COURSE IMPRESSIONS |

The Harvard GHP 298 Winter Session Trip brought ten masters and doctoral students of public health to India to examine the country’s framework for addressing non-communicable disease in partnership with the Public Health Foundation of India (PHFI). Students also learned about the broad array of community-based interventions targeting chronic conditions, primarily hypertension and diabetes, that PHFI and the UDAY Foundation have launched in recent years. After an initial briefing at PHFI’s headquarters in New Delhi, students visited program sites in Visakhapatnam (or Vizag) on the southeast coast and Sonipat to the north of the National Capital Region. Over a period of two weeks, trip participants engaged in a mix of rural and urban site visits around these areas. The following is an account of the 2017 Winter Session Trip, beginning with background information on the partner organization in India as well as the current burden of chronic disease in the country. The itinerary for the trip and the host organization programs are reviewed here, as well as suggestions for future moderations of both the Harvard course and the interventions utilized by PHFI and UDAY.

Overview of PHFI The Public Health Foundation of India is a public-private initiative to improve the health of India. Launched by Prime Minister Dr. Manmohan Singh in 2006, PHFI is an independent foundation that aims to improve the country’s institutional capacity for public health. This takes the form of policy development and implementation nationwide, as well as research and training for clinicians and public health professionals. PHFI’s initiative to combat the rising burden of

1 chronic disease is an innovative large-scale community-based effort not seen elsewhere in the country’s health policy. The interventions seen by trip participants were unique in their goal of screening every individual in the catchment area. Despite this scale, PHFI is committed to building strong community ties. Partnerships with community leaders and intensive outreach programs, as well as an emphasis on hiring and training health workers from their home communities, have translated into a high degree of participation and community engagement in PHFI’s goals for improved health. Students were impressed with how effectively health workers were able to build a rapport with community members while managing a large screening caseload.

Overview of Project UDAY India is experiencing a growing burden of noncommunicable diseases (NCDs), with NCDS accounting for 40% of all hospital visits and over 50% of all deaths.1 This growth is thought to be due to a number of factors including increased longevity, tobacco use, and urbanization leading to changing diets and decreased physical activity. The four most prevalent chronic diseases in India are cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic obstructive pulmonary disease, and cancer. For example, there are currently 69 million people in India with DM, and this number is expected to increase to 124 million by 2030.1 As CVD and ​ DM risk can be modified by lifestyle changes and appropriate medical care, initiatives to address these diseases will be critical in stemming the rising burden. One example of such an initiative is PHFI’s Project UDAY. UDAY is a comprehensive diabetes and hypertension (HTN) prevention and management program currently being implemented in both Sonipat district, Haryana and Visakhapatnam district, Andhra Pradesh. UDAY first trained community health care workers to collect baseline health assessments of the total population

1 U​ padhyay, RP. An overview of the burden of non-communicable diseases in India. Iran J Public Health. 2012;41(3):1-8. Epub 2012 Mar 31. 2 (400,000). This helped calculate the current prevalence of DM and HTN in the two districts, as well as the prevalence of modifiable risk factors such as tobacco and alcohol use. Subsequently, UDAY has been screening adults (≥30 years) for DM and HTN and then referring high risk patients to the health system for appropriate diagnostics and treatment. UDAY workers follow up with these patients regularly to track compliance with medical referrals and determine barriers to treatment access. Follow-up visits for those in compliance with UDAY recommendations consist of medication regimen review and confirmation of patient comprehension of access points within the healthcare system, as well as blood pressure readings and finger stick glucose checks. Additionally, workers take advantage of the in-home aspect of screenings to provide health education and disseminate prevention messaging. UDAY has created a culturally sensitive education booklet for use in increasing the public’s awareness of HTN and DM risk factors. This tool is then used during regular follow-up visits to bolster a patient’s understanding of disease progression and key interventions.

3 Overview of Itinerary The trip orientation took place in October, during which time Dr. Cash provided a brief overview of the goals and plans for the course. Through a November dinner, students had the opportunity to meet fellow classmates and discuss certain aspects of Indian history and culture. Dr. Mohan of the Public Health Foundation of India was available on Harvard’s campus in November for a brief session with all participants to answer any questions. The course officially commenced on January 2 with a team meeting at PHFI headquarters in Gurgaon, where Dr. Mohan presented on PHFI’s work and provided an overview of chronic disease in India. PHFI had organized an overnight stay for students at the USI premises, a hotel located within a military base on the outskirts of New Delhi, and coordinated all transportation. After the morning orientation, all students flew to Visakhapatnam for the first week of field work. From January 3-8, students shadowed Dr. Nikhil and the UDAY team in Visakhapatnam, one of the sites wherein PHFI conducts diabetes and hypertension screenings. We had the opportunity throughout the week to meet a diverse array of representatives from the health system – patients, providers, women’s groups, and health workers, from urban, rural, and tribal settings. Divided into groups of five students, we met daily with various representatives from the community during question and answer sessions lasting from approximately 30 minutes to one hour. We also observed a mobile community engagement event spearheaded by PSI to raise awareness of cardiovascular disease. The trip was complemented by an exploration of some of the cultural elements of India –joggers and walkers starting their morning by the beach, yoga at dawn, shoppers preparing for the Visakha Utsav festival, and a trip to the famous Borra caves. See Table 1

