Co-designing the implementation of a rural health systems-strengthening rheumatic heart disease program with remote First Nations Australian communities using Theory of Change

BACKGROUND: Rheumatic heart disease (RHD) is highly prevalent and under-detected in remote First Nations Australian communities. Rural communities face severe health workforce shortages that impact negatively on health outcomes. Task-sharing using local healthcare workers, trained to screen for active RHD cases (using handheld ultrasound with remote support from experts), has been proposed as a means of improving early detection whilst also strengthening referral pathways. Implementing new models of care within remote communities, however, requires local knowledge, cultural and operational adaptation, whilst ensuring consistency and quality assurance across multiple sites. This study aimed to co-design local implementation strategies for an RHD active case finding program with five remote communities and explain how and why the task-sharing program might lead to improved health outcomes. METHODS: A qualitative study using a Theory of Change approach and 'yarning' methods, was conducted with five remote First Nations Australian communities. We used a combination of participant observation, extensive field notes over sequential visits to each site, supplemented with document analysis to inform co-design of Theories of Change for each community. Data were curated using NVivo software and analysed using Powell's refined compilation of implementation strategies framework. RESULTS: Through the co-design process, a total of 24 locally tailored implementation strategies were identified. All sites identified the need for a positive implementation environment, including recognition of local healthcare workers through positive messaging and celebratory events for achieving key training milestones. Other key themes included the importance of opportunistic RHD screening, and the integration of local languages during both training and screening. Five locally adapted versions of the Theory of Change were co-designed to include planned outcomes, assumptions, causal mechanisms, and indicators for the program at each community. CONCLUSIONS: Our study identified implementation strategies and Theories of Change for the training and screening aspects of a new model of care for RHD screening in five remote First Nation Australian communities. These findings will be used to support future program evaluation and exploration the mechanisms by which the RHD screening program achieves its outcomes.