JMIR Publications

ABSTRACT

Background Chronic obstructive pulmonary disease (COPD) and mental health conditions represent intersecting public health challenges, especially in resource-limited rural China. Existing care models often neglect the psychosocial needs of high-COPD-risk populations, resulting in limited effectiveness of prevention and management strategies for the condition. This study evaluates an integrated intervention designed to improve both mental and physical health outcomes among high-COPD-risk individuals with mental health symptoms, using a population medicine framework. Methods We are conducting a 12-month, two-arm cluster randomized controlled trial (cRCT) across 26 townships in Xishui County. A total of 44,000 residents aged 35 years or older were screened using the COPD-SQ, resulting in identification of 10,000 individuals at high risk for COPD. Among them, 6,000 individuals with WEMWBS scores below 45 were enrolled as participants. Intervention components include digital CBT-based mental health support, community screening, chronic disease management, patient education, digital follow-up, and team-based care. The primary outcomes are depression symptoms (PHQ-9), anxiety symptoms (GAD-7), and mental wellbeing (WEMWBS). Secondary outcomes cover numbers of chronic diseases controlled, physiological and functional indicators such as lung function, health-related quality of life, mental and behavioral health, healthcare utilization, knowledge of COPD and asthma, productivity loss, and care cascade indicators for chronic conditions. Discussion This study is the first to integrate psychological support, chronic disease management, and community-based screening into a single scalable intervention package targeting multimorbidity in China. It tests the feasibility of applying population medicine principles—emphasizing integrated, preventive, and population-level care—within primary care systems in low-resource settings. By targeting both mental and physical health, it redefines chronic care beyond traditional organ-specific approaches. Trial registration ClinicalTrials.gov Identifier: NCT06458218. Registered on June 9, 2024.