4 for a detailed description of Vizag itinerary. From January 9-13, we complemented our south India experience by visiting Sonipat, a city two hours north of Delhi. The stay began with an in-depth presentation on the structure of India’s healthcare system and the National Rural Health Mission. We then spent the next week meeting with patients, providers, managers, schoolchildren, health workers, and government representatives across both public and private systems. Primary activities included a meeting with district health authorities, a visit to the anganwadi, and consultation with medical officers at a primary health center, a private hospital, and a community health center. Each day ended with a debrief led by Dr. Prashant at the PHFI field office to reflect upon daily activities. See Table 2 for a detailed Sonipat itinerary. After a 5-day break during which time students were free to travel, the trip concluded with a debrief at the PHFI Gurgaon office with Dr. Cash and Dr. Mohan to reflect upon the experience and share suggestions program improvements. These recommendations are summarized below for consideration as adaptations to next year’s winter session. Overall Impressions The program provided an excellent overview of India’s health system and approaches to combatting diabetes and hypertension from a variety of perspectives: patient, provider, health worker, urban, rural, tribal, public, and private. Visiting both a south Indian and north Indian site exemplified India’s heterogeneity and the resulting unique challenges faced at different locations in terms of culture, diet, infrastructure, and values. PHFI, in tackling such a large-scale project (screening every adult over the age of 30 in each catchment area) demonstrated significant creativity in addressing unique site challenges. Both teams were committed to ensuring local investment in UDAY’s work by recruiting and training local healthcare workers, identifying community members to serve as positive deviant examples amongst their peers, and scheduling regular mobile clinic activities to raise awareness of diabetes and hypertension. The Harvard cohort was impressed by the level of rapport that had clearly developed between UDAY site leaders and local community officials, as well as the high

5 level of general community buy-in and involvement in UDAY’s work. The site teams in Vizag and Sonipat developed thoughtful and comprehensive itineraries for the winter session students; all transportation, community meetings, and activities were well-organized and impeccably executed. The students also greatly appreciated PHFI’s decision to divide the group into two teams of five students each. This was an ideal number per site visit to facilitate connection and more fruitful conversation with community representatives and healthcare providers.

SUGGESTIONS FOR POTENTIAL COURSE MODIFICATION |

Pre-Departure Preparation: There was collective agreement among participants in the GHP 298 Winter Session Trip that all would have benefited from a series of high-level briefings prior to departure to familiarize students with India’s health system, the organizational structure of PHFI, and the Foundation’s current projects. Student could be provided with a packet of materials during fall term for individual review. This could be complemented by a series of interactive evening lectures at Harvard in late October or early November focusing on the burden of chronic disease in India, key features of the health system, and the Foundation’s approach to NCD intervention at the community level. Acknowledging that it was extremely difficult this year to ensure student participation in pre-departure meetings given scheduling conflicts, the winter session leadership team could consider making these meetings a mandatory component of the trip. To ensure that the PHFI-Harvard partnership is mutually beneficial, we recommend connecting with the site teams in Vizag and Sonipat in early fall each year to set research

6 priorities for the winter session and outline a final student deliverable. Simultaneously, session participants can discuss learning goals and specific areas of interest for investigation during pre-departure meetings. This information can be shared with PHFI to ensure that the program is tailored to best meet the needs and expectations of both Harvard students and UDAY site teams. Given the limited time frame of this trip, such conversations prior to departure will enable students to have a more focused, tailored experience. Students will also feel more adequately prepared to meaningfully interact with community members, patients, healthcare providers, and UDAY community health workers. As the winter session itinerary emphasizes community engagement through question and answer sessions, it will be most consequential if students are equipped with a research question to guide conversation and qualitative data collection.

Adjustment of Trip Logistics As the winter session is currently structured, students spend one day in New Delhi for participation in an orientation meeting, travel to Vizag for one week of field work, travel to Sonipat for an additional week of field work, and then have five days for self-directed travel before meeting in New Delhi for a brief concluding meeting. If possible, travel could be arranged and consolidated in such a way as to streamline trip logistics and minimize burden of cost/travel time on students. One suggestion for consideration is having students meet directly at the first field site, where an orientation with staff at PHFI headquarters can be arranged via WebEx or a similar platform. Students can then spend the first two weeks conducting field work and gathering qualitative data based on a previously defined and agreed-upon research objective. Following site visits, students could shift to New Delhi and spend 3-4 days at PHFI headquarters developing a report for the Foundation or conducting further research into topics of interest based on field experiences; this will still allow for a free weekend of travel to nearby sites such as the Taj Mahal. Additionally, there could be a series of learning sessions focusing on “deep dives” into such topics as hypertension and diabetes, barriers to field site program implementation, best practices in the design of community interventions, or PHFI community health worker recruitment and training protocols. As the academic course is just three weeks, students would like to make the most of this brief period to fully engage with PHFI at both the satellite offices and headquarters.

