ORIGINAL ARTICLE Care for Stroke , a web-based, feasibility ......ORIGINAL ARTICLE ‘Care for Stroke’, a web-based, smartphone-enabled educational intervention for management of

ORIGINAL ARTICLE

‘Care for Stroke’, a web-based,smartphone-enabled educationalintervention for management ofphysical disabilities following stroke:feasibility in the Indian context

K Sureshkumar,1 G V S Murthy,1 Suresh Munuswamy,2 Shifalika Goenka,3

Hannah Kuper1

1International Centre forEvidence in Disability, LondonSchool of Hygiene and TropicalMedicine, London, UK2Institute of PublicHealth-Hyderabad,Hyderabad, Telangana, India3Institute of Public Health-Delhi,Gurgaon, Haryana, India

Correspondence toSureshkumar Kamalakannan,International Centre for Evidencein Disability (ICED), LondonSchool of Hygiene and TropicalMedicine, Keppel Street,London, WC1E 7HT, UK;[email protected]

Received 10 April 2015Accepted 16 May 2015

To cite: Sureshkumar K,Murthy GVS, Munuswamy S,et al. BMJ Innov 2015;1:127–136.

ABSTRACTIntroduction Stroke rehabilitation is a processtargeted towards restoration or maintenance ofthe physical, mental, intellectual and socialabilities of an individual affected by stroke.Unlike high-income countries, the resources forstroke rehabilitation are very limited in many low-income and middle-income countries (LMICs).Provision of cost-effective, post-strokemultidisciplinary rehabilitation services for thestroke survivors therefore becomes crucial toaddress the unmet needs and growingmagnitude of disability experienced by the strokesurvivors in LMICs. In order to meet the growingneed for post-stroke rehabilitation services inIndia, we developed a web-based Smartphone-enabled educational intervention formanagement of physical disabilities following astroke.Methods On the basis of the findings from therehabilitation needs assessment study, guidancefrom the expert group and available evidencefrom systematic reviews, the framework of theintervention content was designed. Web-basedapplication designing and development byProfessional application developers weresubsequently undertaken.Results The application is called ‘Care forStroke’. It is a web-based educationalintervention for management of physicaldisabilities following a stroke. This intervention isdeveloped for use by the Stroke survivors whohave any kind of rehabilitation needs toindependently participate in his/her family andsocial roles.Discussion ‘Care for stroke’ is an innovativeintervention which could be tested not just for its

feasibility and acceptability but also for its clinicaland cost-effectiveness through rigorouslydesigned, randomised clinical trials. It is veryimportant to test this intervention in LMICswhere the rehabilitation and information needsof the stroke survivors seem to be substantialand largely unmet.

BACKGROUNDStroke rehabilitation is a process targetedtowards restoration or maintenance ofthe physical, mental, intellectual andsocial abilities of an individual affectedby stroke.1 Stroke rehabilitation enablesthe stroke survivor to perform his/herdaily activities at an optimal functionallevel and helps the stroke survivor to par-ticipate in his/her social roles as inde-pendently as possible.2 The strokesurvivor relearns the skills that are lost orimpaired due to brain damage followingstroke through rehabilitation.3

An insult to the human brain due tostroke might have various effects on thestroke survivor, and hence healthcareprofessionals from various disciplineshave to provide the stroke survivor witha patient-centred, comprehensive, multi-disciplinary rehabilitation.4 Unlike high-income countries (HICs), the resourcesfor rehabilitation, especially the rehabili-tation workforce and infrastructure,are very limited in many low andmiddle-income countries (LMICs).5 If wetake India as an example, rehabilitationservices are often unidisciplinary, drivenpredominantly by physiotherapists, with

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lack of support from occupational therapists, speechtherapists and so on. Many government-run districtrehabilitation centres are non-functional and theprivate hospitals are staffed with only a physiotherap-ist in their rehabilitation centres.6 Given the scarceresources, the rehabilitation needs of the stroke survi-vors, especially in the LMICs, remain largely unmet.7

