Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India
Jeemon et al. BMC Public Health
Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India
Panniyammakal Jeemon 0 1 2
Gitanjali Narayanan 0 2
Dimple Kondal 0 2
Kashvi Kahol 0 2
Ashok Bharadwaj 2 3
Anil Purty 2 7
Prakash Negi 2 6
Sulaiman Ladhani 2 5
Jyoti Sanghvi 2 4
Kuldeep Singh 2 4
Deksha Kapoor 0 2
Nidhi Sobti 0 2
Dorothy Lall 0 2
Sathyaprakash Manimunda 0 2 9
Supriya Dwivedi 2 8
Gurudyal Toteja 2 8
Dorairaj Prabhakaran 0 1 2
On behalf of DISHA study investigators 2
0 Centre for Chronic Disease Control , Sector 44, Plot 47, Gurgaon, Haryana , India
1 Centre for Control of Chronic Conditions, Public Health Foundation of India , New Delhi , India
2 Measures Age , Sex, Marital Status, Religion, Education, Income, Occupation
3 Rajendra Prasad Government Medical College , Tanda, Himachal Pradesh , India
4 Sri Aurbindo Institute of Medical Sciences , Indore , India
5 Aga Khan Health Services , Mumbai , India
6 Indira Gandhi Medical College , Shimla , India
7 Pondicherry Institute of Medical Sciences , Puducherry , India
8 Indian Council of Medical Research , New Delhi , India
9 National Centre for Disease Informatics and Research , ICMR, Bangalore , India
Background: Effective task-shifting interventions targeted at reducing the global cardiovascular disease (CVD) epidemic in low and middle-income countries (LMICs) are urgently needed. Methods: DISHA is a cluster randomised controlled trial conducted across 10 sites (5 in phase 1 and 5 in phase 2) in India in 120 clusters. At each site, 12 clusters were randomly selected from a district. A cluster is defined as a small village with 250-300 households and well defined geographical boundaries. They were then randomly allocated to intervention and control clusters in a 1:1 allocation sequence. If any of the intervention and control clusters were <10 km apart, one was dropped and replaced with another randomly selected cluster from the same district. The study included a representative baseline cross-sectional survey, development of a structured intervention model, delivery of intervention for a minimum period of 18 months by trained frontline health workers (mainly Anganwadi workers and ASHA workers) and a post intervention survey in a representative sample. The study staff had no information on intervention allocation until the completion of the baseline survey. In order to ensure comparability of data across sites, the DISHA study follows a common protocol and manual of operation with standardized measurement techniques. Discussion: Our study is the largest community based cluster randomised trial in low and middle-income country settings designed to test the effectiveness of 'task shifting' interventions involving frontline health workers for cardiovascular risk reduction.
Task shifting interventions; Cardio-vascular disease; Low and middle-income countries; India
Globally, cardiovascular disease (CVD) is the leading cause
of death and disability [
]. Among different regions of the
world, low and middle-income countries (LMIC)
contribute a disproportionately high burden of CVD (more than
two third of the total burden) [
]. As per the recent Global
Burden of Disease (GBD) study estimates, one of four
deaths in India is attributable to CVD and the epidemic in
India is rapidly advancing [
]. The age standardized CVD
mortality rates in India is currently well above the global
average and that of high income countries [
and effective implementation of evidence-based policies
with emphasis on prevention, early detection, and
treatment using both conventional and innovative techniques
are required to address this major public health problem.
Nearly a quarter of total DALYs (75 % from CVD) in
India are attributable to high blood pressure, dietary
risk, smoking, high blood sugar and elevated total
cholesterol levels [
]. All these risk factors are interwoven
with each other, linked to lifestyle changes and amenable
to interventions. However, effectiveness of behavioural
interventions for lifestyle changes at the population level
is not tested systematically in the Indian settings.
