Title: NIHR Global Health Research Group on Improving Stroke Care, University of Central Lancashire
Funder: Department of Health and Social Care

Abstract: a)UCLan's research strategy is to develop and deliverg world-class research with real world impact, by increasing research activity and delivering a step-change its quality. Our focus is on delivering patient-centred applied research that is relevant to local, national and international challenges. Several UCLan research teams are recognised as delivering world-class research (1), one of which is the Stroke Research Unit (SRU) within the Faculty of Health and Wellbeing (FHW), led by Prof Dame Caroline Watkins (CW). The SRU has developed and delivered large-scale collaborative national and international studies. The creation of this GHRG aligns with our research ambitions. This genuine partnership, the available support, and our real world approach will create an environment to enable development of high quality stroke research with India. b) UCLan can make this application as we have the required knowledge, experience, skills, support mechanisms and staff to deliver the project. We will build on our previous achievements to develop capacity in research aimed at addressing global health challenges with LMICs. We are committed to the success of the partnership ensuring building for sustainability. The UCLan team draws on those with clinical and research expertise accessing staff from the large Stroke Research Unit(n=18), methodologists (n=7), and the Research Support Team; a flexible resource of research administrative and academic staff (n=20) who can be assigned to the programme or can initiate work whilst new appointments are made. UCLan Faculty's Lancashire Clinical Trials Unit (CTU, n=10) has experience of developing, delivering and supporting delivery of multi-centre studies, including national coordination and trial management across multiple sites for global studies. c)Formation of the GHRG will be the first opportunity for the collaborating organisations and individuals to develop and deliver stroke research on global challenges faced by India and other LMICs. We will build on successful collaborations that have effectively supported practice-changing research over many years. These include joint appointments, jointly held funding awards, research support infrastructure and centres, shared support for postgraduate research students, internships, research training and clinical networks. We will extend and formalise our existing connections to strengthen the partnership. We will work with research funders, policy and decision makers, commercial and non-governmental organisations to identify, create and benefit from opportunities to extend and sustain stroke research beyond the end of the award period. d)Stroke is a recognised global health challenge; cardiovascular disease including stroke is now the most common cause of death globally(2). India is one of the three countries with the greatest number of recorded stroke deaths worldwide (3), and people typically suffer a first stroke at a much younger age than in the UK (India, age 57 (4); UK, age 72 [male] and age 77 [female](5)) leading to significant socio-economic burden (6). In the last 20 years, the UK has achieved significant improvements in stroke care and outcomes, including reduced mortality. With only 35 stroke units serving India’s one billion population, there is enormous unmet need (7). Stroke unit care has great potential to reduce mortality and morbidity as it is the most widely applicable effective intervention (8). We will work in partnership with colleagues in India to develop, support and undertake relevant needs-led research around stroke unit care that is suited to current services and systems, and supports improved stroke care through smart solutions workable in LMICs. We will deliver outcomes that reduce the burden of stroke in India, and that have global relevance. Together, we have already identified key priorities in stroke care, and thus research opportunities in India. We have begun to develop criteria for understanding what is desirable and feasible to maximise clinical and cost-effectiveness, including potential for large-scale implementation; patient numbers who may benefit; and low-cost interventions with high gains. Decisions about specific priorities and methodological approaches will be agreed early in the development of the group (See attachment 1 for illustrative plan). The agreed interventions will be investigated in three geographically diverse centres in India (All India Institute of Medical Sciences (AIIMS), New Delhi; Christian Medical College (CMC), Ludhiana; Sree Chitra Tirunal Institute for Medical Sciences and technology (SCTIMIST), Thiruvananthapuram including private, charitable and state-owned healthcare organisations. We will focus on piloting defined bundles of care within emergency treatment (e.g. assessment (9)), acute care (e.g. monitoring) and rehabilitation (e.g. self-practice (10)) and organisation of stroke care. Our priorities will focus on implementation in clinical practice and the practicalities of conducting research in a low-cost health economy. We will develop methods to disseminate successful components of research and practice to other hospitals and settings. The bundles of care and relevant clinical outcomes will be co-designed with key stakeholders including patients, carers,families and the public (PCPI) . We will need to develop effective systems for collecting outcomes, other than mortality, as other outcomes are not currently routinely available in care records. We will draw on our experience of forming partnerships including those for studies, national and international research centres, research infrastructure and implementation support, and clinical networks. We will form an effective GHRG group by co-developing a collective vision and purpose, built on mutual respect, with clarity regarding responsibilities, agreement on decision-making, fair allocation of resources, development of understanding of context, and clear management and governance arrangements. From the outset we will focus on ensuring continuation and expansion of the group through existing and new connections to develop links with key stakeholders. We will expand the ability of the UCLan partners to engage in research in India and other LMICs. We will disseminate information to make other UK-based researchers aware of our work and to promote further collaborations. Partners in Australia have experience of delivering collaborative large trials in India, from which all parties in the group will benefit. Within UCLan (SRU and CTU) we will build expertise in conducting research with LMICs. Within India, we will build experience of working with multi-disciplinary researchers in the UK. In the first 6 months, we will explore the skills, learning and support required for the group and for individual partners, in order to develop a comprehensive plan for research capacity building. We will map expertise and needs across the group in order to maximise opportunities for co-learning and to identify where external expertise needs to be harnessed. The partnership will provide opportunities for researchers in the UK and India to share and develop knowledge and skills in collaborating to deliver research within LMICs. The group will provide a peer support network to enable early- and mid-career researchers to develop leadership skills for global health research. We will organise Masterclasses with international researchers from within and outside the group to share knowledge, expertise and experience, to embed understanding and to build capacity and capability at all levels including leadership. The content will be determined following agreement of needs. These are different from, but complementary to, those activities included in the RCUK application. Our 6 month delivery targets are: •Set up (contractually and managerially) the group, set up the stakeholder group, develop a strategy for PCPI, conduct feasibility assessment of the centres for the proposed study, agree the work plan, including the focus, design and content of a pilot study to investigate a number of care bundles in 3 centres, map and plan to address learning needs and opportunities across the group, plan the initial masterclass, apply to the Health Ministry’s Screening Committee(HMSC) for research permissions Our medium term (1-2 years) targets are: •Set up the three centres: recruit staff, agree roles, introduce protocols, collect and capture baseline data, process and outcome data, deliver and evaluate the impact of research capacity building activities, evaluate the engagement with, and impact of, PCPI activities across the partnership, apply for further funding to develop other priority areas of research. In the longer term (2-3 years) we plan to: •Complete the work plan, develop new partnerships and research collaborations,secure further funding and investment for follow-on work, analyse data and disseminate widely, deliver accessible evidence for use by practitioners, commissioners and policymakers, which will inform care and service development to enable further stroke research, and will significantly improve the lives of those in India and other LMICs. e)We have requested £90K to ensure that resources are available to buy in the additional time of co-applicants as needed or to facilitate the inclusion of subject experts. f) Continuation of the partnership will be achieved primarily through securing the necessary resources to support further research, and via capacity development, training and investment. This will be developed throughout the project in conjunction with stakeholders and others. The proposed project also presents an opportunity to establish key collaborations between the organisations involved, and for the development of strategic plans to support the sustainability of the work, in stroke and other relevant healthcare fields, beyond the timescale of the current application

