Indian Journal of Public Health Research &DOI Number: 10.

37506/v11/i2/2020/ijphrd/195018
Development, February 2020, Vol. 11, No. 02  1389

E-Ways (Early Warning System):

A Literature Study of Smartphone Application-Based Stroke
Early Detection

Muhamad Jauhar1, Lita Heni Kusumawardani2, Rasdiyanah3,

I. Gusti Ayu Putu Desy Rohana4, Utami Rachmawati5
1
Nursing Department, Health Polytechnic of Minsitry of Health, Semarang, 2Nursing Departement, Faculty of
Health Sciences, Jenderal Soedirman University, Purwokerto, 3Nursing Department, Faculty of Medicine and
Health Sciences, Alauddin State Islamic University, Makassar, 4Primary Health Services Department, Universitas
Indonesia Hospital, Depok, 5Faculty of Nursing, Universitas Indonesia, Depok, Indonesia

Abstract
Stroke is one of the highest causes of catastrophic death in Indonesia. Lack of knowledge and public awareness
about stroke caused the delay of health care and post-disease recovery. So that, they impacted on death or
disease complications and even disability. There were needs for prevention efforts and early detection that
could be done at home. Today, the early detection was carried out by health workers in health care facilities
through skrinning. The use of smartphones could minimize the delay of health care. This would be an
opportunity to develop smart phone applications as media for stroke early detection because most people
used smartphones in their daily lives. This study aimed to identify the use of smart phones as media for
stroke early detection. Comprehensive literature analysis through Google Scholar, Proquest, and EBSCO in
the last 5 years, with keywords: stroke early detection, sourceinformation, smartphone application. Inclusion
criteria were smartphone application and stroke articles in the past 5 years. Data were analyzed in a table
consisted of title, author, year, and result. A total of 21 articles had showed the use of smartphones might
provide sign assessment and mild stroke symptoms experienced by individuals effectively and efficiently.
These media had been globally used for early detection and information sources about strokes. Smartphone
applications became innovative media that could help individuals to carry out early detection and obtain
practical information about stroke and be accountable. The results of this literature study could be used as
references to determine the form of appropriate intervention ormedia as support toward the efforts of stroke
case prevention in Indonesia.

Keywords:  Smartphone application, early detection, stroke.