7 Understanding that it may be too logistically challenging for PHFI to rearrange the current winter session format, we suggest that the wrap-up meeting occur via WebEx at the second field site. From here, students can either travel to a preferred destination for 4-5 days (and from there, travel back to the United States), travel directly back to the United States, or travel to PHFI headquarters in Gurgaon for further research or shadowing opportunities.

Further Tailoring of Itinerary The winter session itinerary developed by PHFI provided a rich diversity of opportunity for student exploration of the different levels of the Indian healthcare system, firsthand experience of UDAY program operations, and meaningful interaction with patients and providers. However, a number of small group sessions and pre-arranged interviews focused on maternal and child health care. In the institutional setting, we interacted often with antenatal care providers. While it was fascinating to hear their experiences and learn more about such a critical component of the healthcare sector, it felt difficult at times to conduct meaningful interviews with these providers; students had anticipated discussion around chronic disease and felt unprepared for such interactions. Given that non-communicable disease is intended to be the primary focus of the field experience, students would be grateful for more opportunities for discussion with healthcare providers specializing in chronic disease around India-specific protocols for care provision and patient management. We also recommend that Harvard and PHFI consider rearranging the order of site visits, if feasible. The Sonipat itinerary facilitated exposure to and interaction with both the urban Indian health system and the

8 National Rural Health Mission through visits to a sub-centre, a primary health care center, a district hospital, and a private hospital. These site visits framed student understanding of the realities of care delivery by exposing them to country-specific health system infrastructure. In having students visit Sonipat first, PHFI would enable visualization of and appreciation for the context within which UDAY operates its diabetes and hypertension programs. This will also better equip students to ask informed questions by improving understanding of the experiences of patients in accessing chronic disease care through the formal system.

RECOMMENDATIONS TO UDAY TEAMS IN VISAKHAPATNAM AND SONIPAT |

The Harvard students were extremely impressed by Project UDAY’s commitment to and work with communities in both Vizag and Sonipat. Health workers were thoroughly trained and seemed highly capable, patients were engaged and responsive to educational messaging, and community members appeared to be strongly supportive of the Foundation’s mission. Furthermore, health workers maintained meticulous records of patient visits by cataloguing information electronically via tablet within a shared database. Project UDAY’s data-driven approach will enable it to build on current successes and correct any potential program weaknesses. As we met with the teams at both sites, there was a consistent request for feedback on program design and implementation. While we remain excited by UDAY’s impressive work

9 and can offer no significant recommendations, the following are some smaller suggestions the Foundation could consider incorporating if practical and/or feasible: Cooking Demonstrations to Enhance Healthy Dietary Habits One of the key aspects of the Project UDAY diabetes and hypertension prevention and management program is the promotion of healthy dietary habits for the prevention of diabetes and hypertension, or—in the case of already-diagnosed patients—as an aid to doctor-prescribed medications in the management of these diseases. In our discussions with screening participants in Sonipat and Visakhapatnam during our January visit, we heard repeatedly that changing dietary habits was one of the key barriers faced by both patients and those at risk for diabetes and hypertension. Many women we spoke with indicated that they had been unable to successfully implement dietary changes within the household and felt unsupported by their families in cooking healthier dishes or changing dietary habits. We hypothesize that one of the issues faced by these women may be that despite receiving extensive information from Project UDAY regarding types of foods appropriate for increased consumption to help manage diabetes and/or hypertension, their lack of experience in cooking with these healthier ingredients and in healthier ways (e.g., use more vegetables, use less white rice, cook with less oil, etc.), as well as their lack of access to recipes for healthy dishes that their family will enjoy eating, significantly limits their ability to improve family dietary habits. Similarly, family members who are at risk for or have been diagnosed with diabetes and/or hypertension, but who

