Why do strategies to strengthen primary health care succeed in some places and fail in others? Exploring local variation in the effectiveness of a community health worker managed digital health intervention in rural India

Bibliographic Data

ID21880682
AuthorsGill Schierhout (0000-0002-6399-7624, UNSW Sydney), Devarsetty Praveen (0000-0002-0973-943X, UNSW Sydney, corresponding author), Bindu Patel (0000-0002-8410-6464, UNSW Sydney), Qiang Li (0000-0003-2737-0768, UNSW Sydney), Kishor Mogulluru (George Institute for Global Health), Mohammed Abdul Ameer (George Institute for Global Health), Anushka Patel (0000-0003-3825-4092, UNSW Sydney), Gari D Clifford (0000-0002-5709-201X, Georgia Institute of Technology), Rohina Joshi (0000-0002-3374-401X, The George Institute for Global Health), Stéphane Héritier (0000-0002-0993-9933, Monash University), Pallab K Maulik (0000-0001-6835-6175, UNSW Sydney), Pallab Maulik (UNSW, Sydney, New South Wales, Australia), David P Peiris (0000-0002-6898-3870, UNSW Sydney)
Year2021
Volume6
IssueSuppl 5
Pagese005003
Publication date2021-07-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueBMJ Global Health (JOURNAL)
Journal identifiersISSN: 2059-7908 • E-ISSN: 2059-7908
PublisherBMJ (PUBLISHER • GB)
DOI10.1136/bmjgh-2021-005003
PMID34312146
OpenAlexW3183720791
LanguageEN
Citations received3
References cited28

INTRODUCTION: Digital health interventions (DHIs) have huge potential as support modalities to identify and manage cardiovascular disease (CVD) risk in resource-constrained settings, but studies assessing them show modest effects. This study aims to identify variation in outcomes and implementation of SMARTHealth India, a cluster randomised trial of an ASHA-managed digitally enabled primary healthcare (PHC) service strengthening strategy for CVD risk management, and to explain how and in what contexts the intervention was effective. METHODS: We analysed trial outcome and implementation data for 18 PHC centres and collected qualitative data via focus groups with ASHAs (n=14) and interviews with ASHAs, PHC facility doctors and fieldteam mangers (n=12) Drawing on principles of realist evaluation and an explanatory mixed-methods design we developed mechanism-based explanations for observed outcomes. RESULTS: =62.4%, p<=0.001). The observed heterogeneity in trial outcomes was not attributable to any single factor. Key mechanisms for intervention effectiveness were community trust and acceptability of doctors' and ASHAs' new roles, and risk awareness. Enabling local contexts were seen to evolve over time and in response to the intervention. These included obtaining legitimacy for ASHAs' new roles from trusted providers of curative care; ASHAs' connections to community and to qualified providers; their responsiveness to community needs; and the accessibility, quality and appropriateness of care provided by higher level medical providers, including those outside of the implementing (public) subsystem. CONCLUSION: Local contextual factors were significant influences on the effectiveness of this DHI-enabled PHC service strategy intervention. Local adaptions need to be planned for, monitored and responded to over time. By identifying plausible explanations for variation in outcomes between clusters, we identify potential strategies to strengthen such interventions

Business · Community health · Digital health · Environmental health · Family medicine · Health care · Political science · Primary care · Primary health care · Public health · Global Maternal and Child Health · Medicine · Mobile Health and mHealth Applications · Nursing · Telemedicine and Telehealth Implementation

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