A quality improvement approach to scaling up a complex health system intervention for the prevention and management of cardiovascular disease in rural Indonesia

Scaling up effective public health interventions is crucial for achieving universal health coverage, yet remains challenging. We report the use of the Plan-Do-Study-Act (PDSA) quality improvement model to support the iterative scale-up of a community-based cardiovascular disease risk management program in Malang District, East Java, Indonesia. A pragmatic implementation study comprising three PDSA cycles was conducted in 10 'test of scale-up' villages between April 2021 and December 2022. Each cycle included: 1) the capture of quantitative outcomes, such as the number of new community members screened per month and diagnostic summaries with predicted risk status; and 2) semi-structured interviews and focus group discussions with health care workers, community members, and community health workers in each village to assess acceptability, adoption, adaptations and perceived effectiveness. Based on identified implementation barriers, local Technical Working Groups designed change strategies, which were implemented and evaluated in subsequent cycles. The COVID-19 pandemic disrupted program delivery in the first two PDSA cycles, reducing screening to an average of 112 and 7, respectively. In cycle 3, 463 community members were screened. Across the 10 participating villages, 42 interviews and 30 focus group discussions were conducted per PDSA cycle. Key barriers included difficulty reaching male community members, inadequate resourcing, limited essential medications and poor integration with existing health information systems. Change strategies included centralising screening activities, leveraging instant messaging platforms, additional activities to engage men and streamlined procurement processes. Each village demonstrated versatility in addressing implementation challenges. These findings highlight the utility of the PDSA model in supporting the iterative scale-up of a community-based cardiovascular disease risk management programs in real-world settings, even amid significant disruptions such as the COVID-19 pandemic.