Lay abstract: Stroke is a worldwide health problem and, with heart disease, is now the most common cause of death globally. In low to middle-income countries (LMICs) like India, the number of people having and dying from stroke is increasing. India now has the third-highest number of people dying from stroke of any country. People in India also tend to have strokes younger than people in wealthier countries like the UK – in their 50s rather than in their 70s. This often causes immense hardship for them and their family. There has been great progress in stroke audit and research in the UK in the past 20 years, which has led to major improvements in stroke service organisation and care. These improvements have reduced death and disability from stroke. This project aims to share knowledge and skills with LMIC countries to assist in improving stroke care. Our GHRG works in partnership across the UK and India (with support from key colleagues in Australia) to improve stroke care in India. The group brings together multidisciplinary researchers with expertise in a range of methodological approaches, with differing professional backgrounds, experience, at different stages of their research careers, and with expertise in truly collaborative global health research and development. We are co-designing, developing, supporting and undertaking a programme of research relevant to the needs of patients, carers and health professionals in India. Whilst this research will work with India’s current stroke services and systems, it will have the potential to support system change and through implementing research findings in practice will reduce the burden of stroke in India. This research will gain global recognition and inform stroke care across the world. There are 3 key stages: - 1.) We have worked in partnership and agreed research priorities using co-developed criteria. The areas selected aim to benefit as many people as possible, and are affordable and achievable in acute stroke setting in India. We will develop and explore the feasibility and acceptability (staff, patients and carers) of delivering these evidence-based interdisciplinary care bundles for the management of stroke. We have now agreed the three care bundles, which are: - 1. Assessment and management of swallowing problems; 2. Monitoring and management of neurological and physiological signs and symptoms; 3. Education and training of relatives in supporting acute stroke care. 2.) We have assessed the feasibility of implementing the care bundles at the three centres in India. We are working together to develop new systems for collecting research data in India. We are providing opportunities for healthcare staff in India who wish to develop their skills and experience in undertaking research, and interested in implementing findings in practice. 3.) We are reinforcing our partnership through developing a longer-term, sustainable, programme of stroke research and service development with teams in India and other LMICs. We will pursue further funding, and ensure that the research findings are available to healthcare staff and policy makers.

Research activity codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: STROKE