Provision of cost-effective, post-stroke multidisciplin-ary rehabilitation services for the stroke survivorstherefore becomes crucial to address the unmet needsand growing magnitude of disability experienced bythe stroke survivors in LMICs.The past few years have seen a tremendous increase

in the use of Smartphones by health professionals andalso by the general public.8 Evidence from a recentsystematic review suggests that Smartphones could bean extremely useful tool to educate patients tomanage their health problems.9 Another systematicreview on the use of Smartphone applications forstroke rehabilitation also demonstrates the advantagesof Smartphone applications for provision ofstroke-related information.10 These Smartphone appli-cations are regarded as important by health profes-sionals providing stroke rehabilitation themselves.10

In order to meet the growing need for post-strokerehabilitation services in India, we developed a web-based Smartphone-enabled educational interventionfor management of physical disabilities followingstroke. This paper provides a detailed description ofthe intervention and the processes involved in itsdevelopment. The paper also discusses the importanceof such rehabilitation interventions for meeting theunmet needs of the stroke survivors.

DEVELOPMENT OF THE CONTENT FOR THEINTERVENTIONSystematic review of the available interventionsEvidence from systematic reviews in relation to strokerehabilitation and information provision for strokesurvivors and caregivers was extensively used todevelop the intervention. We also conducted a com-prehensive and a global systematic review on educa-tional interventions for reducing disabilities inacquired brain injury to investigate the evidence thatwas available to develop this intervention.

Rehabilitation needs assessment studyThe content of the intervention was developedprimarily based on the needs expressed by the strokesurvivors and caregivers who participated in a rehabili-tation needs assessment study carried out exclusively todevelop this intervention. The rehabilitation needsassessment study was carried out to guide the develop-ment of a need-based rehabilitation intervention andhad two components in it. One was a structured surveywith 50 stroke survivors and their caregivers to identifythe various kinds of rehabilitation needs that theyexperience. The other was a detailed in-depth

interview with a subsample of the stroke survivors andcaregivers selected for the survey. The purpose of thein-depth interviews was to gain a detailed understand-ing of the experiences of the stroke survivors in rela-tion to accessing stroke rehabilitation services and theirrehabilitation needs following a stroke. In-depthinterviews with health professionals involved in theprovision of stroke rehabilitation services were alsocarried out to understand the perspective of thehealth professionals about provision of strokerehabilitation services, their knowledge about theexisting Smartphone-based health interventions andtheir attitudes and opinions about the use of aSmartphone-enabled, care-supported education pro-gramme for domiciliary stroke rehabilitation.

Expert group for content developmentIn addition to the needs assessment, expert guidancewas obtained from a team of eight highly qualifiedand experienced health professionals from variousneurorehabilitation disciplines (physical medicine andrehabilitation, neuropsychiatry, clinical psychology,occupational therapy, physiotherapy, social sciences,information technology, public health and m-health)with both national and global expertise in the field ofneuropsychiatric rehabilitation. The expert team alsoincluded three stroke survivors and their primary care-givers. All the team members were from Tamil Naduand they were Tamil-speaking. The key characteristicsof the expert group, such as their experience, expert-ise, global exposure and language, facilitated thedevelopment of a culturally specific, patient-centredintervention for management of physical disabilitiesfollowing a stroke.

Framework of the intervention contentOn the basis of the findings from the rehabilitationneeds assessment study, guidance from the expertgroup, and available evidence from systematic reviews,the framework of the intervention content wasdesigned. The content framework included fiveimportant sections related to post-stroke rehabilita-tion. The sections were:1. Information about stroke (know more about stroke)2. Exercises (home-based exercises)3. Functional skills training (preparing oneself for daily

living)4. Activities of daily living (engaging in activities of daily

living)5. Assistive devices (devices to assist daily living).

CONTENT OF THE INTERVENTION SECTIONSKnow more about strokeAs the section title suggests, this section enables thestroke survivors and caregivers to know more aboutstroke, the impact of stroke on an individual experien-cing it and advice from experts on the way forward(life after a stroke). The important subsections/topics


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and videos that this section includes are provided intable 1.The primary objective of having this section is to

create awareness and enable the stroke survivors andtheir caregivers to gain more knowledge about stroke,because this would assist them in preventing recurrentstroke, modifying their lifestyle, making treatmentdecisions and planning for life after a stroke.

