A randomized controlled trial of medication adherence and management of risk factors for secondary prevention of stroke (MaMoRS) using a smartphone-based application.

BACKGROUND: There are little data on the use of smartphone-based applications for medication adherence and risk-factor control for the secondary prevention of stroke in low-and-middle-income countries (LMICs). AIMS: The aim was to determine whether a smartphone-based app improved medication adherence, risk-factor control, and provided health education to stroke survivors for lifestyle and behavioral modifications. METHODS: An unblinded, single-center randomized controlled double arm trial with 1:1 allocation among stroke survivors was performed in South India. The primary outcome was medication adherence, with co-primary outcomes of lifestyle and behavioral factors and control of vascular risk factors, at 3 and 6 months. RESULTS: Among 351 stroke survivors screened, 209 were recruited. The mean (standard deviation (SD)) age of the intervention (n = 105) group was 60 (12) years and that of the control (n = 104) group was 60 (10) years. In the primary outcome, mean medication adherence significantly improved in the intervention group with a between group difference of 0.735 (95% confidence interval (CI) = 0.419 to 1.050), p < 0.001. Being in intervention group (OR = 4.5; 95% CI = 2.3 to 8.9), stroke recurrence (OR = 3.3 (95% CI = 1.9 to 7.8)), and regular physician visits (OR = 2.1; 95% CI = 1.0 to 4.4) were significant predictors of good medication adherence. Considering the co-primary outcomes, compared to the control group, participants in the intervention group had a greater improvement in self-reported healthy diet intake (p = 0.003), intake of fruits (p = 0.005), and were physically more active (p = 0.001). At 6 months, mean fasting blood sugar (p = 0.005) and high-density lipoprotein cholesterol higher (p = 0.024) in the intervention group. CONCLUSIONS: The use of a mobile app is an effective method to improve medication adherence and risk-factor control in stroke survivors and is feasible in LMICs like India. DATA ACCESS STATEMENT: Data used during the study are available from the corresponding author on request. TRIAL REGISTRATION: The study is registered in Clinical Trial Registry of India (CTRI/2022/06/042980).

Development and effect of a coordinated Community Health Worker (CHW) Intervention (C-CHW-I) model for the stroke survivors in Kerala, South India.

INTRODUCTION: Structured models for secondary prevention of stroke in community settings are scarce. We aimed to develop and evaluate a model for improving medication adherence and enhanced risk factor monitoring. METHODS: We developed a multimodal C-CHW-I model for stroke survivors. Following training, all patients received a minimum of three CHW home visits, and once in 3-month telephone-call and health education for six months by CHWs. Seven blocks from 16 blocks of the study area were randomised to additionally receive an SMS alert for six months to reinforce CHW involvement. The primary outcomes were medication adherence and risk factor monitoring, and the secondary outcome was risk factor control. RESULTS: The mean age of the study population was 64+12 years, 765(85%) had ischaemic stroke. In the overall study cohort receiving the CHW intervention, mean medication adherence significantly improved from 3.56(0.88) at baseline to 3.78(0.61) at 6 months; p<0.001. Overall risk factor monitoring improved from 42.7% to 49.7%, and mean (standard deviation) systolic blood pressure (SBP) significantly reduced from 138(21) mmHg to 132(15) mmHg at 6-months; p<0.001. In patients additionally receiving SMS-based intervention, a statistically significant improvement in medication adherence was seen at 3 months (3.76+0.64 versus 3.61+0.81; p=0.008) however no difference persisted at 6 months. The proportion of smokers and alcohol users reduced in both groups with a trend to greater reduction in the intervention group (smokers:5.9% versus 2.8% (p=0.446) and alcohol users: 1.6% versus 1.4%(p=0.474)). At six months, the SBP did not differ (SBP (132.1(16.2) in the SMS group versus 133.2(15.8) mmHg in the control group, p=0.409). CONCLUSION: Our model improved medication adherence and risk factor monitoring of stroke survivors in community settings, and this can reduce stroke burden in the community.