Introduction needed to design appropriate programs and policies

Indonesia is faced with a triple burden disease
situation, where control of infectious diseases has
not been resolved but the trend of an increase in non-
communicable diseases occurs every year, especially
catastrophic diseases. The period of January-June 2014
had increased in the number of cases and the cost of
treating catastrophic diseases such as vascular disease
(heart disease, stroke), diabetes mellitus, kidney disease,
cancer, thalassemia, and hemophilia(1). The management
of catastrophic diseases requires higher cost because
the numbers of cases have increased and made various
kinds of complications and even death. The government
through the management of risk factors and calculate
disease financing(2). One of catastrophic diseases that
could be minimized through risk factor management
was stroke.
Stroke is non-communicable disease that contributes
for the highest mortality after heart disease and cancer
and is the first cause of serious and permanent disability.
This could be prevented through appropriate treatment
considering on the risk factors(3). A total of 15 million
people worldwide suffered from strokes, 5 million people
die from strokes, and 10 million other people survived
with permanent disability. This permanent disability
1390  Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02
resulted dependence on others(4). The numbers of stroke
cases in Indonesia was 2,137,941 (12.1%) cases. This
number have increased 3.8% from the previous year,
so that, Indonesia was currently as the country with the
highest number of stroke cases in Asia(1).
Stroke stands for Cerebro Vascular Accident (CVA)
isneurological disorder that occurs due to disruption
of blood circulation to the brain for 24 hours or more
and tends to be permanent. Clinical symptomsoccured
suddenly and progressively, they resulted acute brain
damage in focal or global(5). A total of 87% people had
ischemic stroke caused by the blockage of blood flow to
the brain and the rest occurred hemorrhagic strokes(6).
Stroke attacks could affect anyone due to unhealthy and
instantaneous lifestyle at this time(7).One of the efforts
was early detection of symptoms or the risk of stroke.
Currently, early detection was not only implemented
conventionally but also in modern way through the
advances of health information technology. E-health
appeared as a form of existence in the health sector that
refered to the delivery of information and the provision
of internet-based health services and technology. This
was supported by the development of smartphone use
among communities included in Indonesia from time to
time. The numbers of internet users in Indonesia until
2014 reached 88 million people(8)(explained that 67.6%
used smartphones to access the internet and social media,
87.3% accessed the internet and social media sites for
20-50 hours per week).
Previous research had proven the success of
smartphones as accessible media, improved medication
compliance, immunization schedule reminders(9).
Monitoring system consisted of website-based server
applications and Android-based client applications
could help monitor the compliance and development
of CD4(clients’HIV/AIDSARV) in order to succeed
the implementation of ARV therapy(10). The Girl Talk
application increased the knowledge significantly from
the baseline level (35.3% vs. 94.1%; p <0.001)(11). At
present, there was no study on the implementation and
impact of using smartphone applications as media of
information and early detection of stroke in Indonesia.
Based on this phenomena, there was a need for
literature review on the use of smartphone technology
as efforts to provide information and early detection of
stroke in various countries. The results of this study were
expected to be used as references in the development
of smartphone application-based stroke early detection
media. This study aimed to identify research articles that
described the use of smartphones as media of information
and early detection of stroke.
Research Method
The strategy of searching research articles carried
out comprehensively through the databases of Google
Scholar, Proquest and EBSCO research journals in the
last 5 years, it was obtained 21 articles. The keywords
used in the searching for research articles were stroke
early detection, source information, smartphone
application. Searched articles using punctuation
“AND” so that the writing “stroke early detection and
smartphone application” and “source information for
stroke and smartphone application”.
Result
The utilization of smartphone applications in
various countries as media for early detection and
stroke prevention based on the analysis of 21 articles.
The application functioned as screening for clients with
risk of stroke, information sources of stroke, detection
of abnormalities in the use of walking patterns, routine
blood pressure checks, detection of heart problems, stop
smoking, checking cholesterol and blood sugar, regular
physical activity, and low salt diets.
The results of literature review showed smartphones
that were used as media for early detection and prevention
of stroke, namely ARM Strokes, FAST-ED (Field
Assessment Stroke Triage for Emergency Destination),
Stroke 119, and mSTOPES. Study result showed that
86 doctors (74%) used the application for patient care
process, either for personal use or recommending to
patients(12). Doctors used the application to manage
stroke risk factors (25%) all of the time. 77% of doctors
stated their interests in using the application because
it could help their patients managing their risks. 90%
of doctors agreed that this application was useful if
provided patient care.
The e-wars prototype provided additional features
about information to reduce the risk of stroke, it consisted
of checking routinely blood pressure, detection of heart
problems, stop smoking, checking cholesterol and blood
sugar (DM clients), regular physical activity, low sodium
diet (low salt) (Erawantini et al.,2018). The mSTOPES
application was able to identify and improve the AF
screening method for stroke prevention. The results of
 Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02  1391
