Lijing Yan CMPIS Seminar

Transcript

• 00:00I'm very pleased to introduce
• 00:01our speaker, Doctor. Li Jing
• 00:03Yang, who is a PhD,
• 00:05Miles per hour, professor of
• 00:07global health and head of
• 00:08the non communicable chronic disease
• 00:11research
• 00:12at the Global Health Research
• 00:13Center
• 00:14and director of the implementation
• 00:16science research on noncommunicable
• 00:19diseases
• 00:20management laboratory
• 00:21called Iron Man Lab at
• 00:23Duke Kunshan University.
• 00:25And maybe you can tell
• 00:26us a little bit about
• 00:27what Duke Kunshan University is
• 00:30as well.
• 00:31Li Jing is currently an
• 00:32adjunct professor at Beijing University
• 00:35Institute for Global Health and
• 00:37Development.
• 00:38The School of Public Health
• 00:40is Wuhan University,
• 00:42Duke Global Health Institute, Duke
• 00:44University in the United States,
• 00:46and the Department of Preventive
• 00:47Medicine at the Feinberg School
• 00:49of Medicine at Northwestern University
• 00:52in Chicago.
• 00:54Quite a lot of affiliations.
• 00:57Previously, she was the director
• 00:58of graduate studies for the
• 00:59master of science in the
• 01:01global health program at Duke
• 01:03Kunshan University,
• 01:04the deputy director of the
• 01:06George Institute for Global Health
• 01:08at Beijing University
• 01:09Health Science Center
• 01:11and director of the China
• 01:12International Center for chronic disease
• 01:15Prevention, a large network of
• 01:17five international
• 01:18academic institutions
• 01:20and seven Chinese institutions
• 01:23dedicated to combat NCDs in
• 01:25China.
• 01:26She is the former secretary
• 01:28general of the China
• 01:29Consortium of Universities for Global
• 01:31Health and the current standing
• 01:33council member of the Global
• 01:35Health Society
• 01:36and the NCD Prevention and
• 01:38Control Society of the Chinese
• 01:40Preventive
• 01:41Medicine Association.
• 01:42She has a bachelor's degree
• 01:44in sociology
• 01:45from Beijing University,
• 01:47a master of public health
• 01:48and epidemiology,
• 01:49and a doctorate in demography
• 01:51from the University of California
• 01:53at Berkeley.
• 01:54Her main areas of research
• 01:56are primary care and community
• 01:58based chronic disease prevention and
• 02:00control,
• 02:01including hypertension,
• 02:02stroke,
• 02:03heart disease and diabetes,
• 02:05healthy aging, digital health innovations,
• 02:08and implementation
• 02:09science.
• 02:10She is the principal investigator,
• 02:11a co investigator of over
• 02:13twenty US NIH and UK
• 02:16MRC funded and China funded
• 02:18research grants
• 02:19totaling over ten million US
• 02:21dollars.
• 02:22She has published over two
• 02:23hundred peer reviewed scientific papers,
• 02:26some in leading medical journals,
• 02:28including JAMA, The Lancet,
• 02:30the New England Journal of
• 02:31Medicine, the British Medical Journal
• 02:33and circulation.
• 02:34Her Google Scholar age index
• 02:36is fifty nine and
• 02:39I ten index one hundred
• 02:40and twenty three with total
• 02:42citations over seventy five thousand
• 02:44as of June twenty twenty
• 02:46four. She advises national international
• 02:49organizations, including the China National
• 02:51Health Commission
• 02:53and World Health Organization.
• 02:54So we clearly have an
• 02:56extremely accomplished,
• 02:58public health researcher in NCDs
• 03:00and in implementation
• 03:02science here with us today,
• 03:04probably the leader
• 03:06of this work in
• 03:08China. And so I'm very
• 03:09happy to have here and
• 03:10to turn this over to
• 03:12doctor.
• 03:15Yeah. We we need to
• 03:16make sure we have you
• 03:17set up properly now.
• 03:19We probably wanna
• 03:20maybe minimize this.
• 03:23Don't show this again. Oh,
• 03:24maybe yeah. Let's try that.
• 03:28Oh, maybe I know. Now
• 03:29we can minimize it over
• 03:30here,
• 03:31but the thing would go
• 03:32away.
• 03:36Because there's no mouse here.
• 03:38It's very I have don't
• 03:39like these keypads. Yeah. An
• 03:40attached pad. Mhmm.
• 03:42Say,
• 03:43yeah. I mean Or click
• 03:45on somewhere else. Oh, okay.
• 03:48Sorry.
• 03:51Denise, you know what to
• 03:52do? I'm good.
• 03:53That's the voice mail. It's
• 03:55not. It's okay.
• 03:58No. Pull pull that screen
• 04:00down, and that way, the
• 04:02thing will, like, go away.
• 04:05It. Maybe because I did
• 04:07the laser pointer thing. Yeah.
• 04:08But I just have to
• 04:09get to the bar here.
• 04:11Yeah. And then we're gonna
• 04:12go here. Now to the
• 04:13next one. The left. Next
• 04:15one. Now in Austin. Yeah.
• 04:17Click that. There you go.
• 04:19I think now you're in
• 04:20a good Okay. Well, thank
• 04:21you so much.
• 04:23Thank you, Donna for the
• 04:24invitation.
• 04:25Thank you, Ally and Denise,
• 04:27for helping.
• 04:28I I'm
• 04:29surprised that Donna read through
• 04:31the file. Yeah. Yeah. It's
• 04:33so No. It's so boring.
• 04:36I hope my talk will
• 04:37not be so boring. Mhmm.
• 04:39And, also, of course, I
• 04:41know Yale, and, I have,
• 04:43collaborated and know people in,
• 04:45including, you know, Donna, Professor
• 04:47Li and others. And one
• 04:49of my former students, and
• 04:50he's also here. So, so
• 04:52glad to see you all.
• 04:54But this is my very
• 04:55first time,
• 04:56in the university in the
• 04:57city. So, great to be
• 04:59here. And today, I will
• 05:01be very focused in talking
• 05:02about,
• 05:04this study, which is a,
• 05:06trial that, for people familiar
• 05:09with implementation science is the
• 05:10effectiveness implementation trial.
• 05:13So
• 05:14the,
• 05:17I think I should try
• 05:18to move this,
• 05:20below.
• 05:22That's kind of hard to
• 05:23do, but it's doesn't it?
• 05:24So yeah. You can put
• 05:25it down.
• 05:26Okay. Now it's working. Sort
• 05:28of.
• 05:30And my mortality
• 05:31view is.
• 05:34Okay.
• 05:35So today, I will introduce
• 05:37this study according to this
• 05:39paradigm,
• 05:39that is, called the titles.
• 05:42You can see what petals
• 05:44is.
• 05:45And then I will talk
• 05:45about revaluation,
• 05:47which is the s part
• 05:48of the petals. So let's
• 05:50take a look at petals.
• 05:55This works better.
• 05:57Okay. So this is for
• 05:59this is proposed by professor,
• 06:01Roman Xu,
• 06:02a leader in implementation science
• 06:04that Donna knows well,
• 06:06that this is to this
• 06:08is a model for implementation
• 06:09research. You can see it
• 06:10starts with the problem p.
• 06:12So the real world problem
• 06:14that we want to address.
• 06:15And the EBP is the
• 06:16evidence based practice that we
• 06:18adopt in the study.
