Scale-up of a primary care intervention (SMARThealth) for cardiovascular risk management in Malang, Indonesia

Women from villages in rural Indonesia, armed with smart phones are playing a key role in detecting and preventing cardiovascular disease, the most common cause of death in Indonesia. Researchers have found that their SMARThealth intervention has increased the use of blood pressure medication by 41% among individuals at high risk of heart disease. People taking the most effective combination of medication increased by 14.5%, compared to villages that didn't receive the SMARThealth diagnosis.

Indonesia is the world’s fourth most populous country, home to 260 million people. Poverty has been reduced by 50% since 1999 and it is the world’s 10th largest economy in terms of purchasing power parity. Life expectancy has risen steadily and currently averages 72.

Yet rapid demographic transition has brought its own challenges. Non-communicable diseases such as heart failure and stroke are on the rise. Cardiovascular disease accounts for one in three adult deaths.

Healthcare provision in Indonesia is limited, particularly in rural areas. People generally only seek primary care when urgently required, but with non-communicable diseases, this can often be too late. Dr Gindo Tampubolon's research demonstrated that almost 70% of respondents with moderate to high cardiovascular risk didn't receive cardiovascular care.

To tackle the problem, Dr Tampubolon teamed up with researchers from The University of Manchester's Faculty of Medicine, the George Institute for Global Health in Australia and the University of Brawijaya, Indonesia.

They developed a new intervention, called SMARThealth, which provides village health workers (locally known as kader) with training on blood sample collection, a smart phone to aid assessment and data collection, alongside specific cardiovascular care guidance. Health workers then share the data with qualified health professionals – resulting in a radical shift in healthcare delivery and improved cardiovascular care.

This research is being led by researchers at The University of Manchester in collaboration with, Anushka Patel, David Peiris, Praveen Devarsetty, Seye Abimbola, Blake Angell at The George Institute for Global Health, Sydney, Sujarwoto at The University of Brawijaya and Muhammad Abdurrahman at Malang district health authority.

This project is funded by the Australian government (National Health & Medical Research Council).

Findings

A recent study into the effectiveness of SMARThealth demonstrated striking improvements across eight Indonesian villages, covering 6,579 high-risk individuals.

After being diagnosed as high risk by SMARThealth, 57% of people were using blood pressure medication. This compares to rates of just 16% in villages that didn’t receive the intervention.

15.5% of high risk individuals in the SMARThealth villages were using the most effective combination of medications, compared with just 1% in the control villages.

SMARThealth has also enhanced the role of the kader community health workers, who has previously focused on supporting mothers and infants. The kader’s central role in the intervention and their link with doctors via the app has boosted their status within the community.

The SMARThealth programme has been adopted by the district of Malang as part of their innovative public health programme, which will make it available to the 3 million residents in the region.

Malang received an innovation award from the Indonesian government for its implementation of SMARThealth in November 2019.

SMARThealth has recently received a four year research grant for scale up evaluation from the Australian National Health and Medical Research Council.

Newspaper coverage of SMARThealth
Newspaper coverage of SMARThealth

Impact

For the past year, the SMARThealth programme has been adopted by the district of Malang as part of their innovative public health programme.

It has been recently launched by the regent, H. Sanusi, in a ceremony in Malang to mark its deployment to all villages in the district. The government is committed to funding this scale-up from local funds, securing its sustainability.

The complex intervention, based on SMARThealth mobile app, has secured an award for our local partner, the government of Malang district as the most innovative district in Indonesia for empowering people through mobile apps. The Indonesian government through the ministry of health conferred this award in a ceremony on 12 November 2019. Watch the video of the conferment

Outputs

Maharani, Tampubolon 2014. Unmet needs for cardiovascular care in Indonesia. PLoS One.

Maharani, Sujarwoto, Praveen, Oceandy, Tampubolon, Patel 2019. Cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in Indonesia: The SMARThealth Extend study. PLoS One.

Patel, Praveen, Maharani, Oceandy, Pilard, Kohli, Sujarwoto, Tampubolon 2019. Effect of a multifaceted mobile technology-enabled primary care intervention on cardiovascular disease risk management in rural Indonesia: a quasi-experimental study. JAMA Cardiology. In press.

Additional materials

PhD opportunities

If you have secured PhD funding, these are some research topics in this group:

  • Developing cardiovascular and cerebrovascular risk scorings in the community to replace the WHO and Framingham risk scorings currently in use and deploy them as an Open Data Kit app
  • Economic costing of cardiovascular disease and diabetes using blood biomarker signals
  • Medication compliance in use of essential medicine in rural population.

The group has experience working with large longitudinal cohort (tens of thousands of well characterised participants), blood biomarkers, severe attrition, survival information and payment for health care.