10 do not perform the day-to-day cooking in their families (e.g. men, older family members) may have trouble adopting healthier dietary habits if those who perform the cooking in their family lack the practical information (e.g., recipe ideas) necessary to facilitate the preparation of healthier dishes. One solution we suggest to address this issue is leveraging Project UDAY’s positive deviance community education model in order to enhance women’s healthy cooking skills: identifying women in the community who have successfully incorporated the healthy eating information received from UDAY into their cooking, and then helping these women (e.g. the positive deviants in their community) organize regular (e.g. monthly) cooking demonstrations for their community. These cooking demonstrations will enable women to gain hands-on experience with cooking healthier dishes for their families, based on the Project UDAY healthy eating recommendations, which also cater to the taste preferences of their families. We suggest the following plan as an example for how to organize the cooking demonstrations:2 2-3 weeks before the cooking demonstration (or longer, if necessary): 1. Identify a suitable location for the cooking demonstration, which should have the necessary space for the anticipated number of participants, as well as the required cooking equipment. 2. Announce the cooking demonstration day/time/location and invite community members, particularly women, to attend. Other family members (e.g. men, children, teenagers) should ​ also be encouraged to participate, if possible, in order to enhance the effectiveness of the health education the demonstration is intended to promote (i.e., healthy dietary habits

2 White, S., Alva-Ruiz, R., Chen, L., Conger, J., Kuang, C., Murphy, C., Okashah, N., Ollila, E., Smith, S.A., Ansa, ​ B.E. The Eating and Cooking Healthy (TEACH) Kitchen: A Research Protocol. J Ga Public Health Assoc. 2016;6(2):331-336. doi: 10.21633/jgpha.6.2s20. Internet link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215654/

11 through cooking healthier dishes). A few days before the cooking demonstration: 1. The cooking demonstration leader (e.g. the woman identified as a positive deviant in her community) practices the cooking demonstration with the Project UDAY representatives who will assist with the session, ensuring that each step is clearly communicated. ​ 2. Project UDAY representatives prepare the health information they will deliver at the beginning of the session and print the healthy recipe handouts (prepared ahead of the time, together with the session leader) that will be given to the session participants at the end of the cooking demonstration. 3. The session leader, assisted by Project UDAY, sources the ingredients for the recipe she will prepare during the cooking demonstration and any additional cooking utensils she will need beyond what is already available in the session location. During the cooking demonstration: 1. Brief nutrition education (10-15 minutes) by Project UDAY representatives on the specific foods that will be used in the cooking demonstration and their health benefits with regard to diabetes prevention/management and cardiovascular health. 2. Presentation by the session leader (i.e. the positive deviant) on the changes she has incorporated into her cooking in order to prepare healthier dishes (10-15 minutes). 3. Healthy cooking demonstration (60-90 minutes) by session leader. 4. Participants sample the prepared food. 5. Guided post-cooking discussion (15-30 minutes): Portion size, cost, healthy shopping, healthy meal planning, healthy cooking ingredients and techniques. 6. Distribution of healthy recipe handouts to participants, including specific ingredient lists, prepared prior the cooking demonstration by the session leader together with Project UDAY.

Targeted Nutrition Education for Adolescents Approximately 30% of India’s population, representing 243 million individuals, are between the ages of 10 and 19, a period known as adolescence.3 This transition phase from childhood to adulthood is characterized by rapid physical and psychological growth, with highly

3 Anand, Deepika, and R. K. Anuradha. "Malnutrition Status of Adolescent Girls in India: A Need for the Hour." ​ 12 specific nutritional requirements. As India quickly moves through the epidemiologic transition, adolescents no longer only suffer from undernutrition. 2007 estimates indicate 11% of adolescents were overweight and 2% were obese.4 Wasnik et al. reported that 5.8 % of girls that resided in social welfare hostels in an urban district were overweight, while 56.4% of girls were undernourished, highlighting the important fact that undernutrition and overnutrition can co-occur in the same population.5 Obesity can cause many adverse outcomes in adolescents including psychosocial problems, sleep apnea, orthopedic conditions, and gastrointestinal diseases. Moreover, obesity can lead to abnormal glucose metabolism and cardiovascular risk factors, contributing to the large rise in non-communicable diseases seen in Indian adults, including diabetes and hypertension that Project UDAY aims to prevent and manage.6 The current target population of Project UDAY is men and women above the age of 30 in urban and rural sub-sites. While this over-30 population is at the greatest risk of diabetes and hypertension, adolescents that engage in poor nutrition choices are susceptible to develop these conditions later in life. Here we suggest integrating nutrition behavior messages targeted specifically for adolescents in Project UDAY’s activities. This might be through three key methods: 1. Developing health pamphlets and educational material that are geared toward adolescents. These might differ from materials for adults by providing child-friendly language, demonstrative images of healthy food choices, and ways to stay active in different settings (home, work, and/or school). 2. Training community health workers to interact with adolescents at households where they are already

4 Haddad, Lawrence James, et al. Global Nutrition Report 2015: Actions and accountability to advance nutrition and ​ sustainable development. Intl Food Policy Res Inst, 2015. 5 Wasnik, Vinod, B. Sreenivas Rao, and Devkinandan Rao. "A study of the health status of early adolescent girls ​ residing in social welfare hostels in Vizianagaram district of Andhra Pradesh State, India." International Journal of Collaborative Research on Internal Medicine and Public Health 4.1 (2012): 71-83. 6 Anand, Deepika, and R. K. Anuradha. "Malnutrition Status of Adolescent Girls in India: A Need for the Hour." ​