• 06:20And determinants
• 06:21actually,
• 06:22refers to facilitators
• 06:24and, barriers
• 06:26for implementation.
• 06:28And action is the term
• 06:30used, to show,
• 06:32to mean implementation
• 06:33strategies. That's the typical term
• 06:35in implementation research. And l
• 06:37is for long term sustainment
• 06:39of the implementation.
• 06:41And scale is for,
• 06:45evaluation and scaling up. So
• 06:47this is the PEDLS model.
• 06:49And, you can see PEDLS,
• 06:51the acronym is gray because
• 06:53it shows like it's like
• 06:54the bicycle pedaling.
• 06:55And, there is this iterative
• 06:57process and the circle is
• 06:59showing that. And two other
• 07:00things to point out is,
• 07:02one, is the application of
• 07:04various models and frameworks throughout,
• 07:07and then also the co
• 07:08production
• 07:09process with stakeholders,
• 07:11are important.
• 07:13So for our study, what
• 07:15is the problem that, we
• 07:17are interested in addressing?
• 07:19In a nutshell, it's,
• 07:21stroke prevention and control and
• 07:23particularly in rural China. So
• 07:25I would point your attention
• 07:27to these two figures.
• 07:29You can see this is
• 07:30over time from the, early,
• 07:34century for this one from
• 07:35nineteen ninety three to twenty
• 07:37seventeen.
• 07:38And, the blue one is
• 07:40urban. The red one
• 07:42is rural. So in terms
• 07:44of the prevalence of stroke,
• 07:46you can see,
• 07:47the big rise,
• 07:49in rural China in the
• 07:51prevalence of stroke to the
• 07:53point of surpassing,
• 07:55beyond twenty thirteen. It's passing
• 07:58on urban areas in terms
• 07:59of its burden.
• 08:01However,
• 08:01in terms of the mortality,
• 08:03it's being pretty much consistently
• 08:05higher
• 08:06than urban areas. The blue
• 08:08being rural and red being
• 08:09urban. Green is overall in
• 08:11the middle. So we have
• 08:13very large burden and it's
• 08:15the
• 08:16number one cause of death
• 08:18and disability in rural China.
• 08:20And to to address this
• 08:21burden, there are so many
• 08:22evidence based practices already.
• 08:25Lots of guidelines, clinical guidelines,
• 08:28even for, a for a
• 08:29stroke per se. And,
• 08:32right at the time when
• 08:33we started,
• 08:35work on this study, there
• 08:36is this,
• 08:39guideline
• 08:41produced,
• 08:42in China in Chinese
• 08:44for the primary care level
• 08:46stroke prevention and control.
• 08:48So it's a booklet,
• 08:50and it's being,
• 08:52edited by our collaborators in
• 08:54the tertiary hospital called Tian
• 08:55Tan Hospital, the leading neurology
• 08:57hospital in China.
• 08:58However, even for this, that
• 09:00is earmarked for primary care,
• 09:03it turned out to be,
• 09:05as my question there, it
• 09:07it's not so easily
• 09:10applicable
• 09:11to the reality of primary
• 09:13care in rural China. So
• 09:16we set out to do
• 09:17the study. This is the
• 09:18site.
• 09:19Our study,
• 09:20is conducted
• 09:21was well, is because it's
• 09:23still ongoing, conducted in,
• 09:26one county in this province.
• 09:28And the province is called
• 09:29Hebei. It happened to be
• 09:30my, well, I chose it
• 09:31to be my hometown.
• 09:32And this is actually the,
• 09:35wisest
• 09:36choice I made, if I
• 09:37can speak on that.
• 09:39Because,
• 09:41this,
• 09:42was
• 09:43done in the last few
• 09:44years of my mom's life.
• 09:46So because I chose it
• 09:48here, I was able to
• 09:48see her, more often than
• 09:50I had otherwise.
• 09:52And, but not that's not
• 09:54the only reason. The other
• 09:55reasons would be collaborations,
• 09:57but also the high burden.
• 09:58You can see, Hebei is
• 10:00in the darkest,
• 10:01color in terms of incidence
• 10:03for stroke.
• 10:05And Sorry, Nikki. Can you
• 10:06go back one second? Sure.
• 10:08So is the whole population
• 10:10of the Hebei province
• 10:11three hundred and sixty thousand
• 10:13people? No. It's the total
• 10:15population for the county we
• 10:16chose. Oh, okay. Yeah. Because
• 10:18I thought that was very
• 10:19low for China. Right. It's
• 10:21for this particular county. And
• 10:23the particular county had two
• 10:24hundred eighteen villages. We worked
• 10:25in fifty villages. Okay. Yeah.
• 10:28So, this is a busy
• 10:30timeline, but I would like
• 10:31just to point out there
• 10:32is this long phase where
• 10:34we call formative
• 10:36research where we did, you
• 10:37know, the barriers and the
• 10:38facilitators and the comp contextualization,
• 10:41tailoring.
• 10:42And then after the pilot
• 10:44study, we had this intervention
• 10:46that is only one year
• 10:47long. So this is important
• 10:49to keep in mind. The
• 10:50intervention, the active phase was
• 10:52only one year long. And
• 10:54then after that,
• 10:56after it's over,
• 10:58we had a hiatus,
• 11:00during the COVID,
• 11:02but then we were able
• 11:03to have follow-up studies,
• 11:06which, in October of twenty
• 11:08twenty,
• 11:09two,
• 11:10was one of the two
• 11:11who went to the field
• 11:12to to to support the
• 11:14follow-up study.
• 11:16So, in the for the
• 11:18barriers and facilitators, we did
• 11:19three field visits, forty nine
• 11:21interviews, and four workshops,
• 11:23and one steering committee meeting,
• 11:25in order to, do it.
• 11:27So just quickly for forward
• 11:29to, the conclusion part of
• 11:31the determinants
• 11:33in terms of the barriers.
• 11:34They actually come from multiple
• 11:36levels.
• 11:37At the patient level, there
• 11:39is the low awareness,
• 11:40and poor adherence to medication,
• 11:44and,
• 11:44poor physical functioning,
• 11:47generally low health literacy,
• 11:49And even for the literacy
• 11:51level among women,
• 11:53because most of these patients
• 11:54were older, it is,
• 11:57less than,
• 11:59a third of them could
• 12:00read.
• 12:02Yeah. So,
• 12:03at the village doctor level,
• 12:04there is also the low
• 12:05awareness on clinical guidelines for
• 12:07stroke because they focus a
• 12:09lot of their effort on
• 12:10maternal and trial health and
• 12:12other,
• 12:13conditions such as,
• 12:15hypertension and diabetes according to,
• 12:18the National Public Health package.
• 12:21And they also have low
• 12:23incentive for preventive care. I'll
• 12:26get my cell phone for
• 12:27time control.
• 12:30Where the lack of preventive
• 12:32care, and here we focus
• 12:34on secondary prevention
• 12:36for stroke,
• 12:37instead of, the acute phase,
• 12:39which is not suitable for
• 12:41the primary care.
• 12:42At the county level,
• 12:44they are acute state oriented
• 12:46and provide fragmented fragmented
• 12:48care without patient follow-up, and
• 12:50they're overburdened.
• 12:52I remember visiting the hospital
• 12:54during the winter, you know,
• 12:55around this time.
• 12:57Outside of the neurology ward,
• 12:58there will be lots of
• 12:59deaths and, patients and family
• 13:02members even living in the
• 13:04corridor,
• 13:05because, they they have a
• 13:07surge of,
• 13:08patients, during the wintertime.