A considerable body of research in high income
countries with well-established health systems
indicates that community health workers (CHWs) in the
primary health care system are effective in improving
chronic disease care and health outcomes [
network of frontline health workers exists at the village
level in India and they are known in different names
such as community health workers (CHW),
community health representatives (CHR), anganwadi workers
(AWW), junior public health nurses (JPHN), health
visitors, health inspectors, and accredited social health
activists (ASHA). They are often trusted members
from the same community and recognized widely in
their respective villages. However, they have been so
far trained and involved in activities related to
maternal and child health and infectious disease
management. We propose to train the frontline CHWs as
community agents to impart lifestyle changes for
cardiovascular risk reduction at the population level
(task shifting). A cluster randomised controlled trial
(RCT: DISHA study) was designed to test the
effectiveness of this approach at the population level. The
details of the cluster RCT are summarized below.
Study design and settings
DISHA is a cluster RCT conducted across 10 sites in
India (Fig. 1 and Table 1). At each site, one district was
selected based on convenience and from each district 12
clusters were randomly selected using computer
generated random numbers (total = 120 clusters in ten sites).
A cluster is defined as a small village (ideally including
1–3 Anganwadi Centres) with 250–300 households. The
Anganwadi centre is part of the integrated child
development service program of Government of India at the
village level and typically provides basic health-care
including contraceptive counselling and supply, nutrition
education and supplementation, and pre-school activities.
Over a million such centres are currently active in India.
The identified 12 clusters were then randomly allocated to
intervention and control clusters in a 1:1 allocation
sequence using computer generated random numbers.
Random allocation of the clusters was done by a statistician
who is unaware of the study settings and cluster locations.
If any of the intervention and control clusters were
<10 km apart, one was dropped and replaced with another
randomly selected cluster from the same district. The
iteration continued till we managed to get 6 intervention
and 6 control clusters that are at least 10 km apart in each
site. The study was initiated in 5 sites in the first phase
and in the second phase it has been extended to 5 more
additional sites in India. The DISHA study included a
baseline cross-sectional survey in all sites involving both
the intervention and control clusters with equal
representation. The study staff had no information on intervention
allocation until the completion of the baseline survey.
After completion of the baseline survey in all clusters,
frontline health workers (mainly Anganwadi workers and
ASHA workers) were trained to deliver CVD risk
reduction interventions in the entire intervention clusters for a
period of minimum 18 months. A post intervention
survey is planned in a representative sample from the
same clusters immediately after the intervention phase.
The detailed study flow-chart is presented in Fig. 2.
Baseline risk factor survey
A baseline risk factor survey was carried out initially in the
5 centres included in the first phase (2013–2014) using a
structured questionnaire and it is currently on-going in the
centres included in the second phase (2014–2015). The
survey was conducted among participants from randomly
identified 120–150 households in each cluster with a target
to obtain a minimum of 300 participants. To account for
non-response rate we randomly selected up to 10 % more
households from the same cluster initially and in 5
instances up to 20 % more households. All adults over
18 years of age in the randomly selected households were
eligible to be included in the survey. The survey
questionnaire was translated into local languages (Hindi, Gujarati,
Tamil, Oriya, Assamese and Telugu), back translated into
English and pilot tested in 30–50 participants at each site
(Additional file 1) for internal validity. The survey included
assessments of demographic details, general health status,
diet, physical activity, tobacco, and alcohol consumption
(Table 2). The world health Organization (WHO) STEPS
instrument for chronic risk factor surveillance has been
modified and adapted to capture local, contextual
information. Other components have been adapted
from the General Health Questionnaire-12, Fagerstrom
Test for Nicotine Dependence (FTND), and WHO
AUDIT (Alcohol Use Disorders Identification Test).
The general health questionnaire incorporated in the
main questionnaire was a measure of current mental
health or psychological wellbeing and it is extensively
used in different settings and different cultures. A
detailed dietary survey was conducted in a sub-sample
of 100 random participants at each site. It included, a
standardized, semi- quantitative food frequency
questionnaire based assessments and two separate 24 h diet
recalls within a week time.
Anthropometric and blood pressure measurements
Anthropometric measurements including height (in cm),
weight (in kg) and waist circumference (in Inches) was
also measured using standardized techniques (Table 3).
All measurements were taken with the participant
wearing light clothes and the reading were rounded off
Phase I Sites Phase II Sites
to one decimal point. Blood pressure (BP) and pulse rate
were measured using electronic BP monitors (OMRON
7080). Three measurements were taken, two minutes
apart and after resting the participant for at least five
minutes before starting the measurement. Participants
were instructed not to consume any beverages (coffee,
tea or soft drinks) and alcohol at least one hour before
taking the measurements. They were also instructed to
abstain from smoking. The average of last two BP
readings was used for analyses.
