaltrials.gov/ct2/show/NCT02618265.

An Ambulatory Blood Pressure Monitor Mobile Health System for Early Warning for Stroke Risk: Longitudinal Observational Study

BACKGROUND

Stroke, as a leading cause of death around the globe, has become a heavy burden on our society. Studies show that stroke can be predicted and prevented if a person's blood pressure (BP) status is appropriately monitored via an ambulatory blood pressure monitor (ABPM) system. However, currently there exists no efficient and user-friendly ABPM system to provide early warning for stroke risk in real-time. Moreover, most existing ABPM devices measure BP during the deflation of the cuff, which fails to reflect blood pressure accurately.

OBJECTIVE

In this study, we sought to develop a new ABPM mobile health (mHealth) system that was capable of monitoring blood pressure during inflation and could detect early stroke-risk signals in real-time.

METHODS

We designed an ABPM mHealth system that is based on mobile network infrastructure and mobile apps. The proposed system contains two major parts: a new ABPM device in which an inflation-type BP measurement algorithm is embedded, and an abnormal blood pressure data analysis algorithm for stroke-risk prediction services at our health data service center. For evaluation, the ABPM device was first tested using simulated signals and compared with the gold standard of a mercury sphygmomanometer. Then, the performance of our proposed mHealth system was evaluated in an observational study.

RESULTS

The results are presented in two main parts: the device test and the longitudinal observational studies of the presented system. The average measurement error of the new ABPM device with the inflation-type algorithm was less than 0.55 mmHg compared to a reference device using simulated signals. Moreover, the results of correlation coefficients and agreement analyses show that there is a strong linear correlation between our device and the standard mercury sphygmomanometer. In the case of the system observational study, we collected a data set with 88 features, including real-time data, user information, and user records. Our abnormal blood pressure data analysis algorithm achieved the best performance, with an area under the curve of 0.904 for the low risk level, 0.756 for the caution risk level, and 0.912 for the high-risk level. Our system enables a patient to be aware of their risk in real-time, which improves medication adherence with risk self-management.

CONCLUSIONS

To our knowledge, this device is the first ABPM device that measures blood pressure during the inflation process and has obtained a government medical license. Device tests and longitudinal observational studies were conducted in Peking University hospitals, and they showed the device's high accuracy for BP measurements, its efficiency in detecting early signs of stroke, and its efficiency at providing an early warning for stroke risk.