• 13:11And then,
• 13:12our specialists, they are very
• 13:14experienced,
• 13:15world class, but they are,
• 13:16they don't know the rural
• 13:18situation. So in the county,
• 13:20this is the three tier,
• 13:23health care delivery system, county
• 13:26hospital being only one, and
• 13:28the leading,
• 13:29facility.
• 13:31And then there are fifteen
• 13:33township health care centers throughout
• 13:35the county. And then each
• 13:37county each township
• 13:38health care centers manages a
• 13:40number of village clinics,
• 13:42that is staffed by village
• 13:43doctors,
• 13:44and, nurses, sometimes pharmacists too.
• 13:47And the village doctors
• 13:49can prescribe medicine. This is
• 13:51different from, for example, Nepal
• 13:53or India,
• 13:54but,
• 13:55they are not board certified
• 13:57physicians as you understand them.
• 14:00They usually receive vocational
• 14:03professional training of two years
• 14:05beyond high school or after
• 14:06middle school.
• 14:08Then, they get certificate from
• 14:10the government to be a
• 14:11village doctor. Some of them
• 14:13full time, many of them
• 14:14also part time doing farming
• 14:16or other things,
• 14:18on the side. Can I
• 14:19ask you one question? What?
• 14:20Can you do that? Sure.
• 14:21The line about,
• 14:23poor adherence to treatment. Mhmm.
• 14:25Just because I don't know
• 14:26I don't know the context.
• 14:27Is the adherence because of
• 14:29access barriers or education or
• 14:31other things? Things? Yeah. That
• 14:33is a great question. There
• 14:34are many reasons. If I
• 14:36focus on the most important
• 14:38adherence,
• 14:39problem, there are
• 14:41not one there are two.
• 14:42One is cost.
• 14:44Some of these medicine are
• 14:45not free, and, I constantly
• 14:48hear patients saying, oh, can
• 14:49we get this for free
• 14:51or at lower cost? And
• 14:52the other thing would be
• 14:53well, the costing we can't
• 14:55really address in our study.
• 14:56We didn't address that in
• 14:57our study. The other thing
• 14:58is the, health literacy. Like,
• 15:02they, would stop their medicine
• 15:04when there is no symptom
• 15:05or they may forget.
• 15:07So there's that kind of
• 15:09reasons.
• 15:10Sorry,
• 15:12On the cost question,
• 15:14can you be how clear
• 15:16can you be about what
• 15:18what exactly is free? Like,
• 15:19a first line WHO
• 15:22recommended antihypertensives
• 15:24free.
• 15:26Are they in stock at
• 15:27all of these, I guess,
• 15:28would be village clinics? At
• 15:30the time time we were
• 15:31working there, the active trial
• 15:33from twenty seventeen to twenty
• 15:34eighteen,
• 15:35these frontline medicines, what we
• 15:37call in the essential formulary
• 15:39Yeah. They are
• 15:40usually they were usually in
• 15:42stock.
• 15:43So availability is not an
• 15:44issue. However,
• 15:46in terms of free, at
• 15:47that time, nothing was completely
• 15:50for free. They needed to
• 15:51have co pay.
• 15:53If they register as a
• 15:55chronic disease patient
• 15:57through that special policy, they
• 15:59get a larger discount, but
• 16:00it's still not free Mhmm.
• 16:02At that time.
• 16:05Later, it became a little
• 16:06better.
• 16:07And just to calibrate that,
• 16:09what percent of, like, the
• 16:11monthly income
• 16:12would it cost to pay
• 16:13for that medicine?
• 16:15Loss? Well, the medicines we
• 16:16promote actually are very cheap.
• 16:18Mhmm.
• 16:19Like,
• 16:20they could be just a
• 16:21few yuan per month or
• 16:23even
• 16:24like, aspirin is, like, a
• 16:25few yuan per year Mhmm.
• 16:26Which is less than a
• 16:27dollar per year. Mhmm. But
• 16:29the better branding
• 16:31aspirin, like, from there, that
• 16:33costs more. But that's not
• 16:34what we're that's not what
• 16:36we're promoting. Exactly.
• 16:38And, I don't think I
• 16:39would remember to mention this,
• 16:41but some of you may
• 16:42know,
• 16:43that it's led by professor,
• 16:45Jiang He from Tulane who's
• 16:47at Texas now, and professor
• 16:49from
• 16:50China. They published two papers
• 16:52in Lancet, and I wrote
• 16:53an editorial for them. They
• 16:56had this large trial of
• 16:58three hundred,
• 16:59or so clusters of thirty
• 17:01three thousand patients,
• 17:03with first result of eighteen
• 17:05months follow-up of a blood
• 17:06pressure reduction.
• 17:08It's humongous. It's like fourteen
• 17:09millimetric
• 17:10blood pressure reduction
• 17:11because they provided medicine for
• 17:13free not because of that.
• 17:15But the large reason was
• 17:16that they provided medicine for
• 17:18free to over ninety percent
• 17:19of those in the international
• 17:21are.
• 17:22That that they did that.
• 17:23And then in the thirty
• 17:24six month follow-up, they had
• 17:26a reduction of somewhere between
• 17:28fifteen to twenty five percent
• 17:30in cardiovascular.
• 17:31So that's their their study.
• 17:33And, our study
• 17:35was different,
• 17:37in
• 17:38terms of the provision of
• 17:39medicine.
• 17:40And we observed a much
• 17:42smaller
• 17:43effect size. Because you're using
• 17:44the health system rather than
• 17:46providing Yes. We use we
• 17:47use the existing, system as
• 17:49much as as we could.
• 17:51Yeah. I'm sorry. I also
• 17:52have a question of the
• 17:53village doctors. Mhmm. So do
• 17:55they have would you say
• 17:56that they all have a
• 17:57high school education?
• 17:59Some of them would mean,
• 18:01community college. Uh-huh. So they're
• 18:02They may not have high
• 18:03school. They may go to
• 18:05the vocational school for health
• 18:07after middle school. But they're
• 18:09all literate. Sure. Oh, yes.
• 18:10They're all literate.
• 18:12And other than, a small
• 18:13percentage of, let's say, ten
• 18:16percent ten to fifteen percent
• 18:17at that time, all of
• 18:19the village doctors are used
• 18:20used a smartphone
• 18:22even in twenty seventeen.
• 18:24At this time, I think
• 18:25it's nearly a hundred percent
• 18:26as the older village doctors,
• 18:28retired.
• 18:29However, even as of now,
• 18:32nearly no patients
• 18:34use smartphone.
• 18:37They at least have, had
• 18:39a shared
• 18:40cell phone, that is a
• 18:42feature phone, like a basic
• 18:43phone. They can receive calls
• 18:45and text messages.
• 18:47So But that's very different
• 18:48than, say, community health workers
• 18:50in Nepal or ASHA's in
• 18:52India who could be even
• 18:54barely literate or even not
• 18:56literate. Right. That's different. And
• 18:58so this is a full
• 18:58time job. They're not volunteers.
• 19:01They're not volunteers. Some of
• 19:02them are part time, but
• 19:04they're paid. They they receive
• 19:05some payment from the government.
• 19:07And they are doctors, and
• 19:09they could even they're not
• 19:10just literate literate, but they
• 19:11could prescribe medicine
• 19:12in the formula, in the
• 19:14essential formula.
