Potential Improvement in a Portable Health Clinic for Community Health Service to Control Non-Communicable Diseases in Indonesia

Abstract

The COVID-19 pandemic has limited routine community health services, including screening for non-communicable diseases (NCDs). An adaptive and innovative digital approach is needed in the health technology ecosystem. A portable health clinic (PHC) is a community-based mobile health service equipped with telemonitoring and teleconsultation using portable medical devices and an Android application. The aim of this study was to assess the challenges and potential improvement in PHC implementation in Indonesia. This study was conducted in February–April 2021 in three primary health centers, Mlati II in Sleman District, Samigaluh II in Kulon Progo, and Kalikotes in Klaten. In-depth interviews were conducted with 11 health workers and community health workers. At the baseline, 268 patients were examined, and 214 patients were successfully followed-up until the third month. A proportion of 32% of the patients required teleconsultations based on automatic triage. Implementation challenges included technical constraints such as complexity of applications; unstable networks; and non-technical constraints, such as the effectivity of training, the availability of doctors, and the workload at the primary health center. PHCs were perceived as an added value in addition to existing community-based health services. The successful implementation of PHCs should not only be considered with respect to technology but also in terms of human impact, organization, and legality.

1. Introduction

Non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases are the leading causes of death and disability globally, contributing to 70% of deaths, of which nearly 80% occur in low- and middle-income countries (LMICs) [1]. Epidemiological transition has resulted in the increasing prevalence of NCDs in Indonesia over the last 30 years. This requires the early prevention and control of NCD risk factors during all stages of the life cycle (continuum of care) through cross-program and cross-sector integration. Community health service for NCDs is a priority of primary health centers, which are oriented to control NCDs through the implementation of early detection of the risk factors, counseling, early follow-up, and referrals when needed [2].

The coronavirus disease 2019 (COVID-19) pandemic has had a serious impact on various health programs including NCDs [3]. There has been a change in health-seeking behavior in Indonesia, as indicated by a 14% decrease in primary health center visits [4]. Furthermore, the community health services did not operate regularly and even stopped during the pandemic [5,6]. The health situation in the community is under-monitored, especially among vulnerable populations, and some people tend to be passive and prefer to be visited by health workers [7].

To overcome these challenges, quality and easily accessible health services need to be developed to ensure resilience to health crises. Additionally, an adaptive and innovative approach is needed through the use of digital technology that enables remote services and the development of a health technology ecosystem [8]. Remote services using mobile technology have the potential to improve health access at the community level. Telemedicine was significantly adopted during the COVID-19 pandemic due to social restrictions and a health facilitation strategy with the aim of providing continuous patient care and promoting more efficient health care services without a reduction in quality [9,10]. Telemedicine is mostly conducted between health professionals or providers and patients for individual patient care. It provides benefits for patients in terms of cost savings and travel time and reaches communities in which it is difficult to access health facilities, in addition to reducing the contact between health workers and patients during the pandemic [11,12]. This is important because people with NCDs have a higher risk of complications requiring intensive care and have a worse prognosis if infected with COVID-19 [13,14].

The development of a health technology ecosystem was planned in the Ministry of Health and Digital Transformation, which created an integrated health data and health service application system for primary and referral health care [2]. TEMENIN has been implemented by the Ministry of Health as a telemedicine services application in health facilities since 2017. The pandemic situation has supported the widespread acceptance of online teleconsultation between health providers and patients [15]. A portable health clinic (PHC) was designed as a community-based telemedicine service and has potential to be linked between community health workers and primary health centers. PHCs are equipped with telemonitoring and teleconsultation using portable medical devices and an Android application.

These PHCs were initiated by Kyushu University, Japan, together with Grameen Communication, Bangladesh [16], and have been implemented in several countries, including Bangladesh, Japan, Cambodia, China, India, Malaysia, Pakistan and Thailand [17]. The aim of a PHC is to improve the quality of health services for targeted unreached community members in various health programs including maternal and child health [18], telepathology, tele-eyecare and virtual blood banks, as well as for health services during the COVID-19 pandemic [19].

Three primary health centers have been piloted in Indonesia by health workers at the centers and volunteer community health workers for NCD monitoring and outreach activities. PHC examinations include health interviews, as well as anthropometric, clinical and laboratory examinations (blood and urine) using portable medical devices and mobile applications. The applications facilitate teleconsultation between doctors and patients at the primary health center based on the examination results that are inputted in real time. The examination results are presented in a triage format, which shows the level of urgency for education and drug administration.