13 screening adults. This might begin as engaging adolescents while the adults are being screened, or even collecting preliminary data for children of high-risk adults. CHWs might also assess adolescent awareness of modifiable disease factors associated with cardiovascular disease, hypertension, and diabetes with simple surveys. With this information Project UDAY can gain valuable feedback that will inform interventions targeted at younger populations. 3. Outreach programs at schools to provide educational yet fun nutrition information to adolescents. Evidence exists that a combination of interventions including nutrition, physical activity, knowledge, attitudes, or health-related behaviors has the potential to reduce the risk factors associated with obesity among preadolescent girls.7 Intensive interactive nutritional education focusing on healthy food selection, food energy calculation, and food exchanging has also shown some changes in participants' BMI and impact on their healthy dieting attitudes.8

Medication Adherence During a number of our field visits, we witnessed confusion among more senior community members in regards to medication regimens. Near the end of many home-based screening follow-up sessions, patients would produce bags containing a variety of medicines and request health worker assistance in determining correct dosages. The UDAY workers were uncomfortable in dispensing medication recommendations and have not been trained to recall various treatment regimens or determine potentially harmful interactions. Partially due to low literacy rates in certain communities, poor medication ​ ​

7 Salam, R. A., Hooda, M., Das, J. K., Arshad, A., Lassi, Z. S., Middleton, P., & Bhutta, Z. A. (2016). Interventions ​ to Improve Adolescent Nutrition: A Systematic Review and Meta-Analysis. The Journal of Adolescent Health, 59(4 Suppl), S29–S39. 8 In-Iw, Supinya, Tridsanun Saetae, and Boonying Manaboriboon. "The effectiveness of school-based nutritional ​ education program among obese adolescents: a randomized controlled study." International journal of pediatrics ​ 2012 (2012). 14 adherence appears to be a significant impediment to the success of UDAY’s diabetes and hypertension programs in improving health outcomes over the long term. Thus, we have outlined a few key recommendations for UDAY to consider as validated strategies in improving medication adherence.

Pictograms Patients with low literacy rates may attempt to recall verbal instructors from their healthcare provider, which may be misremembered, rather than read the printed text instructions on medicine labels.9 This may make it difficult for patients to comply with medication regimens and schedules. The use of pictograms to aid in the identification of medications has been widely studied as a vehicle for improved medication adherence in patient populations with low literacy rates. A pictogram is a pictorial depiction or symbol of the visual appearance (shape, color, size) of a medication and the associated treatment schedule.10 These images can be compiled into a medication sheet (Figure 1)11 or pasted as labels onto medication bottles (Figure 2).12 Pictograms have been shown to improve comprehension and recall of treatment information by providing patients with a visual aid to refer to post-visit.13 Pictograms have also been shown to significantly improve treatment adherence, as well as a patient’s general knowledge of their medical condition, such as diabetes.14 Thus, we recommend that UDAY incorporate pictograms into community programming to help improve patient medication treatment adherence.

9 Negarandeh, R., Mahmoodi, H., Noktehdan, H., Heshmat, R., & Shakibazadeh, E. (2013). Teach back and pictorial ​ image educational strategies on knowledge about diabetes and medication/dietary adherence among low health literate patients with type 2 diabetes. Primary Care Diabetes, 7(2), 111-118. doi:10.1016/j.pcd.2012.11.001 ​ ​ ​ ​ 10 Gazmararian, J., Jacobson, K. L., Pan, Y., Schmotzer, B., & Kripalani, S. (2010). Effect of a Pharmacy-Based ​ Health Literacy Intervention and Patient Characteristics on Medication Refill Adherence in an Urban Health System. Annals of Pharmacotherapy, 44(1), 80-87. doi:10.1345/aph.1m328 ​ ​ ​ 11 Hawkins, L. A., & Firek, C. J. (2014). Testing a novel pictorial medication sheet to improve adherence in veterans ​ with heart failure and cognitive impairment. Heart & Lung: The Journal of Acute and Critical Care, 43(6), 486-493. ​ ​ ​ ​ doi:10.1016/j.hrtlng.2014.05.003 12 Dowse, R., & Ehlers, M. (2005). Medicine labels incorporating pictograms: do they influence understanding and ​ adherence? Patient Education and Counseling, 58(1), 63-70. doi:10.1016/j.pec.2004.06.012 ​ ​ ​ ​ 13 Gazmararian, J., Jacobson, K. L., Pan, Y., Schmotzer, B., & Kripalani, S. (2010). Effect of a Pharmacy-Based ​ Health Literacy Intervention and Patient Characteristics on Medication Refill Adherence in an Urban Health System. Annals of Pharmacotherapy, 44(1), 80-87. doi:10.1345/aph.1m328 ​ ​ ​ 14 Hawkins, L. A., & Firek, C. J. (2014). Testing a novel pictorial medication sheet to improve adherence in veterans ​ with heart failure and cognitive impairment. Heart & Lung: The Journal of Acute and Critical Care, 43(6), 486-493. ​ ​ ​ ​ doi:10.1016/j.hrtlng.2014.05.003