• 19:16Is it a full time
• 19:17job, or do they have
• 19:18another job and they just
• 19:19do the same size? A
• 19:21a percentage of them. During
• 19:22the time when we did
• 19:23our trial, I think it's
• 19:24higher now,
• 19:25because China is changing so
• 19:27fast.
• 19:28At that time, about,
• 19:31I would say, a little
• 19:32less than half had this
• 19:33as a full time job.
• 19:35Mhmm. But the other over
• 19:37half of the village doctors
• 19:39worked as a village doctor,
• 19:41but at the same time,
• 19:42also did their own business
• 19:44or farming.
• 19:46So it's a mix.
• 19:47But nowadays, more, of them
• 19:49are full time village doctors.
• 19:51Okay. Thank you. So these
• 19:53are important background for you
• 19:54to understand in our study.
• 19:56This is the core functions
• 19:58and core function and forms
• 20:00model that some of you
• 20:01may be familiar. So we
• 20:02start with identification of the
• 20:04problem that needs and identify
• 20:06the standardized
• 20:07core functions,
• 20:08but tailor the core functions
• 20:10to,
• 20:12have the different forms for
• 20:13the different contexts.
• 20:15So,
• 20:16we didn't,
• 20:17actually use this until later
• 20:19on,
• 20:21when we wanted to transfer
• 20:23learnings from this study to
• 20:25other settings. And we realized
• 20:27that this could be used
• 20:28in a retrospective
• 20:29way even to facilitate the
• 20:31transformation,
• 20:33the transferability.
• 20:34For example, we could keep
• 20:35the core functions if we
• 20:37identify the core functions
• 20:39to be transferable.
• 20:41But the forms definitely needs
• 20:42to be adapted and tailored
• 20:44to a different context, which
• 20:45is what we're trying to
• 20:46do,
• 20:47in Nepal with Nepal, actually
• 20:49with Archana,
• 20:50and,
• 20:51other Viraj and others, in
• 20:53Nepal.
• 20:54So, this is a very
• 20:55busy slide.
• 20:57Sorry. Very busy slide, but
• 21:00I don't mean for you
• 21:00to read them, but this
• 21:02is our way of trying
• 21:03to map what we have
• 21:04done,
• 21:05throughout,
• 21:06this
• 21:08matrix.
• 21:10The model that we actively
• 21:12adopted when we were designing
• 21:13the intervention,
• 21:15was,
• 21:16at that time, was the
• 21:17chronic care model.
• 21:19I don't have time to
• 21:20go into a lot of
• 21:21details, but it covers,
• 21:23six domains,
• 21:24most of them within the
• 21:25health care system.
• 21:27Some in, this one is
• 21:29in the community.
• 21:30And the emphasis of this
• 21:32model is on productive
• 21:34interactions
• 21:35between
• 21:36the,
• 21:38provider team and the patient,
• 21:40which is also our emphasis,
• 21:43for the intervention.
• 21:45So now this is a
• 21:46revealing of the acronym called
• 21:48cinema. I've been calling it,
• 21:49since the outline slide.
• 21:51It's,
• 21:52the acronym means,
• 21:55system integrated,
• 21:57technology enabled
• 21:59model of care.
• 22:01And,
• 22:02it's,
• 22:02covering three levels.
• 22:04So
• 22:05the, our way of addressing
• 22:07patient level barriers is through
• 22:09the monthly follow-up visit by
• 22:11the village doctors, the interaction
• 22:13between
• 22:14the the face to face
• 22:15interactions between village doctors and
• 22:17the patients.
• 22:18And then, we provide self
• 22:20management support
• 22:22through the voice messages, and
• 22:23there is a lot of,
• 22:25formative research going into why
• 22:27is voice message not the
• 22:29text message and how we
• 22:30design the voice message, etcetera.
• 22:33And then at the village
• 22:35doctor level, we have training
• 22:37and technology empowerment, which is
• 22:39through a smartphone based app
• 22:41called the cinema app, and
• 22:43also incentives.
• 22:44Incentives both
• 22:45financial incentives, but also,
• 22:48nonfinancial
• 22:49incentives such as recognition,
• 22:51award,
• 22:53etcetera.
• 22:54And then,
• 22:55working with the specialists,
• 22:57to
• 22:58task shift and tax share
• 23:00with the primary care providers.
• 23:03Hey, Jane. Can I ask
• 23:04a question about performance based
• 23:06incentives?
• 23:07Yeah.
• 23:08From my somewhat limited experience
• 23:11in low and middle income
• 23:12countries, there's a lot of,
• 23:14resistance
• 23:15to performance based incentives
• 23:18because,
• 23:19governments
• 23:20don't wanna kind of create
• 23:22a dependency where people
• 23:24don't do their jobs unless
• 23:26they get an incentive.
• 23:27And I've also experienced
• 23:29in a study where I
• 23:30worked on it. The same
• 23:32people are, like, the ones
• 23:33who do a really good
• 23:34job every single month. I
• 23:35don't always get the incentives.
• 23:38So I'm just wondering, like,
• 23:39since you said you were
• 23:41co designing with stakeholders
• 23:42Yes. Were they really happy
• 23:44about that, and did they
• 23:45feel it was sustainable?
• 23:47Or I'm so glad you
• 23:49thoughts. I'm so glad you
• 23:50asked this question because I
• 23:51won't
• 23:52spend too much time on
• 23:53this, but this is such
• 23:54a great question that I
• 23:55do want to respond to.
• 23:56Indeed, the concerns are true
• 23:59that, it may provide the
• 24:01wrong incentive for people to
• 24:03just do it
• 24:04if, you know, they don't
• 24:05do it well if they
• 24:06are not getting paid.
• 24:07And,
• 24:09it's usually just the better
• 24:10reform performers.
• 24:12These are valid concerns. I
• 24:14would even say I see
• 24:15that happening in China.
• 24:17Like, China has this performance
• 24:19based
• 24:20system within our national health
• 24:22care system,
• 24:23whether it's for the hospitals
• 24:25or for the public health
• 24:27package, national public health package.
• 24:29And they have very detailed
• 24:31performance measures.
• 24:33That's usually controlled by the,
• 24:35county CDC
• 24:37for the whole county, and
• 24:38then they evaluate
• 24:40the the people and then
• 24:41give them well, having said
• 24:43that, there is the per
• 24:44capita fee for the puppy
• 24:45house plus
• 24:47some fee that is forewarns
• 24:48based. So there is this
• 24:50culture of forewarns based payment
• 24:52in China. So the resistance
• 24:54from the government,
• 24:56officials was low,
• 24:58but I do see a
• 24:59problem with that,
• 25:01that the culture is such.
• 25:03For example, we're designing another
• 25:05study. We're trying to create
• 25:07a culture of, for example,
• 25:09peer leaders
• 25:10or community health volunteers.
• 25:12But the resistance I always
• 25:14get is, will the volunteers
• 25:16be paid? If not, they
• 25:17may not be incentivized.
• 25:19So so there are I
• 25:20mean, I'm not saying China
• 25:21doesn't have a volunteer culture,
• 25:23but I think that's less
• 25:24than some other cultures. And
• 25:25then this room space, payment
• 25:27scheme is,
• 25:29is a double edged sword.
• 25:30Yes.
• 25:32Given our culture, this seems
• 25:33to be working well, and
• 25:35we
• 25:36really designed the indicators for
• 25:38performance to be very simple
• 25:39and is embedded in the
• 25:40app so they could see,
• 25:42etcetera. Yeah.