Many mobile health or mHealth applications have been developed and implemented by patients or health workers, but few have been facilitated by community health workers to conduct health examinations [20] at research locations. During the pandemic, health professionals prioritized the COVID-19 patients, with the impression of neglecting patients with chronic disease. Community health workers play a significant role in monitoring chronic disease patients in their surrounding area. To fill this gap, PHCs have been introduced to support health workers not only in telemonitoring and teleconsultation but also in providing basic physical examinations and simple lab tests to monitor chronic disease patients through monthly community health service programs. Therefore, the objective of this research was to implement PHCs and assess the challenges and potential improvements to deal with endemic conditions, in order to better control NCDs and support the resilience of the health system.

2. Literature Review

Development of mHealth options for chronic disease has been increasing in recent years including LMICs that are mostly used by the health workers and the patients [21]. The health workers used mobile technology for health consultancy and health care management [16]. Meanwhile, the patients usually used the mobile technology for self-screening, monitoring and health education [19]. In some developing countries including Indonesia, health services are limited due to the shortage of health professionals who are willing to stay in the outreach areas. Accordingly, the community health workers play significant roles in supporting the health program implementation such as monthly health post meetings at the village or sub-village level within the primary health center coverage area. The health post is normally facilitated in the community by community health workers where a health worker visits and provides basic services for under-five, elderly or reproductive health [16]. The activities are considered as routine programs, but the implementation of mobile health for the community health workers is still limited [20].

Community health workers are not formal health professionals but are chosen voluntarily by community members, then they are trained and supervised through the health system [22]. Community health workers are involved in various health programs such as maternal and child health, nutrition, vaccination, NCDs, health emergency response and disease surveillance in their working areas. Community health worker workloads are often high so that if they are not supported by adequate supervision, training, remuneration, transportation and equipment, these will negatively affect the quality of performance, productivity, satisfaction and program effectiveness [21]. Mobile technology for community health workers can be used to ensure a more manageable workload, efficiency and facilitate supervision [21,23].

The PHC and the mobile apps have potential to integrate primary health centers and the existing community-based health services, especially during the COVID-19 pandemic. Portable medical devices consist of an anthropometric set (weight scales, C, and metline), vital signs (sphygmomanometer, thermometer, and oximeter), peripheral blood tests kit (glucose, cholesterol, uric acid, and hemoglobin kit), urine examination sets (strips and urine pots), and personal protective equipment (PPE) (masks, hand gloves, hazard box, face shield, and hand sanitizer) as shown in Figure 1.

The Android application was equipped with an algorithm to calculate the health risk of a patient based on 12 parameters. Teleconsultation urgency is divided into four stages: green (normal), yellow (caution), orange (remote medicine) and red (emergency) as shown in

Table 1. Algorithm items to calculate the patient’s health risk [24].

Indicator	Unit	Normal	Caution	Remote Medicine	Emergency
Waist Hip Ratio	cm	Male < 1 Female < 0.8	Male 1 Female 0.8
Body Mass Index (BMI)	kg/m2	18.5–25	25.1–27.0	>27 or <18.5
Blood Pressure	mmHg	<120 and <80	120–139 and 80–89	140–159 and 90–99	≥160
Pulse	dpm	60–99	50–59 or 100–119	<50 or ≥120
Arrythmia		-		+
Body temperature	°C	<37	37–37.5	≥37.5
SpO2	%	≥96	93–96	90–93	<90
Fasting glucose	mg/dL	<100	100–125	126–199	≥200
Two-hour postprandial glucose	mg/dL	<140	140–199	≥200
Cholesterol total	mg/dL	<200	200–239	240–500	>500
Uric acid	mg/dL	Male 3–6 Female 2.5–5	6.1–7.6 5.1–6.3	7.7–9 6.4–9	>9 >9
Hemoglobin	g/dL	Male > 13 Female > 12	>10–13 >10–12	8–10 8–10	<8 <8
Protein urine		-	+	> +
Glucose urine		-	+	> +

Green: normal; yellow: caution; orange: remote medicine (teleconsultation); red: emergency (teleconsultation and need to visit the health facilities)

. The user interface is differentiated based on the field officer and teleconsultation provider. The field officer feature allows for patient search and registration, entry of examination results, generation of triage algorithms, teleconsultation and treatment. The doctor feature allows for telemonitoring and teleconsultation as well as drug administration (Figure 2).