15 Examples of Pictorial Medical Sheets:

Sources: Hawkins, L. A., & Firek, C. J. (2014). Testing a novel pictorial medication sheet to improve adherence in ​ veterans with heart failure and cognitive impairment. Heart & Lung: The Journal of Acute and Critical Care, 43(6), ​ ​ ​ ​ 486-493. doi:10.1016/j.hrtlng.2014.05.003; Dowse, R., & Ehlers, M. (2005). Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Education and Counseling, 58(1), 63-70. ​ ​ ​ ​ doi:10.1016/j.pec.2004.06.012

Blister Packaging Packing of medicine can also influence patients’ medication adherence. According to a number of studies, blister packaging of multiple medicines as part of a multi-component intervention given to an elderly population significantly increases adherence to prescribed medicines. By preparing all medicines together in a blister package, the likelihood of missing a dose is greatly reduced and patients are empowered to maintain an appropriate regimen. Given that patients suffering from non-communicable diseases are typically taking several medications at one time, blister packaging could greatly alleviate treatment burden. However, patients will need to be cautioned to store blister packaged medication in a cool and dry location to prevent oxidation or decomposition.15 UDAY may consider discussing the potential for incorporation of

15 National Collaborating Centre for Primary Care (UK). Medicines Adherence: Involving Patients in Decisions ​ 16 blister packaging into treatment protocols with partners in urban health facilities, private clinics, and the National Rural Health Mission.

Tablet Application PHFI should consider expanding the functionality of an existing application on the health worker electronic tablet to increase medication adherence. The current application focuses on managing safe blood pressure and blood glucose levels through regular monitoring. An extra feature could be added to this application through which the healthcare worker logs all patient medications and receives dosing instructions, an indication of potential side effects, storage precautions, and warnings of any potential interactions. Such an application feature could greatly assist the UDAY community health workers in addressing patient concerns and could be a cost-effective method to improve adherence to complicated chronic disease treatment regimens.

Patient Messaging: Leveraging Community Leaders and Role Models The Prospect Theory proposed by Tversky and Kahneman (1981) notes how message framing is critical in presenting information in a manner that affect people’s behavioral

16,17 decisions. Specifically,​ a gain frame highlights the benefits of taking action, both ​ experiencing positive consequences and avoiding negative ones. Gain-framed appeals are noted ​ ​ to be effective in prevention behaviors, such as making healthy decisions to prevent weight

About Prescribed Medicines and Supporting Adherence [Internet]. London: Royal College of General Practitioners (UK); 2009 Jan. (NICE Clinical Guidelines, No. 76.) 8, Interventions to increase adherence to prescribed medicine. Available from: https://www.ncbi.nlm.nih.gov/books/NBK55448/

16 Rothman AJ, Bartels RD, Wlaschin J, Salovey P. The strategic use of gain- and loss-framed messages to promote ​ healthy behavior: How theory can inform practice. J Commun. 2006;56(SUPPL.):202-220. ​ ​ doi:10.1111/j.1460-2466.2006.00290.x. 17 Randolph W, Viswanath K. Lessons learned from public health mass media campaigns: marketing health in a ​ crowded media world. Annu Rev Public Health. 2004;25:419-437. ​ ​ doi:10.1146/annurev.publhealth.25.101802.123046. 17 gain/obesity.18 A gain-frame is especially critical when addressing modifiable risk factors and diabetes management. For instance, Indian women are socialized to care for others before self-care activities, a critical tension in diabetes management. Acknowledging these values, health messages ought to highlight the importance of self-care to be able to provide for others. As shown in the Positive Deviant groups, community leaders are critical in health promotion and behavior change. Narratives and testimonials are also a powerful mode of observational learning. 19 As an age-old cultural phenomenon, stories and narratives are instrumental in health communication. Specifically, the Transportation Theory, which posits that narratives that engage the end-user to the extent in which he/she becomes immersed and “transported into a narrative

20 world” can lead to belief and behavior change. Narratives​ have great potential to “trust” the ​ medium and to have sustained impact in a specified population.