Blood sample collection
In fasting stage, 5 ml of blood was collected,
centrifuged at the site for serum and plasma separation after
spotting of blood on filter paper, transported and
locally stored at the respective laboratory facilities in each
site under -20 °C freezers. Spotted filter paper, plasma
(1 aliquot) and serum samples (2 aliquots) were
transported to the central laboratory at the Indian Council
of Medical Research (ICMR), New Delhi following
World Health Organization (WHO) guidelines for
packaging and transportation of samples. They were
then stored at -70 °C freezers. All materials used in
sample collection were destroyed using appropriate
color-coded bins/bags following the WHO guidelines.
The biochemical analyses (Table 4) including lipid profile
(total cholesterol, LDL cholesterol and HDL cholesterol),
fasting plasma glucose, and haemoglobin were conducted
at the central laboratory in batches of samples to ensure
standardisation across study sites. The ICMR central
laboratory is accredited by the National Accreditation Board
for testing and calibration of Laboratories (NABL), India.
Data entry and database
The data entry staff under the supervision of site principal
investigator completed data entry on a specially designed
web-based online data application. The software has been
developed on My SQL 7.0 server. The application
uploaded the data directly on a server maintained at the
Central Coordinating Centre (CCC), New Delhi. The data
are collated, cleaned resolved and analysed at the CCC.
We double checked the accuracy of data entry by
matching the biochemical data received from the central
laboratory with the data entry from the sites. If the data errors
were more than 3 %, then we independently verified all
other records. We found serious problems in data quality
from one of the sites participating in the study and
dropped that site from all analyses.
A package was designed using intervention mapping to
guide development of each component of intervention.
The following five main steps were involved in the process
of intervention mapping; (1) creation of matrices
indicating the proximal program objectives from performance
objectives and determinants of behaviour and
environmental conditions, (2) selection of theory-based
intervention methods and practical strategies, (3) design and
organising programs, (4) describe adoption and
implementation plans, and (5) generate an evaluation plan [
In the first step, each component of the healthy lifestyle
behaviour related to CVD risk reduction (diet, physical
activity, tobacco, alcohol and adherence to treatment) was
broken down into performance objectives. They were then
prioritized based on practical feasibility of implementation,
resource constraints and the local context followed by
subjective selection of important and changeable
determinants of the risk behaviour. We then framed a matrix of
potential change objectives and the corresponding
intervention options at individual, group and mass level for
population level CVD risk reduction. These objectives were
created at each level of intervention planning by crossing
performance objectives with determinants and finally
deriving the change objectives.
In the next step, the theoretical domains framework was
used, as described by Mitchie et al. to guide the
development of the potential interventions [
]. A set of 12
10 sites in 9 States
Selection of 1 district each in 10 sites (Convenience Sampling)
Selection of 12 Clusters/ Districts that are at least 10 Km apart
6 X 10 = 60 Clusters
6 X 10 = 60 Clusters
Baseline Cross Sectional Survey
intervention at Individual,
Family, Group and
Usual care and one time
Repeat Cross Sectional Survey
RANDOM SAMPLE OF
domains covering the main factors influencing behaviour
and behaviour change were identified: knowledge; skills;
social/professional role and identity; beliefs about
capabilities; beliefs about consequences; motivation and goals;
memory, attention and decision processes; environmental
context and resources; social influences; emotions;
behavioural regulations; and nature of the behaviours. Using this
theoretical framework the tools were designed such as the
information booklet, calendar, posters, and leaflets.
The target community was actively involved and
played an important role in the development of the
intervention tools. The possible barriers and facilitators
of a healthy lifestyle were identified through focus group
discussions and key informant interviews with target
community members, frontline health workers, primary
care physicians and the respective site investigators. A
proof was prepared initially for each tool (booklets,
posters, leaflets, banners and table-top calendars), pilot
tested to ensure contextual relevance, and then modified
them in an iterative process based on inputs from the
pilot test both with frontline health workers and target
community members. The frequency of use and the
specific target groups (for example; men, women, smokers,
individuals with hypertension etc.) were also determined
based on focus group discussions and pilot test inputs. The
whole process was independently repeated at each site to
account for differences in the local context, cultural issues,
and language differences. The final print materials are
available in the Additional file 2. In addition to the print
materials, a calibrated salt spoon and an oil dispenser was also
developed based on feedback from the focus group
discussions to help each household to measure and quantify their
daily consumption of salt and oil.
