Inclusion Criteria- aged more than 18 years old;
- will live in this village for at least nine months during the next 12 months;
- have a history of stroke (including ischemic and hemorrhagic stroke) diagnosed at county hospital or higher-level facilities, and are in stable condition;
- have at least a basic communication ability (i.e. can understand simple instructions);
- give their informed consent and are willing to participate in the study.
Exclusion Criteria- are bedridden;
- have serious mental diseases;
- have other serious diseases;
- have a remaining life expectancy of less than 6 months.