New morbidity metrics published recently in The Lancet confirm the growing burden of non-communicable diseases, particularly in developing countries. In India, for example, ischemic heart disease, chronic obstructive pulmonary disease, and stroke accounted for 30% of all reported deaths in 2013.
In many rural Indian communities, poor health is a constant threat to the livelihood of entire families. Households typically rely on one wage earner to support three or more cohabiting generations.
Cardiovascular disease increasingly impacts young wage earners (under 60-years old), many of whom receive no healthcare whatsoever. This can take them out of the workforce and leave families without support. For this reason, heart disease is among the most devastating causes of poverty in India.
Obstacles to Care in Rural India
Source: sandeepachetan (Flickr: CC)
Seventy percent of India’s population is rural. The use of affordable preventive treatments for cardiovascular disease (i.e., smoking cessation, aspirin therapy, low-cost statins or beta-blockers) is quite low in these rural communities.
There are systemic roadblocks to healthcare delivery in rural areas, including a physician shortage and high out-of-pocket costs. In addition to long wait times, patients frequently must travel from their rural villages to urban areas to see a doctor. This means higher costs associated with travel—many don’t have cars—as well as time away from work.
SMART, Task-Shifting Solutions for Community Care Delivery
Researchers from George Institute in India, Australia, and the UK have joined forces, developing a decision support tool to attempt to change the way healthcare is delivered in rural villages.
SMARTHealth India is a Systematic Medical Appraisal Referral and Treatment (SMART) platform designed to increase access to care by connecting non-physician caregivers in the field to physicians for referrals and the development of treatment plans.
SMARTHealth India is a task-shifting initiative. It is a low-cost platform that empowers accredited social health activists (ASHAs) in rural villages with decision support using wireless connectivity, custom cloud-based software, and a mobile tablet.
ASHAs use the tablet to register patients, record their medical history, medication status and risk factors, and enter their vital signs (i.e., weight, blood pressure, glucose, etc.). Patient information is stored on secure EMRs that are accessible to local doctors.
The app calculates a patient’s level of risk of developing cardiovascular disease. Patients who need medication for cardiovascular disease are referred to clinics, while borderline patients are given health and wellness advice from the ASHA.
SMARTHealth India enables ASHAs and physicians to provide convenient, state-of-the-art care for chronic diseases at a fraction of the cost.
Change Is Challenging
A recent efficacy study conducted by the developers of SMARTHealth India indicated that, although the decision support tool worked and more patients were referred to physicians, achieving meaningful systemic change would be complex.
Of the 69 patients referred to a clinician for blood pressure medication, only 24 (35%) actually followed through with the visit. Of those 24 patients, only 10 (42%) were still taking their medications after three months.
Shifting patient assessment tasks from physicians and midwives to community health workers illuminated systemic issues, such as insufficient pay for ASHAs, role conflicts among health professionals, the lack of access to medicines in rural communities, and patient privacy concerns. These issues must be addressed before the true value of a system like SMARTHealth India can be recognized.
SMARTHealth India User Feedback Positive Overall
Many community health workers who screened patients using SMARTHealth India reported that the device helped them to better understand the norms for the vital measurements they take, as well as how, and to what degree, variances from the norm can contribute to cardiovascular disease. As a result, the ASHAs were more comfortable advising community members about behavior change.
In-village screening was important for patients, as rural residents screened with the platform liked its convenience and reduced costs.
Physicians felt that device use by ASHAs was a good strategy for maximizing the limited resources of government clinics.
Although originally developed to treat cardiovascular disease, the George Institute group is looking to expand to support the treatment of other common health issues in India, including diabetes, kidney disease, respiratory illness, and tuberculosis.
Jenn Lonzer has a B.A. in English from Cleveland State University and an M.A. in Health Communication from Johns Hopkins University. Passionate about access to care and social justice issues, Jenn writes on global digital health developments, research, and trends. Follow Jenn on Twitter @jnnprater3.