In the final step a structured intervention program was
developed (Table 5). It includes individual level (for
example; individual counselling), household level (for
example; household visits by frontline health workers) and
community level interventions (for example; display of
posters, community level activities and competitions). The
intervention program was focussed on; 1) healthy diets
CARRS Surveillance Study (2012) [
Adapted from Fagerstrom Test for Nicotine
Dependence- Indian Adaptation [
Adapted from WHO AUDIT 
Adapted from WHO [
] Steps [
Few items adapted from WHO Steps [
Few items specifically developed for
purpose of the study
CARRS Surveillance Study (2012) [
CARRS Surveillance Study (2012) [
History, frequency and quantity of tobacco
consumption, type of products used
History, frequency and quantity of tobacco
consumption, type of products used
Levels of sedentary, moderate and vigorous
activity levels & time spent doing activity
Food Habits and Consumption
Hypertension/Diabetes/Diabetes – related
Mortality and/morbidity among participant’s
family due to cardio-metabolic illness/risk factors
Currently knowledge & attitude toward high blood pressure
Specifically developed for study
including low salt, low fats, low trans-fat and high fibre
intake, 2) increasing physical activity of vigorous intensity
for at least 30 to 60 min and 3) quitting of tobacco and
alcohol. The developed tools were assigned to each task and
the frequency of intervention was also prescribed in advance.
Delivery of interventions
In both the groups, one-time lifestyle education was
offered along with baseline risk factor screening by the
project staff. All individuals with established risk factors
such as hypertension, diabetes and dyslipidemia were
referred to the primary care clinics (often primary health
centres, community health centres or the adjacent urban
health centres) for follow-up care.
Structured intervention program
In the intervention arm, the structured intervention
program as described earlier was implemented by frontline
community health workers identified from the local
villages. They were paid a token honorarium for
participation in the study during the intervention phase. All
the households in the selected clusters were eligible to
be included in the intervention program. Before
initiating the interventions, the frontline community health
workers underwent a two day training program on
common CVD risk factors, strategies to prevent the progression
of risk factors, lifestyle interventions and also on the
structured intervention package. They were also trained to
utilise the intervention tools. The duration of intervention
period was 18 months. The frontline health workers were
instructed to conduct 9 house visits (once in two months)
during the intervention period. The objectives of each
household visit was described in detail to all participating
frontline health workers during the training program.
Additionally, the health workers were asked to demonstrate
mock household visits during the training program to
ensure that they understood the purpose of the planned visits.
Household level interventions
The house-visits were micro-planned with the help of the
household map for each cluster. A salt spoon as well as an
oil dispenser each was distributed to all households in the
intervention area. Additionally, each household received a
booklet, leaflets and a table top calendar. During each visit,
the frontline health workers encouraged family members
especially women in the family to use the provided salt
spoon and oil dispenser to quantify the amount of salt and
oil consumption. Additionally, the family members were
briefed about the importance of lifestyle changes using
different intervention tools. The family members were also
instructed to record the amount of monthly consumption of
salt and oil in a log sheet provided along with a table-top
calendar. During the home visits, the frontline health
workers encouraged participants with hypertension, diabetes
and dyslipidemia to seek treatment, take medication
regularly and adhere to the prescribed treatment plan.
Community level interventions
Apart from the household visits, the frontline health
workers also organised public meeting each month in
community settings. During these meetings, they gather
30–40 participants and discussed with them about the
risk factors associated with CVD and healthy lifestyle
behaviours. A community implementation committee
comprised of the study investigators at each site, local
medical officer, village leaders and volunteers from local
self-help groups was organised in each cluster to enable
these public meetings. The behaviours being targeted for
change were the following; a) consumption of oils rich in
mono-unsaturated fatty acids, and poly unsaturated fatty
acids, and reduction of trans-fat consumption, b) increase
in dietary fibre consumption, c) decrease in dietary salt
consumption, d) increase in physical activity, and e)
decrease in consumption of tobacco and alcohol.
