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Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases.
We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients.
With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3.
The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0],
Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost.
Recurrent stroke accounts for approximately 30% of all stroke events and causes greater mortality, disability, and economic burden when compared with first-ever stroke [
Advances in mobile health (mHealth) have enabled remote monitoring and management that were otherwise confined to health centers. The advantages of mHealth technology include ubiquitous access, near real-time responsiveness, and comparatively lower cost when compared with conventional outpatient management [
Complete understanding and proper awareness of stroke are essential for stroke survivors, as stroke awareness is related to in-time treatment of stroke through a decrease in prehospital delay [
mHealth apps that aid in BP control and medication adherence have been reported to improve outcomes in patients with chronic diseases [
As mentioned above, we hypothesized that a multifaceted mHealth platform would improve stroke awareness, mood, and quality of life, as well as support risk factor control in poststroke patients. The aim of this study was to develop a multifunctional mHealth platform that could manage posthospital stroke patients integrated in clinical care and to investigate changes in stroke awareness, mood, and quality of life; adherence to app use; and satisfaction with the system after intervention among stroke patients. The study also endeavored to investigate the effects of mHealth app use on BP control and other physical measurements in stroke patients, as it has been suggested to be beneficial in patients with other chronic diseases.
Smart Aftercare takes a mobile-based holistic approach, and it includes wearable devices, a personalized poststroke management app, and a server-side website for patient monitoring by clinicians (
Schematic view of Smart Aftercare. MQTT: message queue for telemetry transport.
The mobile app supports stroke patients with various health management functions as follows: management and monitoring of medication, clinic visit schedule, stroke education program, self-testing of stroke symptoms, exercise program, and BP, blood glucose, and physical activity measurements (
Image showing the entry screen (left), blood pressure recording (middle), and educational content (right).
Management and monitoring of medication are essential functions of an mHealth app for chronic diseases. Adherence to antihypertensive medication was found to be dose-dependently associated with a low stroke risk in a previous study [
Awareness of stroke and self-testing of stroke symptoms are related to early arrival at the hospital, which is a critical factor for increasing the efficacy of thrombolysis therapy [
Several previous smartphone usage studies about the physical activity influence reported that physical activity increases (by 800-1104 steps/day) [
There have been several randomized controlled trials on the efficacy of mHealth technology to promote BP control for cardiovascular disease prevention [
The website for clinicians stores and displays the patient’s health record generated and sent from the app. Strict access control is in place for the secure database so that only authorized clinicians can view patient data. The site provides a summary of the health progress and status of each patient registered.
Summary of care plan completion on the patient management system.
After the development of an mHealth care system, a 12-week single-arm intervention was performed with eligible poststroke patients from Seoul Metropolitan Government-Seoul National University Boramae Medical Center. The inclusion criteria were as follows: (1) diagnosis of stroke (including ischemic and hemorrhagic stroke) supported by clinical symptoms and brain imaging; (2) age >19 years; (3) agreement to sign a written informed consent form; and (4) adequate ability to use a smartphone (either the patient or the guardian). Candidates who were fully dependent on caregivers owing to stroke sequelae were excluded from the study (modified Rankin Scale score of 4 or 5) [
The intervention comprised the following: (1) measurements of regular BP (twice a day [7 am and 9 pm]), blood glucose (as decided in the clinic), and physical activity (with the smart band); (2) stroke education program module; (3) exercise program module (exercise and stretching education); (4) medication management; and (5) feedback from the patient to the clinician with review of the health records registered in the system. This study was approved by the Institutional Review Board (IRB) at Seoul Metropolitan Government-Seoul National University Boramae Medical Center (IRB #16-2016-98).
The participants had three visits to the clinic (visit 1: baseline, visit 2: 4 weeks from baseline, and visit 3: 12 weeks from baseline) within a span of 12 weeks. At baseline (visit 1), eligibility for the study was determined according to previous medical history, medication history, neurological examination findings, and the modified Rankin scale score, and signed consent was obtained from each participant. Stroke awareness, depression scale scores, and health-related quality of life (HRQoL) were determined at each visit. Physical measurements, including height, weight, body mass index (BMI), waist circumference, and systolic and diastolic BP (SBP and DBP), were checked at each visit. System utilization was checked at the end of the intervention using saved app data. System satisfaction was assessed at visit 3 using a structured self-questionnaire.
Individual utilization of the programs was defined by the average amount of program access during the intervention, which was assessed using the logged data of the mobile app. System satisfaction was evaluated using a 5-point Likert scale, which was calculated from the participants’ responses on their level of agreement or disagreement after 12 weeks (1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; or 5, strongly agree) for overall system satisfaction and on satisfaction subscales (satisfaction of system information, wish to continue the program after the study, wish to introduce the app to others, interest in their health, and reliance on clinicians).
SBP, DBP, BMI, and waist circumference were measured at each visit. The participants were divided into the following two groups: one with SBP >140 mmHg or DBP >90 mmHg and the other with BP in the normal range at visit 1, and the differential effects of the system in patients with uncontrolled high BP and those with BP in the normal range were investigated.
