Association of Multifaceted Mobile Technology–Enabled Primary Care Intervention With Cardiovascular Disease Risk Management in Rural Indonesia

Abstract

IMPORTANCE Cardiovascular diseases (CVDs) are the leading cause of disease burden in Indonesia. Implementation of effective interventions for CVD prevention is limited.OBJECTIVE To evaluate whether a mobile technology-supported primary health care intervention, compared with usual care, would improve the use of preventive drug treatment among people in rural Indonesia with a high risk of CVD. DESIGN, SETTING, AND PARTICIPANTSA quasi-experimental study involving 6579 high-risk individuals in 4 intervention and 4 control villages in Malang district, Indonesia, was conducted between August 16, 2016, and March 31, 2018. Median duration of follow-up was 12.2 months. Residents 40 years or older were invited to participate. Those with high estimated 10-year risk of CVD risk (previously diagnosed CVD, systolic blood pressure [BP] >160 mm Hg or diastolic BP >100 mm Hg, 10-year estimated CVD risk of 30% or more, or 10-year estimated CVD risk of 20%-29% and a systolic BP >140 mm Hg) were followed up.INTERVENTIONS A multifaceted mobile technology-supported intervention facilitating community-based CVD risk screening with referral, tailored clinical decision support for drug prescription, and patient follow-up. MAIN OUTCOMES AND MEASURESThe primary outcome was the proportion of individuals taking appropriate preventive CVD medications, defined as at least 1 BP-lowering drug and a statin for all high-risk individuals, and an antiplatelet drug for those with prior diagnosed CVD. Secondary outcomes included mean change in BP from baseline. RESULTS Among 22 635 adults, 3494 of 11 647 in the intervention villages (30.0%; 2166 women and 1328 men; mean [SD] age, 58.3 [10.9] years) and 3085 of 10 988 in the control villages (28.1%; 1838 women and 1247 men; mean [SD] age, 59.0 [11.5] years) had high estimated risk of CVD. Of these, follow-up was completed in 2632 individuals (75.3%) from intervention villages and 2429 individuals (78.7%) from control villages. At follow-up, 409 high-risk individuals in intervention villages (15.5%) were taking appropriate preventive CVD medications, compared with 25 (1.0%) in control villages (adjusted risk difference, 14.1%; 95% CI, 12.7%-15.6%). This difference was driven by higher use of BP-lowering medication in those in the intervention villages (1495 [56.8%] vs 382 [15.7%]; adjusted risk difference, 39.4%; 95% CI, 37.0%-41.7%). The adjusted mean difference in change in systolic BP from baseline was −8.3 mm Hg (95% CI, −10.1 to −6.6 mm Hg). CONCLUSIONS AND RELEVANCEThis study found that a multifaceted mobile technology-supported primary health care intervention was associated with greater use of preventive CVD medication and lower BP levels among high-risk individuals in a rural Indonesian population.

Interactive Training and Education Improves Basic Hypertension Knowledge of Woman Cadres in Surabaya

“…This study also only evaluates the effect of training and education on the knowledge after interactive education and training, rather than its real impact on hypertension in the community. Therefore, future studies should be done using more samples from various locations to evaluate the benefit of hypertension knowledge improvement in the women cadre toward public awareness of hypertension and willingness to control their lifestyle and compliance with hypertension treatment [23].…”

Cardiometabolic Risk Factors in Pregnancy and Implications for Long-Term Health: Identifying the Research Priorities for Low-Resource Settings

“…The community-based management of hypertension in Nepal (COBIN) cluster randomized controlled trial in the general adult population of Nepal, established the effectiveness of a CHW-led home-based health education and screening for the reduction of Systolic BP (of almost 5 mmHg), in adults with hypertension; and amelioration of age-related increases in BP in adults without hypertension (52). Further examples of community-based programmes with potential to reduce cardiovascular risk in LMIC settings exist (53)(54)(55)(56), however as the COBIN trial team concluded; long-term trials with hard clinical outcomes, such as myocardial infarction and stroke as primary endpoints are needed to confirm the effect of CHW-led interventions on cardiovascular mortality and morbidity (52). Important areas for future research would be to conduct adequately sized, robustly designed trials, demonstrating tangible impact upon mortality across the lifecourse, including cost effectiveness analyses, and exploration of the impact of climate change and seasonal variations on BPrelated endpoints (57,58).…”

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“…In 2016, CVD accounted for a third of all deaths in Indonesia. 88 The government developed a policy for preventing and managing CVD through advocacy, health promotion, and health system strengthening particularly at district health agencies. Systematic Medical Appraisal Referral and Treatment (SMARThealth)-a multifaceted mobile technology-supported primary healthcare interventions was evaluated in populations from eight rural villages in Indonesia.…”

“…Systematic Medical Appraisal Referral and Treatment (SMARThealth)-a multifaceted mobile technology-supported primary healthcare interventions was evaluated in populations from eight rural villages in Indonesia. 88 The mobile application enabled primary healthcare nurses and physicians and community healthcare workers to collect patient information using basic equipment, assess individuals' risk status, receive tailored decision support, provide lifestyle advice and refer high-risk individuals to nurses and physicians. Use of SMARThealth interventions led to a significantly greater proportion of high-risk rural Indonesian population achieving systolic BP target <140 mmHg than those without the intervention (31.0% vs 22.2%, adjusted relative risk 1.3; 95%CI: 1.2-1.5; p<0.001).…”

“…Use of SMARThealth interventions led to a significantly greater proportion of high-risk rural Indonesian population achieving systolic BP target <140 mmHg than those without the intervention (31.0% vs 22.2%, adjusted relative risk 1.3; 95%CI: 1.2-1.5; p<0.001). 88 These effects were driven by a greater use of preventive CVD medications among high-risk individuals receiving SMARThealth interventions compared with individuals without the intervention (56.8% of individuals in the intervention villages used BP medication vs 15.7% of individuals in the control villages). 88…”