Healthcare professionals' perspectives of the provision of, and challenges for, eating, drinking and psychological support post stroke: findings from semistructured interviews across India.

AIM: This qualitative study explores with health professionals the provision of, and challenges for, postdischarge stroke care, focussing on eating, drinking and psychological support across India. DESIGN: Qualitative semistructured interviews. SETTING: Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India. PARTICIPANTS: A purposive sample of healthcare professionals with current experience of working with patients who had a stroke. RESULTS: Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 intensive care unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers resulted in three main themes: integrated inpatient discharge care planning processes; postdischarge patient and caregiver role and challenges; patient and caregiver engagement post discharge. CONCLUSIONS: Discharge planning was integrated and customised, although resources were limited in some sites. Task shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing postdischarge care. Postdischarge care was mainly hospital based, supported by teleservices, especially for rural populations. Further research is needed to understand postdischarge care provision and the needs of stroke survivors and their caregivers.

The Prevalence of Mild Cognitive Impairment (Mci) among Older Population of Rural Kerala: A Cross-Sectional Study.

Background: There are only very few studies on estimating the prevalence of mild cognitive impairment (MCI) from India, particularly from a rural setting. The available studies were heterogeneous. Objective: The study estimated the prevalence of MCI in a rural setting in Kerala, India. Materials and Methods: We conducted a community-based, cross-sectional study among individuals aged 65 and above in rural Thiruvananthapuram, Kerala. A cluster-randomized sampling was adopted, the cluster being the wards in the village. It was a two-phase door-to-door survey. Grassroots-level health workers enrolled 366 elders in the selected four wards in the initial phase and collected information on the sociodemographic details, comorbidities, and other risk factors of the participants, using a semi-structured questionnaire. Additionally, the Everyday Abilities Scale for India (EASI) was administered to assess their activities of daily living. In the second phase, a neurologist and a psychologist examined those screened positive with EASI and diagnosed MCI and dementia based on the MCI Working Group of the European Consortium on Alzheimer's Disease and the DSM V criteria, respectively. Results: The prevalence of MCI and dementia was 18.6% (95% confidence interval [CI] 14.7%-23.4%) and 6.8% (4.46%-10.1%), respectively, among the study participants. The prevalence of MCI was higher among the unemployed and those above 70 years of age. Conclusion: The community prevalence of MCI is more than three times that of dementia among the elderly in rural Kerala.

Medication-Adherence and Management of Risk Factors for Secondary Prevention of Stroke Using Smartphone-Based Application: Protocol for MAMORs-Randomized Controlled Trial.

Background: In LMICs, the medication adherence and risk factor control are suboptimal in the post-stroke follow-up period. With shortage of physicians, smartphone-based interventions can help stroke survivors in secondary stroke prevention. Objectives: We aim to validate a digital innovative technology-based intervention to improve the awareness, medication adherence, control of risk factors through timely intervention of physician among the stroke survivors. Methods: MAMOR is a smartphone-based application to improve the stroke awareness by heath education materials, reminders to timely adherence of medication, alerts on control of risk factors, video files, and timely physician intervention. The study will involve development of the app using contextual research (Delphi qualitative method) followed by a randomized, single center, double arm-controlled trial with 1:1 assignment. The app will be evaluated over a period of 6 months with a target to enroll 192 participants. Process evaluation will be conducted. The sample size was calculated as 192, considering medication adherence of 43.8%, 20% increase in medication adherence by app, power of 80%, and 10% loss to follow-up. Results: The primary outcome will be medication adherence, changes in the lifestyle and behavioral and control of vascular risk factors. The secondary outcome will include vascular events and functional outcome. Conclusion: This study will be one among the few studies for secondary prevention of stroke through digital technology innovation in LMICs with resource constraints. The evidences generated from this study will provide translational evidence for other similar settings for stroke survivors.