PHC acceptance was measured using the technology acceptance model framework [25,26] to analyze empirically the factors that affect the attitudes and intentions of users with the adoption of the new technologies such as telemedicine [16]. User acceptance was divided into two main predictors, perceived usefulness and ease of use. The development of the TAM framework for telemedicine included seven external variables: trust, facilitating conditions, technology anxiety, resistance to use, social influence, perceived risk, and privacy [16,27,28].

3. Materials and Methods

PHC in Indonesia was tested on a limited area at the Samigaluh II Health Center in Kulon Progo District Yogyakarta Province, the Mlati II Health Center in Sleman District Yogyakarta Province and Kalikotes Health Center Klaten District, Central Java Province in February–April 2021. Samigaluh is a rural area with hilly terrain, while Mlati and Kalikotes are urban areas. A qualitative study to assess the potential for PHC improvement was conducted through in-depth interviews with 11 primary health care workers consisting of 3 doctors, 3 nurses, 1 midwife and 4 community health workers. In-depth interviews were conducted using video conferencing in April–May 2022 regarding barriers and acceptance of health workers to the PHC implementation using the technology acceptance model, with their recommendations for sustainability and scaling-up. To ensure the validity and reliability, the instrument was piloted and all the reviewers were trained.

Online training was used due to the COVID-19 pandemic situation. The training process was conducted at a predetermined time span for three days using WhatsApp auto-reply. The training modules consist of the flow of patient examinations, patient care, application usage, as well as health protocols and waste treatment. Each training participant was given pre-test and post-test questions to measure their understanding of the training material in each module and assignments at the end of the training.

The service procedure was conducted through the following steps: (1) patient registration, initial assessment, cognitive, psychological, and vital sign measurements; (2) peripheral blood tests; (3) urine examination; (4) teleconsultation and medication conducted by a primary health care doctor based on an algorithm; and (5) telemonitoring in the next PHC schedule. At first, all patients were collected based on the village health post meeting schedule which was conducted at the village hall. If the patients were unable to attend, the community health worker would make home visits. Monitoring by the authors was carried out online once a month by inviting input from the PHC health workers from three primary health centers, as well as field visits. There was a chat group to communicate between the authors and health workers.

At the beginning of this activity, in February 2021, 90 subjects were collected at Kalikotes Health Center, 83 subjects at Mlati II Health Center, and 95 subjects at Samigaluh II Health Center. A total of 268 subjects agreed to participate in this study. The number of respondents who were successfully followed-up until the third month were 214 subjects, consisting of 86 subjects at Kalikotes Health Center, 57 subjects at Mlati II Health Center, and 71 at Samigaluh Health Center (response rate 79.85%).

4. Results

Hypertension was the most common history of disease mentioned by the subjects, especially at the Mlati II Health Center which affected 73.7% of the subjects, while at the Samigaluh II Health Center, it was 23.3% and the Kalikotes Public Health Center, it was 1.4%. Some subjects also had diabetes mellitus, especially at Kalikotes Health Center (16.3%) and Mlati II Health Center (29.8%). There were 32% of the patients identified based on the automatic triage who required teleconsultation.

Factors that influence the acceptance of the use of PHC consist of technical constraints, non-technical constraints, perceived usefulness, perceived benefits, positive perceptions, risks of using, and support for the work environment. The analysis of PHC acceptance is mapped in Figure 3.

4.1. Perceived Usefulness

PHC is believed to be useful in facilitating access to health services, providing alternative programs in the community, and lowering costs and travel time. From the perspective of health workers. PHC can be used to early detect patients’ disease such as NCDs, monitor health conditions regularly, and follow-up the examinations which usually stop at community health workers so that doctors can provide appropriate therapy.

“The benefit is make it possible for us to conducted screening so we can know if there are patients with new diagnoses using PHC. From the patient’s point of view, there are also many benefits of supporting examinations to find out the diagnosis of the disease. Sometimes we don’t just stay in one place, sis, the locations can move so we can examine lots of people including the new participants”.

(I5, Nurse)

4.2. Perceived Easy of Use

PHC is easy to use because of its simple application, portable medical devices are often used, and there is a group communication to discuss the barriers of implementation.

“There are not too many obstacles because the only thing received by the doctor is a cell phone, on my opinion it is quite easy to use this tool”.

(I6, Doctor)

4.3. Facility Conditions

Facility conditions that affect the implementation of PHC include technical and non-technical constraints. The challenge from a technical aspect is due to the complexity of the application, such as unusable or confusing features, which are not yet integrated, requiring loading the application several times, and an unstable Internet network in some locations. From a non-technical perspective, the online training is still not effective, several officers are not used to conduct examinations and data entry simultaneously, participants are not familiar with the new application, there is limited availability of doctors who provide teleconsultation and the workload is heavy at the primary health center.

