Implementing echocardiographic screening for the early detection of rheumatic heart disease in remote First Nations Australian communities

Thesis

Rheumatic heart disease continues to cause substantial morbidity and mortality in remote First Nations communities in Australia, despite being largely eliminated in the rest of the country. Echocardiography allows for early detection and timely management to prevent disease progression, but access is often limited in highburden settings. A task-sharing model of echocardiographic screening, whereby local healthcare staff are trained to use handheld devices to scan children’s hearts, with remote cardiologist interpretation, has emerged as a promising, evidence-based means of improving access. However, optimal implementation remains unclear. This thesis aims to improve understanding of how echocardiographic screening for rheumatic heart disease can be implemented in remote First Nations communities.

The thesis begins with an overview of the topic in Chapter 1 and an outline of the methods in Chapter 2. This is followed by four original research chapters. Chapter 3 presents a narrative review of implementation lessons from a comparable screening programme and a scoping review of Theory of Change use in programme design and evaluation. Chapter 4 describes the co-design of implementation plans for an echocardiographic screening programme across five remote communities. Chapters 5 and 6 report the process evaluation and realist evaluation of the screening programme, respectively.

The results of this thesis draw on data collected across five remote sites, including 36 interviews, 39 surveys, seven focus groups, 200 researcher-days of observation, 360 scan records, costing data, and administrative data. These data indicated that the implementation of echocardiographic screening resulted in modest and variable activity with a site-level screening coverage of 3–85% of the eligible population. Fidelity to the original programme design was limited by unreliable device readiness, image upload failures, and delays in image review. Set-up and training cost AU$51,903 per site, plus approximately AU$9,858 per year for implementation support. Under the conditions observed across sites, embedding opportunistic screening into First Nations community health workers’ routine practice was difficult. Successful embedding depended on the perceived legitimacy of the scanner role and on support for the invisible logistical and relational work required to scan. Event-based screening increased coverage, albeit at higher cost.

Overall, the findings support a hybrid approach that strengthens the conditions for opportunistic screening within facilities, complemented by periodic screening events with visiting sonographer support. Future research should explore policies, guidelines, and funding models that enable sustained screening and scale-up.

Authors: Jones, B

• DOI: 10.5287/ora-w4qga1dze
• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford
• Language: English
• Keywords: task-sharing; implementation science; screening; realist evaluation; Theory of Change; First Nations health; rheumatic heart disease; process evaluation; remote healthcare; community health workers; echocardiography; Indigenous health
• Subjects: Rheumatic heart disease; Implementation science