this trial also provided greater knowledge of arithmetic
characteristics (eg frequency, duration, average, and
time of day) that associated with symptoms of AF(13).
The ARMStrokes application was developed on
iPhone using the built-iniPhone sensor (accelerometer,
gyroscope, and device orientation sensor) to identify
movement speed and user position information (eg
pitch, roll, and yaw values) during training. Clients
were enthusiastic about using ARMStrokes in their
daily lives because the given feedback was right after
training(14). In addition, the FAST-ED (Field Assessment
Stroke Triage for Emergency Destination) application
provided information through short questions to identify
age, anticoagulants use, final normal values, motion
weakness, visual impairment, and aphasia; stroke
center database that provided endovascular care; and
Global Positioning System to calculate the feasibility
of clients of endovascular care and the distance/time
of transportation to emergency health care centers(15).
Based on the results of these studies, smartphone
applications could help individuals to detect and obtain
stroke information easily and practically because it
might be accessed anywhere and anytime.
Discussion
Stroke is one of eight types of catastrophic diseases
that is included in the National Health Insurance (JKN)
financing. This was due to the high cost of treatment,
various complications emerged and threatened life. The
magnitude of the threat of stroke required prevention
and early detection. One of the preventive actions was
through the use of information technology in the form
of smartphone applications as early warning system
(e-ways). Based on the literature review of 21 research
articles showed various innovations had been developed
as media for early detection and prevention of stroke.
Treskes et al through his research on 200 clients
by applying mobile-AF application in the form of
The Kardia Mobile for early detection of AF (Atrial
Fibrillation) and TIA as the cause of cryptogenic stroke.
The result showed that The Kardia Mobilewas non-
invasive validated device that was easy to use, low cost
and could be used by clients independently(16). This
application had the potential to improve the detection
of AF and TIA in cryptogenic stroke populations and
prevention of recurrent strokes. Similar study was
conducted, through “Stroke 119” application was able
to perform stroke screening and information about the
nearest hospital. This application provided information
about symptoms of stroke, thrombolytic treatment, and
action plans for clients at risk of stroke(17). A study
through the development of stroke mobile pre-detection
application showed that most clients believed this
application could increase their awareness of stroke and
help them to detect early symptoms of mild stroke(18).
Other studiesalso showed the effectiveness of
smartphone applications, among others: “Stroke
Riskometer TM” application which was able to detect
stroke risk factors. Risk factors for stroke included age,
sex, systolic blood pressure, and waist circumference
(>89 for men and women)(19). “Stroke RiskometerTM”
application was an easy to use tool because individuals
could assess stroke risk independently and comfortably,
anytime and anywhere. “Stroke Riskometer” application
and showed the results “this could calculate the risk of
stroke for normal individuals(20).
The benefits of smartphone applications showed
that there was a need to develop smartphone-based
application interventions that could be used extensively
in the health sector, especially in managing carastrophic
diseases. Various problems in health services such as
access to service centers, lack of health care providers,
long treatment times, and high costs or needs of health
care providers both clients and government, made health
problems became complex and needed to get solution for
designing participatory services(21). The World Health
Organization (WHO) stated that digital technology
(mHealth) was intended to improve the quality and
coverage of care, improved access to health information,
services and skills, and promoted positive changes in
health behavior to prevent catastrophic diseases(22).
The benefits of smartphone use were also suggested,
mHealth which was an element of eHealth played
important roles in creating health services that were
easily accessed through smart telephone communication
such as providing health information as effortsto
prevent health problems, collect health data and monitor
clients(23). The mHealth (ex: smartphone) application
facilitated communication among users and the health
care systems, monitoring, and access to information
regarding medical records and developments(24). A
number of mHealth trials on stroke problems had shown
greater benefits from the use of smartphones as early
warning system (e-ways) in the early detection and
strokes prevention, complications and stroke recurrence
prevention. Through this literature review, it was
1392  Indian Journal of Public Health Research & Development, February 2020, Vol. 11, No. 02
expected to provide views on the development of health
technologies, especially the development of mHealth in
chronic diseases and catastrophic.
Conclusion and Suggestion
The use of smart phone as an early warning
system (e-ways) presented opportunities to reach the
wider communities in the effort of early detection and
prevention of stroke. In addition, the use of e-ways was
also able to prevent the recurrence of stroke. Most of the
Indonesian people had used smartphone applications, this
was enable the development of smart phone applications
in health services, especially in the prevention of stroke.
Acknowledgment: We expressed our gratitude for
the prayers and support from all parties, especially to the
our institutions.
Conflict of Interest: The researcher declare that
there are no conflict interests of this study
Source of Funding: This study was not supported
of funding.
Ethical Clearance: The ethical clearence taken
from Nursing Department, Health Polytechnic of
Minsitry of Health, Semarang, Indonesia committee.
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