Task-sharing echocardiographic screening for rheumatic heart disease in remote First Nations Australian communities: implementation evaluation from the NEARER SCAN study
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Background
Rheumatic heart disease (RHD) remains a major cause of premature death in low- and middle-income countries and First Nations communities. Early detection and management can prevent progression, but requires echocardiography, which is limited in high-burden settings. Task-sharing echocardiographic screening is an accessible, evidence-based approach but implementation remains unclear.
Methods
We conducted a prospective implementation evaluation of a co-designed task-sharing screening programme across five remote First Nations Australian communities between May 2023 and November 2025. Predominantly community health workers (CHWs), alongside nurses and doctors, were trained to scan using handheld devices with off-site cardiologist interpretation. We assessed implementation outcomes and used a realist evaluation to explore how context shaped CHWs’ ability to complete training and embed screening into routine work. Data included scanning activity, surveys, costing, interviews, focus groups, and field notes.
Findings
We trained 32 staff (21 CHWs, 8 nurses, 3 doctors) to scan across five sites with 14 achieving certification. Scanning frequency was lower and more variable than anticipated: 360 scans (including training and post-certification) of 5–20-year-olds over 14 months, with site-level coverage of 3–85%. Fidelity was limited by device unavailability, charging problems, and delays in uploads and reviews. Set-up and training cost A$51,903/site, plus A$9,858/year in implementation support. Screening was easier for CHWs to embed when the legitimacy of their role as a scanner was communicated, but harder when invisible work outweighed opportunities to scan.
Interpretation
Future implementation will require efforts to legitimise CHWs’ scanning and support invisible work. Event-based screening offers a promising complementary strategy. Scale-up requires policy support.
Funding
This research was funded by the Australian Medical Research Futures Fund Cardiovascular Health Mission (GNT2015869), in addition to philanthropic donations from Medtronic Australasia, Edwards Life Sciences and the Rotary Club of Kiama. Hand-held devices (Philips Lumify, USA) were donated by Humpty Dumpty Foundation and East Timor Hearts Fund. BJ was supported by a Rhodes Scholarship.
Research in context
Evidence before this study
RHD is concentrated in low-resource settings where access to echocardiography is most limited. Previous studies have shown that task-sharing echocardiographic screening with briefly trained local scanners using handheld devices and simplified protocols to scan with off-site expert review, is an adequately accurate approach that could support early detection. However, the evidence has focused on diagnostic performance rather than implementation in routine health services. Little is known about implementation outcomes, cost, and the conditions required for screening to become embedded in everyday care.
Added value of this study
Our study has identified some of the real-world challenges in implementing this evidence-based early detection programme in practice, addressing a recognised gap for this prevalent disease of inequity. It advances understanding of how to implement task-sharing echocardiographic screening for RHD by identifying key implementation strategies, the mechanisms through which they operate, and the conditions that enable or hinder them. It quantifies what implementation costs in practice and identifies fidelity shortfalls. It extends the task-sharing literature by highlighting the importance of role legitimacy and invisible work when embedding a new practice into the routine care provided by CHWs.
Implications of all the available evidence
Task-sharing echocardiographic screening remains a community-supported and promising approach to early detection in remote First Nations Australian communities, but effective implementation requires more than initial training and devices. Ongoing sonographer visits, screening events, and implementation strategies that signal legitimacy and support invisible work will be needed to create the conditions for CHWs to scan regularly enough to maintain their skills and complete training in a timely manner. Policy support will be required, alongside further evaluation of long-term sustainability.
