Award Title: IMPACT: Innovations using Mhealth for People with dementiA and Co-morbidiTies
Funder: Department of Health and Social Care

Abstract: Health systems in low- and middle-income countries are ill-equipped to cope with rapidly aging populations and associated chronic disease. Dementia is a particular problem in Peru and challenges the health system on many fronts. People with dementia often have other health problems as well (co-morbidities) which go untreated, cause suffering and cost money. There is almost no social care infrastructure and care is provided almost entirely by over-stretched family members. The COVID-19 pandemic has particularly affected the elderly and cognitively impaired in Peru, which has the highest death rate per capita from COVID in the world. 

Our goal is to strengthen the health system in Peru to meet the challenges highlighted by dementia by using technology and trained community health workers to bring expert diagnosis, treatment and support right to where it is needed – to the homes of patients and carers. To achieve this, we will run four linked lines of work to:

i)	assess whether the healthcare system can care for more people with dementia
ii)	improve the diagnosis of dementia and comorbidities
iii)	improve the care of people with dementia and their carers
iv)	evaluate the costs of dementia to society as a whole

Can the Peruvian health system care for more people with dementia? We will interview people with dementia, carers, support organisations, health professionals and government officials. We will find out about current dementia care in Peru and what is needed to improve it

Diagnosis: Dementia and its comorbidities are hard to diagnose in people who live far from health centres or have had little formal education. We will make an ‘app’ to help community health workers diagnose people with dementia and record their comorbidities. We will test how well this app diagnoses 1600 people across four distinct regions of this diverse country.

Care: People with dementia can be difficult to look after, partly because of their comorbidities. Caregivers can also become stressed or unwell. This means families need easy access to help and advice. Moreover, although there is no cure for dementia, group-based activities, physical exercise and proper treatment of comorbidities all help people to live well with dementia. But this type of care is not readily available in Peru. A project in the United States has developed a way of providing this care with smartphones. Because most Peruvians have smartphones, we can use them to develop a similar service, testing whether providing this care with smartphones is feasible in Peru.

Costs: We will measure the cost of dementia and comorbidities in Peru. The health system needs to know how much dementia care will cost, so that it can introduce cost-effective plans for better care.

We will work with dementia charities in Peru and around the world to keep our research focused on patients. We will collaborate with the Peruvian Ministry of Health to develop a National Plan for Dementia, and integrate the findings of our research into the existing health system for the benefit of the most disadvantaged and marginalised in society. We focus on Peru in order to understand the context in depth, but are confident that our findings will be applicable much more widely in South and Central America. In the second half of the project, we will share our methods with the Latin America and Caribbean Consortium on Dementia (LAC-CD) in order to analyse health systems readiness across three other countries in the region.

Lay Abstract: Background: Health systems in LMICs are poorly equipped to care for chronic mental and physical disease, which are rapidly increasing with aging populations. Cognitive impairment challenges health systems on multiple fronts, incurring huge human and financial costs. Latin America has the highest projected increase in dementia incidence globally, and in Peru there are ~300,000 people with dementia (PWD). Many are undiagnosed and lack basic support. Care is often provided exclusively by family members. PWD have twice as many co-morbidities as those without dementia which, despite being treatable, are often missed, poorly managed and reduce quality of life for PWD and their carers.

Aims and objectives: Project IMPACT will use dementia as a tracer condition to strengthen health systems in Latin America through sustainable, integrated, person-centred, community-delivered, technology-enabled innovation. Our specific objectives are to i) evaluate health systems readiness to provide support for PWD; ii) develop and implement an mHealth application for diagnosis of dementia by community health workers (CHWs) in Peru; iii) determine the feasibility of an mHealth-delivered, CHW-supported intervention to improve health-related quality of life for PWD and their carers; iv) assess the socioeconomic burden of dementia in Peru. Through these objectives, and in combination with our Outreach, Capacity Building and Engagement activities, we will identify barriers to and facilitators for high-quality health systems.

Methods: Our strongly interdisciplinary team includes researchers, policymakers and community representatives working together across 5 interrelated work packages (WPs). WP1 (Health System Readiness) will assess the needs of PWD and their carers and the readiness of the Peruvian health system to meet those needs. The tools developed will also be applied in 3 other Latin American countries. WP2 (Diagnosis) will co-produce an mHealth app for CHWs to find cases of dementia and record co-morbidities. We will evaluate the acceptability and accuracy of this app in 1600 PWD and controls from four distinct regions of Peru: the capital city (Lima), a coastal semi-urban region, the Andes mountains and the Amazon jungle. We will test integration of the app into primary health care. WP3 (Intervention) will adapt an existing mHealth intervention, developed in the US, to the Peruvian context. The intervention will include co-morbidity management help, motivation for physical exercise and group-based activities and carer support. Its implementation will be assessed in a feasibility study. WP4 (Health Economics) will estimate the economic burden and impact on quality of life of dementia and co-morbidities using questionnaires administered to the PWD and controls identified in WP2. WP5 will oversee all project management activities and engage stakeholders and the wider community to increase awareness and tackle sigma.

Anticipated impact and dissemination: We will work with patients, carers, health care workers, not-for-profit organisations, academics and policy makers to co-design our research and ensure maximum impact for PWD in Peru and beyond. We envisage: i) the diagnostic app being implemented nationwide within the health service; ii) preparing for a full trial of the complex intervention; iii) informing the design of a National Dementia Plan in Peru; iv) adaptation and application of health system readiness tools in other Latin American countries.

Research Activity Codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health Categories: NEUROLOGICAL