Home-based exercisesThis section includes home-based, task-oriented exer-cises that the stroke survivors can practise in theirhome in order to maintain or improve their bodyfitness for functional activities. These exercises arebased on eclectic treatment approaches to strokerehabilitation (motor relearning, functional, neurode-velopmental frame of references for therapy) thatenable the stroke survivors to use their affected partsof the body and engage in functional activities.These home-based exercises include the use of

equipment like a chair or bed and table that are com-monly available in most homes in India. They do notrequire the purchase of any sophisticated exerciseequipment. Principles of safety and risk/hazard pre-vention have been thoroughly considered while

developing this section. Some of the important sub-sections/topics and videos that this section comprisesare listed in table 2.The objective of developing this section content is

to enable the stroke survivors to understand the rele-vance of the conscious use of the affected parts of thebody following a stroke and also the importance ofexercises for engaging in functional activities rather

Table 1 Content of ‘know more about stroke’ section

Content of the intervention

Main sections Subsections Videos

Information about stroke ▸ What is a stroke?▸ What is a transient ischaemic attack (TIA)?▸ How does a stroke happen?▸ Warning signs of a stroke▸ What are the common symptoms of a stroke?▸ How does a stroke affect your body?▸ Risk factors for a stroke▸ Common effects of a stroke▸ Recovering from a stroke

▸ What is a stroke?▸ How does a stroke happen?▸ What is a transient ischaemic attack▸ Symptoms of a stroke▸ Effects of a stroke▸ Modifiable and non-modifiable risk factors for a stroke▸ Effects of a stroke on– Balance– Bowel and Bladder– Thinking– Pain– Physical problems– Sleep and fatigue– Sensation– Sleep and fatigue– Speech and language– Swallowing

▸ Recovery from a stroke by– Public health experts– a neuropsychiatrist– a neurologist– a physiotherapist– an occupational therapist– a clinical psychologist– a disability rights expert

Table 2 Content of ‘Exercises’ section


Mainsections Subsections Videos

Exercises ▸ Upper limbexercises

▸ Lower limbexercises

▸ Balance exercises▸ Active exercises▸ Exercises to

improve upper limbfunction

▸ Passive upper limb exercises▸ Passive lower limb exercises▸ Active-assisted exercises for

the lower limb▸ Active exercises for the

upper limb▸ Exercises for the trunk▸ Exercises for balance▸ Improving awareness and

function of the affectedhand



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than just exercising and improving the flexibility,strength and movement of the affected body part.

Preparing oneself for everyday livingFunctional skills are a prerequisite to participate ineveryday living. One should know how to get upfrom a lying down position. In order to sit properlyand feed or groom, one should know how to transferfrom a bed to a chair or a commode for bathing ortoileting. These are very important to the stroke sur-vivor who cannot or finds it difficult to move theaffected part of his/her body. This section highlightsfunctionally oriented tasks that the stroke survivorscan learn in order to participate in their day-to-dayactivities.Exercise training provided by a physiotherapist to

the stroke survivors is directly related to the develop-ment of functional skills of the individual affected bystroke. Hence, this section stresses the importance offunctional skills to participate in everyday living andpreparing oneself for everyday living by acquiring func-tional skills. Some of the important subsections/topicsand videos of this section are depicted in table 3.

Engaging in activities of daily livingThis section comprises adaptive methods and techni-ques to engage in activities of daily living like groom-ing, bathing, dressing and eating. The stroke survivors

can watch, learn and practise these adaptive techni-ques to independently perform their activities ofeveryday living. The content of this section is depictedin table 4.This section is very important from the viewpoint

of both the stroke survivors and their caregivers. Thisis because learning to purposefully engage in one’sown everyday living seems to be an important needand crucial task for the stroke survivors to independ-ently participate in his/her personal, family and soci-etal roles. Although the stroke survivors learn to doexercises and acquire knowledge to manage their pro-blems post-stroke, the overall objective behind theacquisition of these skills and knowledge is to live afunctionally independent life and perform theirvarious roles at home and society actively (table 5).