Additionally, several community activities including competition for
children and adults (painting competitions, physical activity
demonstrations, cooking competitions and healthy recipe
demonstrations) and peer led sessions for tobacco and/or
alcohol cessation were conducted at the community level
in each intervention cluster to sensitize the community.
Monitoring and evaluation of intervention
Every three months the intervention process was evaluated
in terms of campaign components and the delivery
mechanisms. A formal reporting system was established to
communicate the details of community level interventions
at each cluster to the coordinating centre. Although the
interventions were exclusively implemented by frontline
health workers, the DISHA project staff at each site
monitored the intervention implementation. They visited at least
20 % of households in the intervention clusters at quarterly
intervals and documented the progress of interventions in
terms of number of visits made by the frontline health
workers, messages delivered, and utilization of study tools.
Additionally, a team from the coordinating centre
conducted monitoring visits to the sites once in six months to
verify the implementation process.
End-line risk factor survey
Similar to the baseline survey, an independent,
representative, cross-sectional end-line survey is planned in both the
intervention and control clusters. The end-line survey will
follow the same methods as in the baseline survey.
However in the end-line survey, a customised tablet computer
application is developed for data collection in both the
intervention and control clusters.
This multi-site trial is coordinated by a central coordinating
team based at the Centre for Chronic Disease Control,
New Delhi, India. The team consists of epidemiologists,
biostatistician, nutritionists and behaviour communication
experts. Each participating site also has at least two
investigators, 6 field staff or field attendants recruited for data
collection of baseline and post intervention survey, 1 data
entry operator for entry of the questionnaires in the
software and 1 lab technician for sample collection and
processing. Similarly, each study site engaged 6–12 trained
frontline health workers for intervention delivery.
The participants were informed about the study and
provided with a detailed information sheet. Written informed
consent was also obtained from all study participants. The
study was approved by the institutional review boards of
the central coordinating centre (the Centre for Chronic
Disease Control, New Delhi) and all participating sites. The
study protocol is registered with the Clinical Trials Registry
of India (CTRI/2013/10/004049).
Sample size calculation and statistical power
The sample size was calculated with the aim to detect an
epidemiologically significant difference of 2 mmHg in
systolic blood pressure at the population level between the
intervention and control arm of the study. This is based
on the estimate that, a 2 mmHg decrease in mean blood
pressure level at the population level will substantially
reduce the incidence of hypertension and future
cardiovascular events over a longer period of time [
] and the
population approach proposed by Geoffrey Rose as an
effective means of prevention in apparently healthy
]. We assumed an intra-class correlation
coefficient of 0.002 for blood pressure (based on previous
cluster design survey data from India), a type 2 error of
5 % and 90 % power for the study. Based on the
aforementioned assumptions and accounting for design effect (1+
[m-1] X ICC, where m is the average cluster size), the
sample size was estimated as 1620 in each arm.
Accounting for a 10 % drop-out rate, we decided to recruit 300
participants from each cluster, 1800 in each arm of the
study and 3600 in each study site.
Summary of continuous variables will be presented as
means and standard deviations and compared across
intervention and control clusters. In case of skewed data,
medians and inter-quartile range will be presented. All
categorical variables will be presented as frequencies and
percentages. Intra-class correlation coefficients for all
important risk factors will be also presented.
After the completion of the study, analyses will be
performed using cluster level summaries at each site. Equal
weight will be given to each of the six clusters. All analysis
will compare the two treatment arms, unless otherwise
stated. Binary outcomes will be presented as a difference in
proportions. Finally, a meta-analysis will be conducted to
estimate the overall effect size.
Our study is the largest community based cluster
randomised trial in low and middle-income country settings
designed to test the effectiveness of ‘task shifting’
interventions involving frontline CHWs for cardiovascular risk
reduction. The DISHA study conducted in two phases has
adequate power to detect epidemiologically meaningful
population level changes in all cardiovascular risk factors.