• 25:45So this is the pilot
• 25:46study we did in the
• 25:47four villages,
• 25:49to,
• 25:50after the design of the
• 25:51intervention to, fur further refine
• 25:54it and tailor it.
• 25:56Some,
• 25:57this is in Chinese. You
• 25:59can't really see it, but
• 26:00basically,
• 26:01it's the monthly
• 26:02follow-up
• 26:03sheet.
• 26:04And, we focus on the
• 26:06medicine,
• 26:07and the physical activity. There
• 26:09is the goal setting and
• 26:10then also reminders,
• 26:12each month. And so each
• 26:14patient gets one sheet per
• 26:15month. So throughout the year,
• 26:16they get twelve sheets,
• 26:18as reminders for them.
• 26:20And this is the APP.
• 26:21The APP is designed to
• 26:23be user friendly.
• 26:25So it's very easy to
• 26:27use,
• 26:28and, we learned. I think
• 26:30it's okay to do that
• 26:32from the WeChat interface.
• 26:35WeChat is this popular social
• 26:36media,
• 26:38sort of like WhatsApp,
• 26:39in China.
• 26:41And then it has multiple
• 26:42functions
• 26:43at the back end, but
• 26:44made it very easy for
• 26:45the users to navigate.
• 26:49So this is some screenshots,
• 26:52of that, APP.
• 26:54We also,
• 26:55had
• 26:58ways to design
• 27:00the messages,
• 27:01based on the health belief
• 27:03system, model,
• 27:05as well as,
• 27:06focusing on
• 27:08the two
• 27:10evidence based practices,
• 27:12medication adherence and physical activity.
• 27:14There are so many things
• 27:15we could work on,
• 27:16but, we need it really
• 27:18to prioritize
• 27:19to what may generate the
• 27:20larger impact. So these two
• 27:22are what we focus on.
• 27:24I just wanna close your
• 27:25comment. Why didn't you include
• 27:27reducing salt intake?
• 27:29Yes. That's a good question.
• 27:31For this study, we didn't
• 27:33do that. I I I've
• 27:34actually I had many other
• 27:35studies focusing on that. I
• 27:37know. But for for this
• 27:38study, the conscious choice was
• 27:40not to work on education
• 27:42I mean, diet related factors
• 27:44because,
• 27:46it's it's really comp complicated.
• 27:48Not because diet is complicated
• 27:49by itself, but if I
• 27:51add more components to it,
• 27:53it may be too complicated.
• 27:55In indeed, the original proposal
• 27:57included rehabilitation
• 27:59Mhmm. As well,
• 28:00but we decided to cut
• 28:02that part and just focus
• 28:03on the medical and the
• 28:05healthy life lifestyle part. Yeah.
• 28:08So we didn't, choose
• 28:10to have a comprehensive
• 28:12strategy.
• 28:13Having said that, when we
• 28:15build on this and now
• 28:16work in another urban setting,
• 28:18we do have the salt
• 28:20reduction
• 28:21in there.
• 28:24For the long term sustainability,
• 28:26this framework, we didn't, have
• 28:28it at the beginning, but
• 28:29we designed our whole intervention
• 28:31with sustainability and scalability in
• 28:33mind because we don't want
• 28:35it to just be,
• 28:37you know, a one time,
• 28:39kind of effort.
• 28:41But in but having said
• 28:42that, this was investigator initiated,
• 28:46study.
• 28:46So,
• 28:48and,
• 28:49as of now, it's not
• 28:51being,
• 28:52scaled up in China.
• 28:54But I'm hoping with our
• 28:56most recent result
• 28:57with, one just,
• 28:59published to come out on
• 29:00December thirtieth and another one,
• 29:02hopefully,
• 29:03soon,
• 29:04maybe I will initiate this
• 29:06thing about scaling up in
• 29:08China as well. So we
• 29:10did the,
• 29:11access,
• 29:12assessment on sustainability
• 29:14of the study
• 29:16in this summer
• 29:17according to this framework.
• 29:20So this is the pedal,
• 29:22of the study.
• 29:24The problem we address was
• 29:26the, EBP
• 29:27we adopt, which is mainly
• 29:29the monthly follow-up
• 29:31and medication adherence and physical
• 29:34activity,
• 29:35and and our implementation strategies
• 29:37that addresses the local barriers.
• 29:41And
• 29:42now let's, talk about the
• 29:43evaluation of this intervention.
• 29:45So in terms of the
• 29:46evaluation, the
• 29:48research question as it if
• 29:50we put it into one
• 29:51sentence is this,
• 29:53which is can the,
• 29:55primary health care providers, we
• 29:56call them village doctors in
• 29:58China, they're even if when
• 29:59they are supported by the
• 30:00system
• 30:01and equipped with digital health
• 30:03technology, can they provide
• 30:05the essential,
• 30:06higher quality care
• 30:08and reduce systolic blood pressure?
• 30:10So we have this equal
• 30:12emphasis
• 30:13on two outcomes,
• 30:15which makes it a hybrid
• 30:16two,
• 30:18trial.
• 30:19And many of you are
• 30:20familiar with this. So hybrid
• 30:22one, the primary on effectiveness,
• 30:24hybrid three, primary on implementation,
• 30:26and hybrid two Mhmm. Has
• 30:27this equal emphasis.
• 30:29And in their paper published,
• 30:31by professor Curran et al,
• 30:33and they talk about, what
• 30:34makes it a hybrid two
• 30:36trial. So,
• 30:38skipping over this part, but
• 30:39I think this is more
• 30:40legible.
• 30:42It talks about the conditions
• 30:44of when to adopt a
• 30:46hybrid type two trial.
• 30:48And, for example, it needs
• 30:49to be having strong,
• 30:51face validity
• 30:53and a strong base of
• 30:54indirect evidence, a minimal risk,
• 30:56and there is momentum,
• 30:58and it should be,
• 31:00supportable,
• 31:01in terms of the strategies.
• 31:03And, there is reason to
• 31:05gather more data.
• 31:07And the ideal,
• 31:08condition is that, there is
• 31:10reasonably
• 31:11close
• 31:12evidence,
• 31:13and the overall intervention is
• 31:15not overly complex.
• 31:16So, our cinema trial actually
• 31:19fulfills this requirement. For example,
• 31:21there is strong face validity
• 31:23for both the EBP
• 31:25and the implementation strategy,
• 31:27and the strong indirect evidence
• 31:29actually came from our own
• 31:30study
• 31:31in, rural China and as
• 31:33well as from,
• 31:34Tibet
• 31:35in China.
• 31:36And then there is,
• 31:38low risk in the intervention.
• 31:40We didn't have anything of
• 31:42new drugs or new measures,
• 31:43etcetera.
• 31:45Nothing beyond the implementer, village
• 31:47doctors,
• 31:47capability.
• 31:48And the momentum for implementation
• 31:51was,
• 31:52high at that time when
• 31:54the medical care reform in
• 31:56China
• 31:57was really having this push
• 31:58of strengthening primary care, having
• 32:00hierarchical,
• 32:02health care, and task shifting.
• 32:05And,
• 32:06the institutional support was very
• 32:07strong from provincial,
• 32:09even national level, but more
• 32:11at the local level.
• 32:13And there is equipoise
• 32:15that we don't know the
• 32:17whole intervention package as we
• 32:18design them was effective or
• 32:21not.