Devices to assist daily livingThis is a unique section that enables the stroke survi-vors and their caregivers to understand the import-ance of using assistive devices that are readily availablein India and that can assist the stroke survivor toengage in their day-to-day activities independentlyand also with confidence. This section also includesdevices that are tailor-made to the needs of the strokesurvivors living in the southern part of India like anadapted saree, Velcro-based blouse, adapted dhoti andlungi, etc. This section also has devices that are notavailable in India but can be designed and fabricated

Table 3 Content of ‘Exercises’ section



Functionalskills training

▸ Positioning the strokesurvivor in bed and ina chair

▸ Bed mobility▸ Transfers▸ Standing up from a

sitting▸ Mobility/ambulation

training

▸ Positioning on– the Chair –– the Bed –affected

side– the Bed –

unaffected side– the Bed—Lying on

the back▸ Bed Mobility– Rolling on the bed– Scooting on the

bed– Coming up to a

sitting▸ Sit to Stand

(moderate support)Transfers

– Independenttransfers (bed tochair/wheelchair)

– Transfers withmaximum support

▸ Walking

Table 4 Content of ‘Activities of daily living’ section


Main sections Subsections Videos

Activities of daily living ▸ Brushing▸ Feeding▸ Bathing▸ Grooming▸ Dressing

▸ Brushing▸ Feeding▸ Bathing▸ Grooming▸ Washing face▸ Wearing a T-shirt▸ Wearing a Shirt▸ Wearing a dhoti/lungi▸ Wearing a pant▸ Wearing a saree▸ Wearing a blouse▸ Undressing

Table 5 Content of ‘Devices to assist daily living’ section



Assistivedevices

▸ Personal care aids▸ Mobility aids▸ Orthoses and supports

▸ Personal care aids▸ Mobility aids▸ Orthoses and supports



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by the stroke survivors themselves and their care-givers, for example, the universal cuff that can assistthe stroke survivor to use their affected hand forfeeding, brushing, writing and grooming. The keytopics covered under this section is provided intable 5.The primary objective of this section is to inform

the stroke survivors of the importance of assistivedevices that can be used to perform everyday activitiesindependently and safely. Assistive devices can boostthe confidence of the stroke survivor to engage intheir everyday tasks. It also reduces the assistance andsupport provided by the caregivers, thereby reducingthe physical strain in providing care and support forthe stroke survivor in their daily living tasks.

DESCRIPTION OF THE INTERVENTIONNaming the applicationThis application was intended to educate the strokesurvivors and their caregivers to manage their physicaldisabilities following stroke. Therefore, the web-basedapplication was named ‘Care for Stroke’ to emphasisethe importance of enhancing the life of individualsexperiencing stroke and continuum of care that isessential for a stroke survivor.

Logo and tagline of the applicationThe logo of the application was created by the princi-pal investigator himself under the supervision ofexperts from the field of disability, rehabilitation anddesign (figure 1). The logo depicts a stroke survivoraccepting support from another person in a homeenvironment and trying to mobilise himself/herself.The design of the logo stresses the importance of thestroke survivor accepting support from anotherperson and actively engaging in functional activitieswhile staying at home.The tagline of the application is ‘Think Smart—

Take Control’. This tagline emphasises the importanceof proactive, innovative and smart planning fortherapy and rehabilitation services that the stroke sur-vivor and their caregivers should execute, outside thehospital environment. It also encourages the strokesurvivors to take control of their problems followingstroke and work towards an independent life after astroke.

Design of the web-based applicationThis intervention is designed as a web-based applica-tion that uses a website as an interface (the front end).The introductory web page of the application isshown in figure 2 Users can access the application notjust from Smartphones but also from a computer,PDA, Tablet and even digital television that is con-nected to the internet using any standard webbrowser. Some of the key design features of this appli-cation are: User interface, content format, language.

User interfaceAn interface enables a user to interact with a system(Smartphone in this instance) to perform a task. Forexample: Navigating to different web pages in thiswebsite enables a user to find the video content thathe/she prefers to watch. The users can watch thevideos by navigating through user-friendly interfacessuch as the touch and slide option which requires theusers to either touch or slide the icons (ie, picturesand symbols) and pages in the application to watchthe videos they want.

Content formatThis application is exclusively designed to supportdigitised audio–visual content. More than 75% of thecontent of this application is in the form of videos.The users can interact with the images related to themain sections and watch the videos about stroke andthe management of physical disability post-stroke

Figure 1 Logo of the application. Figure 2 Introductory page of the ‘care for stroke’ application.



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through this application. There is very minimalrequirement for the users to read written informationin this application.