Temporal differences in the stroke awareness, BDI, and EQ-5D scores over 12 weeks were investigated using repeated-measures analysis of variance. The effects of the system were compared between patients with initial BDI scores indicative of depression (BDI ≥14 points) and those without depression. Temporal changes in physical measurements, including SBP, DBP, BMI, weight, and waist circumference, were analyzed using repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from the day after visit 2 to visit 3) were analyzed using the paired
This study was approved by the IRB in September 2016, and it enrolled participants from September 2016 to December 2016. A total of 110 patients were enrolled for this study. Of the enrolled patients, one pulled out from the study at visit 1. Additionally, nine patients did not return to the clinic at visit 2 and one patient did not come for visit 3. Thus, 99 patients were included in our analysis (
Study flow chart.
The mean access numbers of the mobile app during the follow-up period were 100.9 for medication intake, 24.0 for the exercise program, 90.6 for BP measurement, and 29.1 for stroke education content. In the 5-point system satisfaction survey, the mean overall satisfaction score and satisfaction score for system information were 3.74/5 and 3.81/5, respectively, which indicated a positive result for satisfaction. Participants wished to continue the program after the study (3.98/5) and were willing to introduce the app to others (4.06/5). Increments in the level of interest in their health (4.02/5) and reliance on clinicians (4.08/5) were observed.
The stroke awareness score of the participants showed a gradual improvement in the aptitude of using the program by 7.98% in 4 weeks (
Trends in the stroke awareness score and its four components using the smartphone-based management system.
Furthermore, the BDI scores decreased at visit 2 (−1.57,
Trends of the Beck Depression Inventory-II (BDI) score in patients who were depressed and not depressed (left) and of the EuroQol-5 Dimensions (EQ-5D) score (right).
Among the 99 patients, 26 had SB
Different trends of systolic blood pressure (SBP) (left) and diastolic blood pressure (DBP) (right) reductions in patients with uncontrolled and normal blood pressure.
In this study, we demonstrated that the mobile health care system Smart Aftercare improved the level of stroke awareness and lowered the depression score among poststroke patients in sequential evaluations that were performed for 12 weeks, when compared with the findings at the start of the study. A multifaceted mHealth system that offered stroke education, medication and exercise management, BP management, blood glucose management, physical activity measurements, and clinician feedback according to patient data provided a high level of system satisfaction to patients and improved the levels of interest in their health and reliance on clinicians. Hypertensive patients at baseline benefitted from the system, with lowered SBP and DBP during the intervention without a change in antihypertensive medication. An improvement in medication compliance was found in accordance with this change.
The findings of this study suggest that mobile health care could enhance stroke awareness in stroke patients. Previous studies using mHealth technology aimed to facilitate BP control and compliance with medication for stroke [
The alleviated depression in stroke survivors using mHealth technology has practical importance in improving the well-being of poststroke patients. One-third of stroke survivors experience depression, and this has a negative effect on functional stroke outcomes, thus limiting participation in rehabilitation activities and impeding social function and adjustment [
This study showed the system’s efficacy in controlling BP, a critical element in the prevention of secondary stroke. Self-measurement of BP has been proven to lower BP when compared with traditional center-based care in hypertensive patients [
This study has several limitations. It was conducted in a single center and was a single-arm study. Owing to the nature of mHealth technology, patients with severe disability or without a smartphone were not included in this study. Furthermore, the effectiveness of the intervention was somewhat attenuated because the participants were treated under the current medical care in the clinic before the study, and therefore, the vital signs and anthropometric measurements, including BP and BMI, of most of the participants were already within the normal ranges at baseline.
Use of Smart Aftercare, which enhances the level of awareness of stroke and depression, could spur a major shift in the planning of poststroke care after hospitalization. mHealth technology with multifaceted programs and responsive capacities might enable feasible, immediate, and efficient poststroke home care and might consequently contribute to cost-effective secondary stroke prevention.
Screenshots of the intervention.
Clinical assessment of outcomes in this study.
Questionnaire of the stroke awareness score in English.
Demographic characteristics and clinical information of the study participants.
Changes in the total stroke awareness score and the scores of each part using the smartphone-based management system.
Changes in the Beck Depression Inventory-II (BDI) scores among patients who were depressed and not depressed and in the EuroQol-5 Dimensions (EQ-5D) scores.
Changes in blood pressure, body mass index, and waist circumference.
Beck Depression Inventory-II
body mass index
blood pressure
diastolic blood pressure
EuroQol-5 Dimensions
health-related quality of life
Institutional Review Board
systolic blood pressure
This work was supported by the National Information Society Agency funded by the Ministry of Science and Information and Communication Technologies (Grant number: 2016-0-00586) and the Technology Development Program (S2464261, Development of Intelligent Care-Planning Technology for Interactive Concierge Services) funded by the Ministry of Small and Medium-sized Enterprises and Startups (MSS, Korea).
None declared.