• 32:22So,
• 32:23you are familiar with this
• 32:24logic model, like, what do
• 32:26we put in? What do
• 32:27we do? What's the immediate
• 32:29output on the media term
• 32:31outcome and the long term
• 32:32impact? So in terms of
• 32:34our study,
• 32:35this is the logic model
• 32:36for our study is color.
• 32:38The color scheme shows different
• 32:40levels. Like, this is the
• 32:41health care system level,
• 32:43and this is the village
• 32:45doctor level,
• 32:46and this is the patient
• 32:48level,
• 32:50in in a summary. So
• 32:52as we design, in terms
• 32:53of the trial,
• 32:55it's a cluster randomized trial.
• 32:57So after we,
• 33:01do the baseline connect collection,
• 33:03then we review
• 33:04the allocation of,
• 33:07the clusters into each groups.
• 33:08This is very important because
• 33:10the for a open label
• 33:12trial,
• 33:13inevitably for complex health intervention
• 33:16like ours, It needs to
• 33:17be open label. There is
• 33:18no way that we can
• 33:19do double blind,
• 33:21but at least it can
• 33:22be concealed
• 33:23for the baseline,
• 33:27measurement.
• 33:28And then, it's in a
• 33:29one to one ratio. So
• 33:31twenty five
• 33:32villages in the intervention, twenty
• 33:34five in control. On average,
• 33:36twenty five patients per cluster
• 33:38of, they're all stroke patients,
• 33:40and we have a quarterly
• 33:41process evaluation, mostly qualitative research.
• 33:44And then in terms of
• 33:45the underlying data collection, it
• 33:47was also,
• 33:50designed to be blinded.
• 33:52Like, the assessors came from
• 33:55a third party, which is
• 33:56the CDC staff from a
• 33:58nearing,
• 33:59neighboring county, not from the
• 34:01intervention county itself.
• 34:03And then they did both
• 34:04the baseline and the end
• 34:06line,
• 34:07according to the same protocol.
• 34:09And from, my observation that
• 34:11they didn't care who who's
• 34:12in the information, who's in
• 34:13the control. We asked them
• 34:14not to ask, and they
• 34:16they just want to do
• 34:17their job, which is the
• 34:19outcome assessment,
• 34:20data, collection and do their
• 34:22job well. Can you come
• 34:23back a second? Mhmm. So
• 34:25my first question is, so
• 34:26this is an individually randomized
• 34:28study or something? It's a
• 34:29cluster randomized trial. Okay. So
• 34:31So twenty five villages into
• 34:33each,
• 34:35three. Okay. Because the way
• 34:36it says it varies, it
• 34:37said six twenty five receiving
• 34:39usual care
• 34:41and,
• 34:42and six twenty five receiving
• 34:44the cinema model. So you
• 34:45So she should have said
• 34:46twenty five versus twenty five.
• 34:48Okay. Yeah. And,
• 34:49because you wouldn't have exactly
• 34:51six twenty five in both
• 34:52groups. You should be in
• 34:53a real study because
• 34:55every village would have a
• 34:56different number of stroke I
• 34:58I don't have exactly six
• 34:59twenty five. Sorry. That's very
• 35:01good catch, Donna. This is
• 35:02wrong. I should have changed
• 35:03it,
• 35:05because,
• 35:07this is the design. I
• 35:08mean, the design also is
• 35:10twenty five versus twenty five.
• 35:11Yeah. Twenty five versus twenty
• 35:12five. I mean, I caught
• 35:13it because this is a
• 35:14main area research in our
• 35:16Yeah. Group looking at Yeah.
• 35:18And I designs and then
• 35:19I should have caught it
• 35:20myself. So that's well, I
• 35:22had another flowchart, but this
• 35:23is a well, yeah. So
• 35:25and
• 35:26I don't think I put
• 35:27in the final flowchart in
• 35:28here. Something that's written like
• 35:30in the back of my
• 35:31chart. Oh, yeah. Sure. Yeah.
• 35:33Can you say a little
• 35:34bit more about what the
• 35:35Morisky Grain Louvain scale and
• 35:37the time jump in Vowetesta?
• 35:40Yeah. So that is the,
• 35:42four item
• 35:44medication
• 35:44adherence scale. And, I'm glad
• 35:47also, I'm glad you asked
• 35:48asked because the more famous
• 35:50one is the eight item,
• 35:51MMAS,
• 35:53which is which needs to
• 35:54be paid. And at Duke
• 35:55University, we were warned
• 35:57that don't use it unless
• 35:58you pay them. Otherwise, even
• 36:00after you publish, you may
• 36:01get into lawsuit.
• 36:02However,
• 36:03this four item one called
• 36:05MGLS
• 36:06is free. So we won't
• 36:08get into trouble. So that's
• 36:09what we did. In terms
• 36:10of the physical function in
• 36:11the time up and go,
• 36:13it's a measure
• 36:14where, we ask them to
• 36:16sit on the chair, and
• 36:18we place a mark three
• 36:19meters away. So we say
• 36:21begin until they stand up
• 36:22and walk three
• 36:24meters. We turn back and
• 36:25sit down. So we time
• 36:26that. So if that is,
• 36:29above fourteen seconds, that means
• 36:31their functioning is not
• 36:32too good in terms of
• 36:34lower.
• 36:35Alright. And then in terms
• 36:36of adherence then, the scale
• 36:38is a self report at
• 36:40the level of the patient
• 36:41where they just say yes
• 36:42or no. They took it
• 36:43or they didn't. Yes. And
• 36:44there was no other validation.
• 36:46No no pill count and
• 36:47or anything like that. So
• 36:49this is, one of the
• 36:50secondary outcomes we have. Yeah.
• 36:52And then in the follow-up
• 36:54study, we try to have
• 36:55other measures, but still not
• 36:57objective
• 36:58type, but another scale to,
• 37:01to assess medication adherence,
• 37:03which was
• 37:04done
• 37:05in this year. Yeah. In
• 37:07this past summer.
• 37:09So in terms of this
• 37:11implementation outcomes framework, you know,
• 37:13there's implementation outcome, service outcome,
• 37:15and patient outcome. So we
• 37:16try to assess, many of
• 37:19this. So, just quick summaries
• 37:21of,
• 37:22in terms of this trial,
• 37:23the primary outcome,
• 37:25for implementation
• 37:26versus effectiveness
• 37:27and then secondary exploratory.
• 37:30So,
• 37:31at the time of the
• 37:32trial, these outcomes were exploratory,
• 37:35such as recurrence of stroke,
• 37:37mortality, hospitalization.
• 37:39But in the long term
• 37:40follow-up, because we were able
• 37:42to accrue enough events,
• 37:44then, they became primary outcomes
• 37:46for the long term follow-up,
• 37:50like,
• 37:51explained here.
• 37:53So,
• 37:55this is more detail that
• 37:56I'm not gonna spend too
• 37:57much time on. You can
• 37:59see our final,
• 38:00patient count. Fifty villages and,
• 38:03twelve hundred ninety nine patients.
• 38:05So it's not exactly six
• 38:06seventy five versus six seventy
• 38:08five.
• 38:10Okay.
• 38:12One nine one two nine
• 38:13nine
• 38:14is the final patient count.
• 38:16So this is a overview
• 38:19of the
• 38:22evaluation,
• 38:23framework, which is mostly the
• 38:25RAIN, but also embedded
• 38:28within the MRC UKMRC
• 38:30process evaluation framework for complex
• 38:32interventions.