LanguageThis application is built with multilingual functional-ity and it currently supports English and Tamil, thenative language of the State of Tamil Nadu in Indiawhere it was piloted.

Technical description of the applicationThe application is built using a LAMP (Linux,Appache, MySQL, PHP) environment. The user inter-face of the application was designed using HTML5,CSS3, Bootstrap, Java Script, JQuery, Ajax, Googlefont API and Touch Swipe. It is to ensure that theuser interface acts as a responsive and interactivedesign. Designing the application with these technolo-gies supports the application to be installed and runon multiple devices like desktop, laptop, IPhone,IPad, Android devices andWindows devices.The back end of the application was built in PHP5

(PHP—Hypertext Processor) language. This is tofacilitate the user to interact with the database(MySQL) and view the requested information withoutany difficulty. Given the issues with video streamingin a country like India (ie, very slow internet connect-ivity and streaming), this application uses Cloud FlareCDN (Content Delivery Network) that enhances thequality and speed of the video streaming while theuser is accessing the videos from the application.This application also has an administrator module,

where the administrator can monitor all the activitiesof the users who have logged into the application. Itcan also generate different types of reports of the userinteraction with the application. Some of the keyinformation that could be monitored are:▸ The title of the sections and videos viewed,▸ Duration of the logged in session▸ Date and time of viewing▸ Number of sections and videos watched during a logged

in session.▸ Device used for logging in▸ Time spent on application,▸ Geo-location information.

STRUCTURE AND FUNCTIONALITY OF THEAPPLICATIONRegistered websiteThis web-based application can be accessed from theregistered website name http://www.careforstroke.com

Home pageThe application has a home page that briefly describesstroke and stroke-related disability in the vernacular(Tamil). First-time users cannot access the interventionwithout registering themselves. This is to ensure pro-active engagement of the users, observe their

utilisation pattern and to generate utilisation reportsfor future evaluations. The home page providesdetails of registration with an icon to register the first-time users. Users who have already registered toaccess the intervention can use the same icon to accessthe sign-in page (figure 2). There is a drop-down iconin the home page to change the language of the appli-cation if required. Currently, the application pageshave the descriptions in English and Tamil.

Sign-in page and registrationThis page contains an icon for first-time users to regis-ter and the sign in boxes with user name and pass-word sections to be filled by the user to sign into theapplication.

Registration pageThis page contains a drop-down box, where the usercan identify and register themselves as a stroke sur-vivor or caregiver of the stroke survivor. This helpsthe investigator or administrator to monitor theengagement and usage of the application by the strokesurvivors and caregivers separately. On the basis of theoptions chosen, the user will be redirected to the spe-cific registration page with drop-down options andtext boxes to fill in the user details requested andregister onto the application. After completing theregistration, users will be redirected back to thesign-in page. Registration requires the users to have ausername and password to ensure identity and privacy(figure 3).

Intervention pageAfter the user signs into the application successfully,the application is redirected to the main interventionpage. This page contains brief written informationabout the intervention and five important sectionsthat contain the content of the ‘care for stroke’ inter-vention (figure 4).Sections: There are five main sections displayed as

photographic icons on the intervention page whichcan be touched and explored further (figure 4). Thesefive sections contain digitised information (videos)about stroke and the various aspects that a stroke sur-vivor can view and understand about the managementof the physical disabilities following a stroke (figure 5).Subsections: When the user touches an icon on the

section page, it is redirected to the corresponding sub-section page that comprises topics (subsections) thatthe respective section contains. For example, the mainintervention page will contain a photograph of thestroke survivor performing his Activities of DailyLiving—ADL (intervention page); if the user touchesthis icon, it will take him or her to the ADL section(figure 5). If the user touches this ADL section icon,the web page will be redirected to the ADL subsectionpage that contains topics with video icons (images)related to ADL, in this instance, stroke survivors



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performing brushing, feeding, dressing, etc. Pleasefind the section web page in figure 6.Content digitised videos: When the user touches a

topic in the subsection, the web page will be redir-ected to a page that contains detailed informationabout that topic in the form of 3–5 min video clips.For example, if the user touches the topic ‘Wearing ablouse’, the web page will be redirected to a video cliprelated to that topic. These videos are streamed onlinethrough internet or mobile internet networks and canbe watched by touching the play button on the videoclip. Please find the video section of the application infigure 7 below.