“We are in the area that there is no signal, the tablet isn’t 4G yet, sis, it’s still 3G, there was only 1 point signal showed in the tablet, so it can’t be loaded in real time”

(I2, Community health worker)

4.4. Social Influence

There is support from the leaders and/or the managers related to the coordination of PHC implementation and the flexibility of tasks at the primary health centers. The community health workers also support this activity by coordinating with the community, conducting health examination, data entry, and drug distribution.

“In my place there are problems with medical devices. If the manager doesn’t support it, it’s impossible to borrow from health center, the manager often evaluates and follows, asks about field constraints so we won’t be ignored”.

(I4, Doctor)

4.5. Resistance to Use

There is a positive response that PHC can be used even beyond the COVID-19 pandemic. PHC has potential to be applied to other health programs such as maternal and child health services and for areas that have not implemented the village health post yet.

“So, in my opinion because of the IT era, right, the PHC was a breakthrough that was initiated during the pandemic, but I think it is suitable in normal situations or the new normal era. It is still relevant to use, but it must be adjusted and repaired. Adjusted because the PHC that you are developed is for common diseases with an adult target. Future it can be separated for under five children so that we can immediately integrate with the village health service for children like that. Now the intervention only stops at the community health worker”.

(I4, Doctor)

4.6. Perceived Risk

Perceived risks were conveyed by doctors because of the limitations of the direct physical examination, so it was feared that there would be an error in diagnosis or medication. This is especially for examinations that require visual check-ups such as skin examination. In addition, communication with the elderly was challenging because some have hearing, visual and cognitive impairments.

“It’s just the drawbacks of not being examined face to face, so we will examine it based on the result obtained by the nurses and community health workers”.

(I4, Doctor)

The potential improvement in PHC was divided into a technical and non-technical (social) approach based on the recommendations from the users (Figure 4). Based on the technical points, applications need to support offline data entry in case of network problems, thus enabling local storage before entering the database. From the organizational side, it is necessary to increase the capacity of community health workers to be more familiar with PHC and be motivated to do data entry in real time. It is necessary to schedule and allocate time between services at the primary health center and community-based services, especially for the doctors who conduct teleconsultation. One of the sustainability aspects of PHC is to shift the role of health workers to community health workers for basic checking assisted by the health risk algorithms in the application.

Coordination with various stakeholders is needed not only between PHC health workers, but in order to expand coverage, it is also necessary to coordinate with the health office. The head of the primary health center will be the supervisor as well as the person in charge of the program at the health center level. The organizational framework for implementing PHC can be structured as shown in Figure 5.

5. Discussion

PHC is an alternative approach to providing the health services that have been disrupted due to the COVID-19 pandemic. PHC provides community-based services where health care workers and community health workers use portable medical devices and mobile applications to provide health services in the outreach areas or through home visits. The PHC improved access to health services in the community level when there are restrictions on visits at the health facilities such as during the COVID-19 pandemic. PHC can reduce the risk of being exposed to the COVID-19 virus on the way to health care facilities, in the waiting rooms, and when meeting with health workers [27,30]. It can determine whether a patient requires further medical appointments to avoid unnecessary visits. Real-time data collection of certain parameters in the PHC enables health care providers to observe patient conditions directly [31], and indirectly save costs, time and travel for the patients [32]. At the same time, the PHC has empowered and increased community participation in NCD prevention and treatment programs [33,34].

Compared to conventional telemedicine, which only facilitates consultation with health workers, the PHC is equipped with clinical decision support systems. It provides alerts and recommendations through a combination of physical examinations, simple laboratory tests related to NCDs, cognitive, mental health and behavior assessments. The algorithms are embedded into the mobile applications where users are assisted to measure the health risks of a patient and determine options for further actions. However, incorporating the PHC into routine community-based activities requires further validation and continuous refinement of the algorithms, with organizational formation, while strengthening the human resources capacity and legality aspects [35].

Improving the capacity of community health workers to use mobile apps was also a solution for supporting community members or patients who have low smartphone experience and can benefit from the emerging information and communication technology [36]. The continuity of patient health records; real time monitoring of patient health status; clinical-decision-support systems through automatic triage from the patient observations; targeted teleconsultation and recommendation of patient referral, health promotion, and education are enhancements to the current community-based services in primary health centers. Moreover, the study showed there was a good user acceptance of the developed mobile technology to facilitate PHC implementation that can further improve the adoption of PHC at the community level [37].

