Identifying and managing cardiovascular risk in rural Indonesian communities

Cardiovascular disease is a global problem. Unbalanced diets, sedentary lifestyles and smoking are all significant risk factors. Awareness of these largely preventable risks, however, is often lower in low-and-middle income countries compared to high income countries, while facilities to deal with cardiovascular health problems are often more limited. These countries face an increasing burden from cardiovascular disease.

Dr Gindo Tampubolon

Gindo is a Senior lecturer in Global Health, at the Global Development Institute. He studies cognitive ageing in industrial countries and non-communicable diseases in Indonesia.

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Indonesia has a population of 267 million, with cardiovascular disease accounting for 1 in 3 deaths. Our research established that 70% of people over 40 were at cardiovascular risk. Identifying and managing these at-risk people is critical, especially in rural communities that are not close to a hospital. We worked with the George Institute for Global Health, Universitas Brawijaya, Indonesia and the District Government of Malang to design the SMARThealth programme to address this challenge in Malang.

Our initial research used blood biomarkers (testing for a protein that circulates in the blood) to find the level of risk in the Indonesian population. We found that at age 40, 70% of those tested were at moderate to high cardiovascular risk but were not receiving cardiovascular care. Inequality was also a factor, as those in rural areas and with lower incomes were less likely to have cardiovascular care needs met.

We then worked with our collaborators to design an algorithm which via, the SMARThealth app, analysed blood samples in real time to identify those at normal, medium and high risk. We used a simple traffic light system to indicate the level of risk. High risk means a 1 in 5 chance of hospitalisation or death from cardiovascular disease within ten years.

The team also trained local health volunteers (known as kaders) to collect blood samples and improve their knowledge of cardiovascular disease and associated risk factors. They were also trained in the technical use of the SMARThealth platform (mobile tablet, SMARThealth application and basic medical equipment).

Dr Delvac Oceandy

Delvac is a Reader in Cardiovascular Biology, with a focus on understanding the molecular aspects of cardiac remodelling and heart regeneration.

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Reducing cardiovascular risk

During a two-year trial across eight villages, around 12,000 people over the age of 40 were screened for heart disease. 6,579 were identified as being at high risk of cardiovascular death. Identifying these people meant their risk of cardiovascular death could be reduced by prescribing lifestyle changes or drugs. 57% of the 6,579 people at high risk are now using blood pressure-lowering medication compared to just 16% in villages that did not receive the SMARThealth intervention. Over the two years, there was a 14.5% reduction in the number of people at high risk and an estimated 3,750 people had an extended life expectancy as a result of the trial.

Wider rollout underway

In 2019, the Malang District Government received the Best Health Services Innovation Award 2019 from the Indonesian Ministry of Health for their role in implementing the SMARThealth programme. SMARThealth has been adopted by the district of Malang as its public health programme and is now being scaled up to three million residents in the region.

A cost-effective programme

Further research showed that compared to current standard care, the SMARThealth programme was a cost-effective way to improve the management of cardiovascular disease in this rural Indonesian population. Further scale-up may lead to additional significant gains in population health and sustainable progress toward universal health coverage for the Indonesian population.