Shuffling between the web pagesUsers can shuffle between the pages by either1. Pressing the back button on the Smartphone2. Pressing the back icon on the web page3. Sliding the web pages back and forth using the touch

screen option on the Smartphone.In addition to this, the user can return to the main

intervention page at any time by touching the logowhich is located on top of every web page of theapplication.

Administrator moduleThis Smartphone-enabled intervention is built with anadministrator module, where the usage and utilisation

Figure 4 Intervention page.

Figure 3 Registration page.

Figure 5 Section page.



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patterns of this application by the users can be trackedcontinuously and reports can be generated to informthe feasibility of this intervention and also to monitorthe progress of any programmes/research projectsrelated to this intervention when scaled up to a largercommunity of stroke survivors. The administrator canalso add videos onto (or remove videos from) theapplication as and when required, thereby customisingor improvising the content of the intervention accord-ing to the needs of the users. The module is protectedand strictly secured through a username and passwordto ensure privacy and confidentiality of the userinformation.

DISCUSSIONStroke is one of the leading causes of death and dis-ability worldwide.11 Globally, nearly six millionpeople die from stroke each year, and much of this

stroke burden is borne by LMICs.12 Though theprimary focus of many LMICs, including India, is toprevent stroke by reducing the prevalence of its riskfactors, similar attention should also be given to thosewho survive a stroke and are disabled post-stroke.13 14

Unlike HICs, organised multidisciplinary rehabilita-tion services for stroke survivors are not available inmany LMICs.15–17 Given the context of many LMICswith a scarce rehabilitation workforce and resourcesfor rehabilitation, it is critically important to developinnovative post-stroke rehabilitation interventions thatcould address the growing magnitude of post-strokedisability and meet the rising need for rehabilitationservices in these countries.The international telecommunication union esti-

mated that six billion people were mobile phone usersduring 2011 globally, which is equivalent to 87% ofthe world’s population. This report has also documen-ted that India is one of the top markets forSmartphone sales globally.18 The management ofchronic diseases using Smartphone technology hasbeen described in a recent systematic review.19 Thisreview identified 15 Smartphone applications formanagement of chronic conditions. Out of these 15applications, there was only one application calledMayo clinic meditation that was similar to the‘Careforstroke’ application. The Mayo clinic applica-tion helped patients practise meditation through a15 min training video on meditation.Some of the Smartphone applications used in stroke

rehabilitation in HICs include the Dr Droid applica-tion that helps therapists to administer and trackupper limb exercises for stroke rehabilitation,20 theThink-FAST application that features stroke preven-tion information and a list of stroke unit locations inAustralia21 and PTX, a physiotherapy exercise applica-tion for individuals with any kind of neurological con-ditions that includes a pictorial description of theexercises for stroke survivors.22 The National Instituteof Clinical Excellence (NICE) guidelines for long-termstroke rehabilitation also recommend the use ofSmartphones for communication problems in patientswith stroke.23

A chronic condition like stroke requires uninter-rupted therapeutic care and constant monitoringduring the entire continuum of recovery.24 In theabsence of any organised stroke care services and withthe limited resources for rehabilitation, aSmartphone-enabled educational intervention formanagement of disabilities could be a strategy to meetthe substantial rehabilitation needs of stroke survivorsin India. The evidence concerning the use ofSmartphones in chronic disease care in India is justemerging and the use of Smartphones in health inter-ventions to combat diseases like diabetes, hyperten-sion and cardiovascular diseases is progressively beinginvestigated.25 Adoption of this strategy could possiblyreduce the barriers to access and availability of strokeFigure 7 Video section of the application.

Figure 6 Subsection page.