The implementation of PHC or telemedicine requires interconnected technology such as electronic medical records, high-speed Internet access [38], standard applications and mobile devices. It is still challenging in some areas that have limited infrastructure and expertise, lack of Internet coverage, non-interoperable electronic medical records and fragmented information systems at the health facility level. High-speed Internet access is required to have synchronous teleconsultation while electronic data capture serves as the tool to collect patient data as their medical records achieve optimal service [39]. In Bangladesh, for example, clinics are still using paper-based medical records which do not make it possible to continuously monitor patients’ health status effectively. The Samigaluh 2 Primary Health Center in Kulon Progo District which is located in a mountainous area faced the Internet problem to operate the PHC mobile apps. Many health care facilities located in rural areas tend to have limited resources to use this type of technology [39]. This is exacerbated by the issue of security, privacy, confidentiality, and data protection.

The PHC is still being implemented while the mobile application is continuously improved to collect health data at the community level, including interoperability with electronic health records at the primary health centers. Pilot implementation of PHC in Bangladesh found that having a unique patient ID using their cellphone number was the key to identifying patients and further recording clinical data [16]. Meanwhile, in Indonesia, the National Identification Number (NIK) and the social health insurance number can be used to uniquely identify individuals. However, this unique ID cannot be shared easily and that barrier hinders the interoperability. Commitment is needed to utilize PHCs where cross-sectoral collaboration should be encouraged [19].

The implementation of PHC and community-based telemedicine is facing several challenges. It is necessary to consider implementation costs, initial funding, and program sustainability in primary health centers and district health offices. Health facilities, health care workers, and community health workers should adapt with the new health care model and the training process, anticipating the benefits and perspective of the workload of utilizing telemedicine [40]. Some health care providers are also concerned about medical errors, low patient satisfaction, communication obstruction between doctors and patients, and lack of monitoring of patients’ health status [9]. As presented in the PHC study in Bangladesh, another non-technical challenge showed that the doctors found it difficult and uncomfortable to use computers to enter data during consultations which impacts the completeness of the patient’s data. This gap will also affect the follow-up process of a patient’s care in the future [19].

Organizing community-based health programs requires strong collaboration between the primary health centers and the community. It is necessary to formally delegate the tasks and responsibilities of health care workers and community health workers, while providing better scheduling of community health program activities, and the continuous monitoring and evaluation of the implementation of the PHC. Furthermore, the adoption of new health information systems needs continuous learning and training [41]. The implementation of a PHC should involve various health care providers in the primary health centers such as pharmacists, nutritionists, psychologists, and other stakeholders such as village heads, community leaders, community health workers, and the local residents. Cultural adaptation requires managerial efforts to provide comprehensive planning so that the role of the health office is needed to ensure the sustainability and scaling-up of the PHC to other community health programs such as school health programs, environmental health, and reproductive health [35].

Based on the legal aspects, by definition, the community health workers have roles including health promotion and disease prevention, while mobilizing and encouraging community members to utilize health services and facilitating access to health care [42]. Several community health workers, especially in the LMICs, have additional roles in providing treatment for basic clinical conditions (first aid) and screening [43]. Community health workers also play a role in assisting in the collection and reporting of health status data in the community [42]. A PHC adapts the role of community health workers and provides basic literacy skills through training.

For the financial sustainability of the PHC, the burden can be divided between the primary health care funds and village funds provided by the government. The Indonesian government regulation states that the priority for developing village funds is for basic social services such as the provision of infrastructure for public health, including village health posts [44]. Financial and logistic support in providing consultation and treatment for community members who are in the chronic disease management program approved by Health and Social Security Agency can be claimed by the primary health centers.

6. Conclusions

The new digital approach that allows remote services has the potential to improve health access and monitor the health status of vulnerable populations, especially those who have been diagnosed with NCDs. The PHC supports health data management at the community level. The PHC was perceived as an added value for the existing community-based health services that are conducted by the primary health center. This model may potentially be used to support a number of health programs where community health workers are involved. Interoperability with medical records in the primary health centers would be beneficial for the continuation of patient care. The successful implementation of PHC is not only considered from the applications of technology but also non-technical aspects related to human impact, organization, and legality.

The scope of this research was limited to a small number of primary health centers in Indonesia. The study was also limited to the perceptions of health workers and community health workers appointed for the implementation of a PHC for monitoring and detection of NCDs in the community. The feasibility of the PHC can be further analyzed to support other health programs or other areas with different resource conditions.