Applying Messaging Lessons to UDAY During our UDAY visits, we spoke with health workers administering vaccinations and a variety of behavior change interventions. We were impressed with the quality of services offered and the time and energy that health workers spent to ensure that patients understood the medications and conditions they were affecte dby - in many low-income settings, this aspect of quality care goes neglected. Adding a video message to the health worker visits has the potential to enhance the narrative appeal of UDAY’s interventions and offer consistent messaging through a variety of mediums. We expect a well-constructed and concise video with a focused message has the potential to influence patients for whom in-person messaging is not as effective. Qualitative research could attempt to determine which subpopulations are less effectively persuaded by in-person messaging in order to inform the creation of video messages. If this research is not conclusive, then video messages could be made with the intention of simply reinforcing key points made by in-person UDAY health workers. One advantage of video

18 Rothman AJ, Bartels RD, Wlaschin J, Salovey P. The strategic use of gain- and loss-framed messages to promote ​ healthy behavior: How theory can inform practice. J Commun. 2006;56(SUPPL.):202-220. ​ ​ doi:10.1111/j.1460-2466.2006.00290.x. 19 V​ iswanath K, Emmons KM. Message Effects and Social Determinants of Health: Its Application to Cancer Disparities. J Commun. 2006;56(s1):S238-S264. doi:10.1111/j.1460-2466.2006.00292.x. 20 ​ ​ G​ reen MC. Narratives and cancer communication. J Commun. 2006;56(SUPPL.):163-183. ​ ​ doi:10.1111/j.1460-2466.2006.00288.x.

18 messaging is that consistency is ensured – as opposed to other methods of persuasion and so long as technology is functioning, videos will not vary depending on the context. As a result, a minimum standard of quality is ensured.

EXPRESSION OF GRATITUDE |

The Harvard students wish to express our deepest gratitude to the Public Health Foundation of India for serving as a gracious host during the winter session program. In particular, we would like to acknowledge the outstanding leadership of Dr. Mohan, Dr. Nikhil, Dr. Prashant, Dr. Rajesh, and Ms. Sajan in facilitating such a unique learning experience, and we thank them for their wisdom, patience, and kindness. We are also incredibly appreciative of the Project UDAY site teams in Vizag and Sonipat, who clearly put an immense amount of time and effort into careful and thoughtful planning of the session. From perfectly coordinated transportation to the varied and comprehensive itinerary, each day was meticulously planned and productive, serving to broaden our knowledge of the Indian health system and deepen our understanding of community intervention around chronic disease. The teams provided an experience above and beyond any student expectations, being so thoughtful as to include social and cultural activities such as a morning yoga session, a hike to the Borra caves, and a memorable evening at Chokhi Dhani. We are particularly appreciative of the insightful lectures delivered at the site offices and the willingness of Project UDAY team members to engage in constructive dialogue with the Harvard students for the benefit of our intellectual growth. Once again, we are immeasurably grateful to the Project UDAY teams and we hope that the partnership between Harvard and PHFI will continue well into the future.

19 APPENDIX Table 1: Vizag Activities

Wednesday, January 4, 2017 Time Activity 07:30 to 10:00 Travel to Makavarapalem village and Lachanapalem village - UDAY rural sub site

Team-1 Team-2

10:00 to 10:45 Visit the Primary Health Centre, Participate in patient network activity Makavarapalem and interact with Medical organized by Mr Rajendra Prasad, Officer. Training Officer, Project Hope and interaction with positive deviance patients. 10:45 to 11:15 Travel to Tamaram village Travel to K Agraharam village

11:15 to 13:00 Interact with village Sarpanch and Interact with village Sarpanch and participate in UDAY follow up activity. participate in UDAY follow up activity. Interact with rural HWs. Interact with rural HWs. Participate in the immunization session Participate in the immunization session and interact with ANMs and ASHAs. and interact with ANMs and ASHAs. 13:00 to 14:30 LUNCH at Narsipatnam Office 14:30 to 15:00 Travel to Chandrayyapalem village

15:00 to 15:30 Visit to Chandra Sanchara Chikisthya Kendra (CSCK) and observe Decision Supportive System activity 15: 30 to 18:00 Travel back to Visakhapatnam

Thursday, January 5, 2017 Time Activity 09:00 to 10:00 Visit to UDAY office. Briefing on project activities and things to do in and around Visakhapatnam by PHFI. Presentations by PSI on the below the line communication activity and by Project Hope on patient networks. 10:00 to 10:30 Travel to ward 8 and 9 Team-1 Team-2

10:30 to 11:15 Interact with diabetic and hypertensive Interact with diabetic and hypertensive patients and participate in door to door patients, participate in door to door screening mop up activity and interact screening activity and interact with with Health Workers. Health Workers.