• 38:36You can't really read it,
• 38:38and I have another slide,
• 38:40showing it. This is from
• 38:41our process evaluation
• 38:43implementation outcome paper,
• 38:45in terms of quotes and
• 38:46the summary, and this is
• 38:48the RE AIM framework. So
• 38:49in summary, in terms of
• 38:51fidelity,
• 38:53is reasonable, not,
• 38:55perfect, but reasonable. For example,
• 38:58in terms of the training,
• 38:59eighty four percent attended both
• 39:01sessions,
• 39:03and, some only attended the
• 39:05first one.
• 39:06And on average, they were
• 39:08able to perform the monthly
• 39:10follow-up.
• 39:11And in terms of the
• 39:13messages sent out,
• 39:15I mean, sorry. This is
• 39:16the WeChat message for the
• 39:17village doctors as one way
• 39:19of,
• 39:20support.
• 39:22And for the patients, you
• 39:23can see
• 39:25there's eleven percent received
• 39:27less than
• 39:28monthly visit,
• 39:30which means,
• 39:31about,
• 39:32eighty nine percent received the
• 39:34monthly visits.
• 39:35And also,
• 39:37in terms of the voice
• 39:38messages though, it was lower.
• 39:40For example,
• 39:42we had,
• 39:43about a little over a
• 39:45quarter
• 39:46who,
• 39:47didn't answer half of the
• 39:48voice messages. Because, basically, the
• 39:51way it worked was that
• 39:52the APP through technical support
• 39:55at the back end can
• 39:56automatically send out the messages
• 39:58to the patients.
• 40:00And the time is in
• 40:01the morning when they were
• 40:02usually at home before they
• 40:04go out to work,
• 40:06in the farm. So
• 40:08they if they pick up
• 40:09this call, then they get
• 40:11to hear the message recorded
• 40:13for them, and it's a
• 40:14one way. There's no interaction.
• 40:17It's not designed to be,
• 40:18so sophisticated.
• 40:20And,
• 40:22the message is usually less
• 40:24than one minute long, so
• 40:26thirty seconds or less, and
• 40:28it's repeated one time
• 40:30in and recorded in, a
• 40:32local dialect,
• 40:34by the wife of our
• 40:36program officer in the country.
• 40:38So if they picked it
• 40:40up, that
• 40:41means they got it. If
• 40:42not, the system will call
• 40:44two more times before eight
• 40:46AM.
• 40:47And then after that, they
• 40:49it will be done for
• 40:50the day. So about a
• 40:51quarter of them didn't receive
• 40:53half. So the fidelity here,
• 40:56is,
• 40:57less than the other measures.
• 40:59So in terms of the
• 41:00summary, we could see,
• 41:03that
• 41:04could you go back?
• 41:05So what I'm wondering is
• 41:07in terms of these fidelity
• 41:08indicators,
• 41:09do you have them, like,
• 41:11do you have them on
• 41:12all privileged doctors and all
• 41:14patients, and how often?
• 41:17That's a good good question,
• 41:18actually. It's a question want
• 41:19to,
• 41:20consult you later on. This
• 41:23is for the intervention religious
• 41:25only, and we have it
• 41:26on all village doctors, all
• 41:28patients in the intervention arm.
• 41:31We don't If you have
• 41:31an alarm, they wouldn't be
• 41:32getting any voice mails Right.
• 41:35Or any of these things.
• 41:36Right? Right. However,
• 41:38there is one thing that
• 41:39we could measure, which is
• 41:40the monthly visit. We ask
• 41:41them. Okay.
• 41:43But, in terms of the
• 41:44other things,
• 41:46the WeChat group, or the
• 41:48voice messages or the APP.
• 41:50They don't talk about that.
• 41:51They don't have it. Yeah.
• 41:52It's gonna be very interesting.
• 41:53Yeah. So, I think for
• 41:55the general
• 41:56outcome, it needs to be
• 41:57across all the clusters and,
• 42:00patients, I think.
• 42:03So this is a summary.
• 42:04They,
• 42:06found that,
• 42:07their
• 42:09knowledge and capability,
• 42:11these enablers
• 42:12being
• 42:13improved,
• 42:14and
• 42:16and there is credibility
• 42:17credibility for the top down
• 42:19approach because we work with
• 42:20the government in implementing this.
• 42:23And,
• 42:24in terms of the patient,
• 42:26they perceive benefits of receiving
• 42:28the most voice messages.
• 42:30They appreciated,
• 42:32the content
• 42:33designed to be simple and
• 42:34tailored and give them practical
• 42:36tips, etcetera, and reminders.
• 42:40And,
• 42:41this is the actual flowchart.
• 42:42I did have it. I
• 42:43forgot,
• 42:44because the actual flowchart was
• 42:46meant to show the long
• 42:47term follow-up mostly.
• 42:50So we have one twelve
• 42:51one two nine nine,
• 42:53and this is,
• 42:54three thirty seven, to be
• 42:56exact in the in twenty
• 42:58five. And,
• 43:00the one year follow-up is
• 43:01that, and the two year,
• 43:04and then the long term
• 43:05follow-up,
• 43:06is reported here. Even if
• 43:09they were not, some of
• 43:10them not in the one
• 43:11year follow-up, they could still
• 43:13be followed up later on.
• 43:14And our follow-up rate was
• 43:16very high. It's above ninety
• 43:18five percent of all people
• 43:19who survived.
• 43:22So this is the main
• 43:23result,
• 43:24for the systolic blood pressure.
• 43:28It's two busy slides, but
• 43:30you can see,
• 43:31here,
• 43:32is the change,
• 43:34by group. The top one
• 43:36is
• 43:38the,
• 43:39control group. The bottom one
• 43:40is the intervention group. You
• 43:42can see the yellow part
• 43:43is the one year of
• 43:44active trial part.
• 43:46There is a large reduction
• 43:47in both groups,
• 43:49including the control group. And
• 43:51then that difference was small.
• 43:53It's being hidden here, only
• 43:56about,
• 43:56two point eight,
• 43:59millimeter mercury,
• 44:00but it's significant for, that
• 44:02lab trial.
• 44:04And then,
• 44:05the long in terms of
• 44:06long term follow-up, you could
• 44:08see both group increased,
• 44:10but the difference,
• 44:11was more or less capped.
• 44:13So you could see the
• 44:14net difference,
• 44:16the result of the test
• 44:17here is is meant to
• 44:18see to show the difference
• 44:20in difference,
• 44:22also here.
• 44:23So it's similar in magnitude,
• 44:25about two point nine or
• 44:27two point eight millimeter mercury.
• 44:28So in terms of the
• 44:29sypholic blood pressure, it was
• 44:31not that high.
• 44:32However,
• 44:33we found that,
• 44:36they are generally consistent
• 44:38across the groups,
• 44:40with stronger impacts among women,
• 44:43among lower educated
• 44:45people, among people with lower
• 44:47income. So in other words,
• 44:48our intervention
• 44:50worked better
• 44:51for the more vulnerable group
• 44:53even
• 44:54overall in the resorts limited
• 44:56setting of rural China.
• 44:59And this is but I
• 45:00just wanna look at those
• 45:01p values for interaction
• 45:03because none of them are
• 45:04actually significant.
• 45:05Yeah. So I'm not saying
• 45:07there is interaction. I'm saying
• 45:09that
• 45:10within
• 45:11the subgroups,
• 45:13the intervention effect was stronger
• 45:15in magnitude.