The first state-level public health program for obstructive airway disease in India: An early field-level evaluation.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India; however, there are no programs for COPD in India at primary care level. Kerala became the first state in India to implement a program at primary care for COPD, called the Step Wise Approach to Airway Syndrome program. OBJECTIVE: The objective of the study was to evaluate and document the implementation status of a program for obstructive airway disease (OAD) in Trivandrum district of Kerala state in India and compare the treatment characteristics of patients with OAD seeking care from the centers implementing and not implementing this program for OADs. METHODS: A cross-sectional study was done as early evaluation of a program for OAD implemented in Kerala state, India, from October 2018 to February 2019. RESULTS: A reflection of the health-seeking behavior due to better facilities at the FHCs. There was no difference in the hospital visits or emergency department visits between the two groups. However, there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Forty-nine (94%) of the COPD and 36 (100%) of the asthma patients underwent spirometry from implementing center itself. A higher proportion of patients receiving care from implementing centers (30.9%) never had to buy inhalers from outside. CONCLUSION: This is the first time that a public health programme for chronic respiratory disease management at primary care level was evaluated in India. The study has provided valuable insights on the need for strengthening the training for health care providers as well as patient education in bringing about a change in patient attitudes.

Assessing health-seeking behavior among Asthma and COPD patients in urban South India.

CONTEXT: Health-seeking behavior of patients with chronic obstructive pulmonary disease (COPD) and asthma and the diagnosis told to them by doctors before they reach tertiary care is not well documented. AIMS: This study aimed at describing the health-seeking behavior of asthma and COPD patients before they present to a tertiary care hospital in Trivandrum in South India. METHODS AND MATERIALS: The hospital-based cross-sectional study was done at one government and one private tertiary care hospital in Trivandrum, Kerala, including diagnosed COPD and asthma patients. Data were collected using a pretested semistructured questionnaire paired with the results of clinical evaluation and spirometry. RESULTS: Among the studied population, about half (53%) of the patients in this study sought initial treatment from government facilities and most patients continued the same pattern of government care or private providers till the final level. Most of them (91%) were likely to have a history of first care from modern medicine system. High proportion of patients (89%) did not have a diagnosis known after the initial consultations, among patients with asthma only 3.4% were given a correct diagnosis and only one person was given a correct diagnosis of COPD out of 129 patients with COPD as the final diagnosis. Out of 739 patients, only 135 patients had done pulmonary functtion test as investigation. CONCLUSIONS: High proportions of patients do not know the diagnosis of their disease when they reached tertiary care. Patients tended to follow the same sector of health care (private/government) where they sought initial care.

Hypertension control status and quality of care for hypertension among patients availing treatment from private sector: A cross-sectional study in urban field practice area of JIPMER, Puducherry.

INTRODUCTION: In low-income countries like India, there is paucity of evidence regarding hypertension control status and the quality of care pertaining to hypertension care among the patients availing treatment from private sector. We wanted to determine the hypertension control status and quality of care pertaining to hypertension received by patients seeking care from private sector. MATERIALS AND METHODS: This was an community based analytical cross-sectional study carried out in an selected urban area of Puducherry. This study was conducted among 265 adults with hypertension, availing treatment from private sector. Blood pressure was measured according to standard protocol. Data were collected using pre-tested semi-structured questionnaire by doing home visits. RESULTS: The proportion of patients who were optimally controlled for hypertension were 43.9%. More than half (64%) of the participants had not checked their blood pressure in the last 1 year. There were 21.3%, 20%, 18.2%, and 9.5% of the participants who had optimally undergone fundus examination, blood sugar, serum cholesterol and serum creatinine examinations, respectively, as per recommended frequency. More than half (64%) of the study participants had not availed follow-up blood pressure monitoring in the last 1 year. The adherence to medication among the study participants was found to be 76.5%. CONCLUSION: Around 4 out of 10 patients had their blood pressure status controlled. More than half of the patients did not have any sort of follow-up investigations for the last 1 year. There was a scope for improvement in frequency of follow-up investigations as per recommendations.