20 11:15 to 11:30 Travel to Simhadripuram, krishna college and HB colony

11:30 to 12:30 1. To participate in invisible screen, BP & Body Mass screening and Games & Fun 2. Communication and Registration activity 12:30 to 14:00 Lunch at Visakhapatnam office 14:00 to 14:10 Travel to DMHO’s Office

14:10 to 14:45 Meeting DHMO Dr Sarojini or Addl. DMHO Dr Suryanarayana to know about the various health programmes being implemented in Visakhapatnam district and major health challenges. th th 14:45 to 15:00 Travel to and 8 ​ and 9 ​ ward ​ ​

15:00 to 16:00 Meet Women’s Self Help Group (SHG) Meet Women’s Self Help Group (SHG) members to known about the activities members to known about the activities undertaken by the group and their undertaken by the group and their involvement in UDAY activities involvement in UDAY activities

Friday, January 6, 2017 Time Activity 07:30 to 10:30 Travel to Nathavaram mandal

Team-1 Team-2

10:30 to 11:15 Travel to Marripalem village to meet Visit the Primary Health Centre, diabetics and hypertensive patients Nathavaram and interact with Medical identified under UDAY and participate in Officer sensitization meeting 11:30 to 12:15 Cooking session at Marripalem village, Cooking session at Nathavaram village, learn to cook a south Indian rural recipe in learn to cook a south Indian rural recipe sustainable kitchen environment in sustainable kitchen environment 12:15 to 13:00 Travel to Jalaripeta reservoir 13:00 to 14:00 LUNCH 14:00 to 14:30 Team 2 will travel to KV Sarabhavaram

14:30 to 15:00 Visit to fisherman's community in Visit to tribal community in intervention intervention area to learn about their area to learn about their lifestyle, dietary lifestyle, dietary habits and difficulty in habits and difficulty in accessing accessing healthcare healthcare 15:15 to 18:30 Travel back to Visakhapatnam

21 Saturday, January 7, 2017 Time Activity 06:15 to 06:30 Travel to Beach Road from Hotel Daspalla

06:30 to 08:30 Walk on the Beach Road. Visit Andhra University Yoga Village and try some yoga asanas. 10:15 to 10:45 Travel to eVaidya centers at Maddilapalem and Fisherman colony from Hotel Dasapalla Team-1 Team-2

10:45 to 12:30 Visit the eVaidya (Telemedicine) facility Visit the eVaidya (Telemedicine) and Urban Health Center at Maddilapalem facility and Urban Health Center at Fisherman colony

13:00 to 14:00 Cooking session at Marripalem village, Cooking session at Nathavaram village, learn to cook a south Indian rural recipe in learn to cook a south Indian rural recipe sustainable kitchen environment in sustainable kitchen environment 12:15 to 13:00 Lunch at Urban office 14:00 to 15:00 LUNCH 14:00 to 14:30 Debriefing at PHFI office, Vizag

Table 2: Sonipat Activities

Monday, January 9, 2017 Time Activity 11:00 to 2:00 Pickup from Delhi Airport and travel to Sonipat

2:00 to 3:00 Lunch

3:00 to 5:00 Orientation to UDAY Sonipat and interaction with Sonipat office staff

Tuesday, January 10, 2017 Time Activity 9:00 to 9:45 Travel to Village Khanda

9:45 to 12:00 Interaction with community and village leaders

12:00 to 1:00 Travel to UDAY office at Sonipat

22 1:00 to 2:00 Lunch

2:00 to 4:00 Orientation about health system in India

4:00 to 5:00 Feedback and discussion

Wednesday, January 11, 2017 Time Activity 9:00 to 9:45 Travel to Village Sisana

9:45 to 11:00 Visit to a rural school in Sisana village and interaction with school children and teachers 11:00 to 12:00 Visit to a temple in village Bidhlan

12:00 to 1:00 Travel to UDAY office at Sonipat

1:00 to 2:00 Lunch

2:00 to 3:00 Meeting with urban health team

3:00 to 4:00 Meeting with registry consultants

4:00 to 5:00 Feedback and discussion

Thursday, January 12, 2017 Time Activity 9:00 to 9:10 Travel to PHC Murthal

9:10 to 10:00 Interaction with medical officers and PHC staff

10:00 to 10:30 Travel to CHC Gannaur

10:30 to 11:30 Interaction with medical officers and CHC staff

11:30 to 1:30 Visit to a local village house

1:30 to 2:00 Travel to office

2:00 to 2:30 Lunch

2:30 to 4:00 Interaction with district health authorities

4:00 to 4:30 Feedback and discussion

23 6:00 to 8:00 Dinner at Chowki Dhani

Friday, January 13, 2017 Time Activity 9:00 to 10:00 Travel to Silana Village

10:00 to 12:00 Visit to Anganwadi at Silana Village

12:00 to 1:00 Travel to Sonipat

1:00 to 2:00 Lunch

2:00 to 3:00 Feedback and Discussion

Name Team Jane Robinson 1 Jennifer Bido 1 Scott Weathers 1 Laura Rapoport 1 Minju Shin 1 Irina Degtiar 2 Lauren Southwick 2 Patrick Ross 2 Cristina Gall 2 Kalin Stovall 2

24