Caregiver-Delivered Stroke Rehabilitation in Rural China

Abstract

Background and Purpose— Stroke disability is a major health burden in rural China where rehabilitation services are inadequate. We aimed to determine the effectiveness of a novel nurse-led, caregiver-delivered model of stroke rehabilitation in rural China. Methods— A multicenter prospective, randomized open, blinded outcome assessed, controlled trial was conducted in 3 rural county hospitals in China: Zhangwu, Liaoning Province (Northeast); Qingtongxia, Ningxia Hui Autonomous Region (Northwest); and Dianjiang, Chongqing Municipality (Southwest). Adult patients (age 18–79 years) with residual disability (Barthel Index score ≤80/100) after a recent acute stroke were randomized to a new service model or usual care. The new intervention was multifaceted and was based on a task-shifting / training-the-trainers model, supported by a custom-designed smartphone application, where patients and caregivers received evidence-based in-hospital education and stroke rehabilitation training (focus on mobility, self-care, and toileting), delivered by trained nurses before hospital discharge, and 3 postdischarge support telephone calls. Outcome assessments were undertaken before hospital discharge and at 3 and 6 months. Primary outcome was physical functioning (Barthel Index scores) at 6 months, assessed by research staff blind to treatment allocation, adjusted for baseline covariates in an intention-to-treat analysis. Secondary outcomes included measures of mobility, health-related quality of life, mood, and caregiver burden. The study included a process evaluation that assessed intervention fidelity. Results— From November 2014 to December 2016, 246 stroke patients were randomized to intervention (n=118) or control (n=128) groups. There was no statistically significant difference in adjusted 6-month Barthel Index scores between groups (70.1 versus 74.1, mean difference, −4.0 [95% CI, −10.0 to 2.9]), nor any differences across the other outcome measures. Process evaluation interviews revealed that the intervention was desirable and positively accepted by nurses, caregivers, and patients but was considered too complex despite efforts to simplify materials for the rural context. Key strategies identified for future studies included the use of community health workers, smartphone application enhancement, and simpler and more frequent training for nurses, caregivers, and patients. Conclusions— A novel nurse-led, digital supported, caregiver-delivered stroke rehabilitation program did not improve patient physical functioning after stroke in rural China. Further stroke rehabilitation research suitable for resource-poor settings is required, with several components being suggested through stakeholder interviews in our study. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02247921.

Moving Stroke Rehabilitation Research Evidence into Clinical Practice: Consensus-Based Core Recommendations From the Stroke Recovery and Rehabilitation Roundtable

“…While a Cochrane Review suggested some benefits of caregivers in assisting with stroke patient exercises, 20 some caution should be exerted in light of the lack of effects from the recent ATTEND trial 21 (n=1,250) and the RECOVER trial 22 (n=246) which used family caregivers in India and China, respectively, to augment the delivery of stroke rehabilitation (e.g., mobility, self-care).…”

Physical Rehabilitation Needs in the BRICS Nations from 1990 to 2017: Cross-National Analyses Using Data from the Global Burden of Disease Study

“…Moreover, the meeting the rehabilitation needs of older adults in the rural, underserved regions of China can be particularly challenging as rehabilitation services typically are distant and/or scant and family support is increasingly absent (e.g., much of the working-age population has moved to urban, industrialized areas) [24]. Caregiver-delivered, digital-supported, and nurse-led interventions have been trialed to close the rehabilitation service gap in rural China, but more work is needed to achieve optimal results [54]. These will be important needs and gaps for China to address through future research and policy development [24,51,54,55].…”

“…Caregiver-delivered, digital-supported, and nurse-led interventions have been trialed to close the rehabilitation service gap in rural China, but more work is needed to achieve optimal results [54]. These will be important needs and gaps for China to address through future research and policy development [24,51,54,55].…”

Understanding the Methodological Issues and Solutions in the Research Design of Stroke Caregiving Technology

“…Health technologies in stroke caregiving consist of different means to promote interaction using web (11-13), Information and Communication Technology (ICT) (14,15), mHealth (16)(17)(18)(19)(20)(21)(22)(23)(24), and telehealth systems (22). Web-based systems are those that are delivered through a browser on different devices such as computer, television, or mobile, with the requirement for access to the internet to use the service (11)(12)(13).…”

“…Web-based systems are those that are delivered through a browser on different devices such as computer, television, or mobile, with the requirement for access to the internet to use the service (11)(12)(13). ICT systems rely on a communication technology to connect numerous different devices (14,15), mHealth relies on mobile devices (16)(17)(18)(19)(20)(21)(22)(23)(24), and telehealth relies on telecommunication devices such as telephone to promote interaction and support (22). The intention of these systems is to promote healthcare delivery and exchange over a wider geographic distance, thereby ensuring more effective and efficient care to the person living with stroke (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24).…”