• 45:16I think it's accurate to
• 45:17say it in this way
• 45:18because we really worked hard
• 45:19on how to say it
• 45:20in the paper in this
• 45:22paper that's coming out soon.
• 45:24There is a stronger effect
• 45:26size for the subgroup of
• 45:29more vulnerable subgroups
• 45:31in within
• 45:33that.
• 45:35Yeah. But the injection wasn't
• 45:37significant.
• 45:43And this is the graph
• 45:44for the mortality. And, again,
• 45:46you can see this is
• 45:47the first year,
• 45:48and there is a small
• 45:49separation,
• 45:51but not,
• 45:53and even then, it was
• 45:54significant,
• 45:55but we only had thirty
• 45:56deaths
• 45:57back then for exploratory outcome.
• 46:00But you could see the
• 46:00separation over time was very
• 46:02clear and,
• 46:04if,
• 46:06significant. In a nutshell,
• 46:08it's about,
• 46:09twenty between twenty to thirty
• 46:11percent relative reduction
• 46:13in,
• 46:13cardiovascular,
• 46:15mortality or all cause mortality
• 46:17or stroke mortality.
• 46:19So cost effectiveness, I'm skipping
• 46:21over the details of the
• 46:23parameters,
• 46:24and, just to show the
• 46:26summary that is highly cost
• 46:28effective
• 46:29with a,
• 46:30incremental cost effectiveness
• 46:32ratio of, little over eight
• 46:35hundred per quality.
• 46:36And the threshold,
• 46:39for one, or one and
• 46:40a half GDP per capita
• 46:42was over twenty three thousand.
• 46:44So it's highly cost effective.
• 46:46And
• 46:47the figures are blocked, but
• 46:49okay.
• 46:50So,
• 46:51coming to the end, I
• 46:52like to summarize and say,
• 46:54this summary is not in
• 46:55terms of the result, but
• 46:57in terms of,
• 46:59the intervention itself.
• 47:00So the core functions
• 47:02we identify being
• 47:03task shifting and task sharing,
• 47:06provider and patient interactions,
• 47:08and the empowerment
• 47:10through different,
• 47:11ways such as training,
• 47:13such as incentives
• 47:14and technology.
• 47:16In terms of the evidence
• 47:18based practices,
• 47:20we focus on these three,
• 47:23follow-up
• 47:24and medication adherence and physical
• 47:26activity. And these are the
• 47:27main implementation strategies of training,
• 47:30incentives, and mobile house technology.
• 47:33So, here is one slide
• 47:35that's in a different scheme
• 47:36because I want to catch
• 47:37your attention.
• 47:38My my, take home message
• 47:40of summary,
• 47:41not based just on this
• 47:43study, but I think it
• 47:44applies to all of the
• 47:45implementation studies we did that,
• 47:47were complex in nature.
• 47:49So the three
• 47:51s,
• 47:53related to the content process
• 47:54and approach
• 47:55in terms of the other
• 47:56two s's I've touched on,
• 47:58saying that even when we're
• 48:00designing it, we hope this
• 48:01is sustainable over time and
• 48:03scalable over space,
• 48:05the designing principles,
• 48:08and the content
• 48:10is undoubtedly
• 48:11complex.
• 48:13It covers multiple levels,
• 48:15patients and village doctors and
• 48:17the system support, and it
• 48:18has technology and all the
• 48:19different strategies.
• 48:21But we should try to
• 48:22keep it simple. And I
• 48:24think some people know what
• 48:25this acronym
• 48:26stand.
• 48:27K?
• 48:29Keep it simple stupid. You
• 48:30know, it's starting from you
• 48:31know, I I I this
• 48:33is a reminder to myself
• 48:34because I tend to make
• 48:35it more complex. I want
• 48:36to pack more into it
• 48:38because I feel, oh, this
• 48:39is needed. The whole clinical
• 48:40guideline
• 48:41is covered so much, but
• 48:42I remind myself constantly.
• 48:45If I don't, I'm being
• 48:46stupid.
• 48:47And the process, we need
• 48:48to have a slim and
• 48:50being streamlined and the approach,
• 48:52with the digital technology, etcetera,
• 48:55to be smart.
• 48:57So
• 49:00the last slide I have,
• 49:02other than the
• 49:03acknowledgments, etcetera,
• 49:05is,
• 49:05about sustainability.
• 49:07I said that we're trying
• 49:08to learn how to transfer
• 49:10and adapt to a different
• 49:11setting such as Nepal.
• 49:13In fact, I'm working on
• 49:14the,
• 49:15multimodility
• 49:16NIH grant proposal
• 49:18to focus on, the adaptation
• 49:20to Nepal. So there's a
• 49:22lot more to learn. In
• 49:23terms of sustainability,
• 49:25I think there's,
• 49:26also
• 49:27a lot of studies that
• 49:29we could do in implementation
• 49:30research.
• 49:31I think we need to
• 49:32differentiate
• 49:33as a very simple scheme,
• 49:35differentiate
• 49:36sustainability versus sustained effects.
• 49:38For example, we observed
• 49:40long term outcomes such as
• 49:42mortality reduction, etcetera, but that
• 49:44sustained effect. It's not about
• 49:46the sustainability
• 49:47of the intervention.
• 49:49And the intervention being a
• 49:50bundle or a package,
• 49:52it includes
• 49:53both the implementation
• 49:54strategies and the evidence based
• 49:56practices altogether
• 49:58as the intervention bundle.
• 50:00I think the most important
• 50:02goal for sustainability is for
• 50:03the EBP
• 50:04to go up,
• 50:06so that, the patients can
• 50:07reap the benefits in the
• 50:09long term outcomes.
• 50:10As for the implementation strategies,
• 50:12whether we need that to
• 50:13be so similar or not
• 50:14depends on whether we need
• 50:15it or not. Maybe, hopefully,
• 50:18we don't need that to
• 50:20go on for a long
• 50:21time if the evidence based
• 50:22practices can go on. So
• 50:24which is,
• 50:26the case for our study
• 50:28that, we have, we didn't
• 50:30continue any of the implementation
• 50:32strategies such as training
• 50:34or incentives or technology.
• 50:36But,
• 50:37we have evidence to show
• 50:38that the EBP, which is
• 50:40the interaction,
• 50:42the medication assurance, and physical
• 50:44activity,
• 50:46some of them were kept.
• 50:48So so this is,
• 50:50still,
• 50:51work in progress, and I
• 50:52welcome really feedback if you
• 50:54are interested in sustainability and
• 50:56scalability.
• 50:57And, also, I want to
• 50:58say we didn't explicitly identify
• 51:00our study.
• 51:01And, as a hybrid two
• 51:03trial
• 51:04in the beginning
• 51:05until later on because it
• 51:07this was funded as a
• 51:08health system trial and etcetera.
• 51:11So there even in the
• 51:12professor Kuran's paper, they say,
• 51:15maybe in the grantsmanship,
• 51:16whether it's if it's better
• 51:17for you to say it,
• 51:18then you say it. Otherwise,
• 51:20maybe you focus on the
• 51:21house outcome, which is okay,
• 51:22but you can do
• 51:23do it as a high
• 51:25hybrid type type two.
• 51:27So this is only a
• 51:28partial
• 51:29acknowledgement list,
• 51:31and my email is here.
• 51:33So this is, my talk.
• 51:35I'm sorry I took pretty
• 51:37long. So only limited time
• 51:38for questions, but I'm available
• 51:40here this afternoon.