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rehabilitation services. It could also aid in efficientand sustained monitoring of patient progress through-out the continuum of care.‘Care for stroke’ is a Smartphone-enabled educa-

tional intervention for management of physical dis-abilities following a stroke. The content of theintervention was developed systematically and primar-ily based on the needs of the stroke survivors andinformed by existing global evidence. It includesinputs from highly qualified and experienced multidis-ciplinary stroke rehabilitation professionals in a digi-tised audio–visual format that is more entertaining towatch and learn compared to the other methods ofpatient education such as an educational workbookand group teaching or lectures.This intervention is culture-specific and language–

specific, and therefore the users can easily understandand adapt the techniques to manage their post-stroke-related disabilities. Since the intervention is loaded ontoa Smartphone, the user can access the intervention asand when they need. Unlike television and DVDplayers, Smartphones are portable and handheld andhence it might aid the user to access the interventionconveniently (without having to plug wires, operate aremote to watch videos or depend on electricity).This Smartphone-based, technology-driven inter-

vention can be less demanding in terms of the physicalabilities required by the users to learn, when com-pared with other kinds of educational interventionslike attending group sessions, using a stroke workbookor watching a DVD educational material about stroke.The application for accessing the intervention is web-based, and hence the users can also access the contentthrough their laptops, desktops and tablets if required.From the point of view of programme managers and

evaluators, this kind of web-based educational interven-tion can continuously monitor the usage and utilisationpattern of the intervention by each user, and it can behelpful to generate reports to monitor the efficiencyand effectiveness of this intervention while scaling up,without having to contact the users. Since the interven-tion is Smartphone-enabled and web-based, the usercan contact the service provider directly by dialling thecontact numbers on the Smartphone or by making askype call using the mobile internet services.This Smartphone-enabled intervention might also

motivate the caregivers and family members to com-prehend the importance of stroke rehabilitation andsupport the stroke survivors in utilising the keyaspects of the intervention in their everyday life. Froma financial perspective, the cost of using thisSmartphone-enabled intervention might be less costlycompared to the other ways of accessing informationabout stroke and the ways to manage post-stroke phys-ical disability from rehabilitation experts or hospitals.The ‘Care for stroke’ application is currently under

pilot testing for its feasibility and acceptability with asmall group of stroke survivors and their caregivers

in Chennai, India. If this application is found feasibleand acceptable, the investigators intend to look atthe clinical and cost-effectiveness of this interven-tion. To date and to the best of our knowledge, therehas not been a web-based, Smartphone-enabled edu-cational application and intervention for stroke survi-vors with a primary focus on the rehabilitationaspect of the stroke. In a global context and from apublic health perspective, ‘Care for stroke’ is onesuch kind of innovative intervention which could betested not just for its feasibility and acceptability butalso for its clinical and cost-effectiveness throughrigorously designed, randomised clinical trials. It isvery important to test this intervention in LMICswhere the rehabilitation and information needs ofthe stroke survivors seem to be substantial andlargely unmet.

Acknowledgements The authors thank the student forundertaking the research study as a part of his doctoral study atthe London School of Hygiene and Tropical Medicine. Theauthors thank the ethics committee of the London School ofHygiene and Tropical Medicine, PHFI-Indian Institute of PublicHealth—Hyderabad and The Voluntary Health ServicesHospital for granting scientific and ethics approval to conductthis research study. The authors also thank the professionalsoftware and technical consultants at Suchirsoftech (India) whodeveloped the web-based application. The authors thank theexpert committee members for assisting in the development ofthe content for the intervention. The authors thank the mediaprofessionals at Selva photography (India) for digitising thecontent for the intervention. The authors also thank the modelswho acted for content digitisation. The authors also thank allthe stroke survivors and their caregivers for their participationand inputs in developing this intervention.

Contributors SK (Doctoral student at LSHTM) conceived thestudy, designed and developed the intervention and drafted themanuscript. GVSM and HK played a pivotal role inconceptualising the stages involved in the development of theintervention and reviewed the manuscript. SM providedsubstantial guidance for the technical development of theweb-based application. SG provided guidance in the concept ofthe research study.

Funding This work was supported by a Wellcome TrustCapacity Strengthening Strategic Award to the Public 542Health Foundation of India and a consortium of UKuniversities. The authors thank the Wellcome-trust and PublicHealth Foundation of India for funding the research study.

Competing interests None declared.

Patient consent Obtained.

Ethics approval London School of hygiene and TropicalMedicine, VHS Hospital and Public health Foundation of India.

Provenance and peer review Not commissioned; internally peerreviewed.

Open Access This is an Open Access article distributed inaccordance with the terms of the Creative CommonsAttribution (CC BY 4.0) license, which permits others todistribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited.See: http://creativecommons.org/licenses/by/4.0/

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