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.

Objective:

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.

Results:

-

Conclusions:

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. Clinical Trial: ClinicalTrials.gov Identifier: NCT06458218. Registered on June 9, 2024.