Table 2 SMARThealth India- Project 7 (IND 7)

Project overview

SMARThealth India uses mobile technologies to provide village-based, non-physician health workers with personalised clinical decision support to guide cardiovascular disease (CVD) risk assessment and management. The system is being tested in rural villages in Andhra Pradesh, India. It is integrated with government primary health care centres. Individuals identified at high CVD risk are referred to the treating doctor for ongoing management and follow-up. The doctor also has access to the decision support tools and patients are provided with interactive voice prompts to support ongoing care and follow-up. The system is being tested in a stepped-wedge cluster randomised controlled trial involving 18 primary health care centres, 54 villages and around 15,000 individuals at high CVD risk. The primary outcome is improvements in the proportion of people at high CVD risk who are achieving national guidelines blood pressure targets.

Previous research conducted to inform this work

The research team has been working in this region for the past decade. Previous studies had been conducted documenting the rise in blood pressure related disease burden in the region and gaps in access to recommended treatments had been quantified [34]. An intervention trial had also been conducted which found that non-physician health workers could perform routine CVD risk assessments to the level of a physician using a simple paper-based algorithm chart [35].

Pilot study

Building on this work, a prototype tablet based decision support 'app' was developed and trialed for use by 11 non-physician health workers and three government doctors for around 200 patients. The COM-B model was used to guide the evaluation [22]. The qualitative component identified three inter-related interview themes: (1) the decision support technology had potential to change prevailing health care models, (2) shifting tasks traditionally performed by a doctor to the community health worker was the central driver of change, and (3) despite high acceptability by end users, actual healthcare transformation was substantially limited by system-level barriers such as patient access to doctors and medicines.

Completion of the survey tool

On the basis of the above information the SMARThealth research team met via teleconference to complete the survey. The target behaviour change is to improve blood pressure control amongst people at high CVD risk. A consensus approach was taken to determine the ratings and this was informed by the recently completed pilot evaluation. Doctor capability was rated high, however, motivation and opportunity were rated low. The pilot evaluation found that working conditions, salary and competing priorities were all factors that limited doctors from improving blood pressure control in the target population. For health workers capability was low as most health workers had no previous experience in conducting CVD risk assessments, however, motivation was assessed as high as previous research demonstrated high levels of interest in expanding current roles to include chronic disease screening and prevention. Current opportunities, however, to do this are low as there are few chronic disease training programs for this workforce. Community capability and opportunity were rated low as previous studies have demonstrated large health literacy gaps and major shortfalls in people's ability to access health care. Motivation to engage in the primary health care sector was rated medium as community members interviewed during the pilot had varying confidence in the ability of this sector to meet their healthcare needs.