In order to ensure comparability of data across sites,
the DISHA study follows a common protocol and manual
of operation with standardized measurement techniques.
Furthermore, additional processes such as centralized
training, translation of all tools and materials in local languages,
and pilot testing and further modification of tools ensured
quality of the collected data. Independent verification of all
entries in the data application related to biochemical
variables with source data helped the coordinating team to
evaluate the accuracy of data entry.
The DISHA study will report the ICCs of
cardiovascular risk factors at both the village level and household
level in adults. The ICC measures the degree to which
responses within the same cluster are correlated to each
other and it is a major determinant of sample size and
power in cluster randomised trials [
]. Ideally the
population within a cluster should be as heterogeneous as
possible but there should be homogeneity between cluster
summary measures. However, homogeneity among units
within clusters (high ICC) may elevate the standard error
of the estimates of interest and thereby decreases the
power of the study substantially [
]. We will be reporting
the ICC for all major cardiovascular risk factors both at
the village level and household level. The ICC data from
this study will be immensely useful for calculating the
sample size and designing future cluster RCTs and studies
with cluster sampling method.
Lifestyle based CVD prevention programs that employ
behaviour change techniques have been extensively
implemented in a variety of settings [
]. However, the
impact of these interventions are mostly assessed at the
individual level. To the best of our knowledge, DISHA is
the only study sufficiently powered enough to detect
meaningful changes in CVD risk factors at the population
level in low and middle-income country settings.
Community based interventions for CVD risk reduction in the
past, especially in the high income country settings, did
not yield expected results due to the following reasons; (a)
effectiveness of these interventions were tested when there
was a strong secular trend in reduction of CVD at the
population level, (b) the ‘dose of the intervention’ was not
adequate to reach at the community level, (c)
interventions were targeted at specific risk factors or risk
behaviours, (d) studies were not adequately powered to detect
meaningful differences at the population level, and (e)
interventions did not take into account the possible barriers
and facilitators of adopting a healthy lifestyle [
DISHA study on the contrary is conducted in India when
there is a strong secular trend of increase in CVD risk
factors at the population level, incorporated mechanism to
ensure fidelity of interventions, comprehensively addresses
all CVD risk factors and risk behaviours, adequately
powered to detect meaningful differences, resource sensitive
and culturally tailored to suit to the local needs of the
population. Beneficial effect on blood pressure was
observed in a cluster RCT of family based home health
education delivered by lay health workers in Karachi, Pakistan
]. The DISHA study is however unique as it measures
population level changes (measurements are planned or
conducted in independent representative population
sample from each clusters before and after intervention) in
blood pressure and other CVD risk factors.
In general, behavioural theory based studies or studies
with behavioural change techniques on self-regulation and
self-monitoring are considered to be more effective
lifestyle interventions [
]. The DISHA study not only
follows a behavioural change model but adopts a theoretical
framework for intervention mapping, describing
performance objectives, identifying practical feasibility of
implementation, assessing and addressing barriers to
intervention, evaluating and prioritising facilitators of
intervention and finally describing the change objectives.
A strong focus also has been given to self-regulation and
self-monitoring with appropriate materials such as
measurement tools for oil and salt, diaries and calendars for
self-monitoring etc. at the household level.
‘Task shifting’ interventions have been tested in different
settings in low and middle-income countries and early
results suggest that they are useful in managing
noncommunicable diseases [
]. Most of these ‘task
shifting’ interventions in the past were focused around
trained nurses in the health system. The DISHA study
focuses on frontline CHWs and shifting their role from
managing maternal and child health conditions and
infectious disease management to predominantly addressing
cardiovascular disease risk factors and risk behaviours at
the population level. The DISHA study results will directly
inform the current National program for prevention and
control of cancer, diabetes, cardiovascular disease and
stroke in India to consider scale-up of the ‘task shifting’
strategy at the national level. Other studies on
effectiveness of CHWs training in screening for global
cardiovascular risk assessment in low and middle-income country
settings also support task shifting’ interventions [
Although there is a lack of clear definitions for roles and
expectations of CHWs, re-designation of health care
services and appropriate resource allocation may help
scaling-up of ‘task shifting’ interventions similar to the
DISHA interventions in LMIC settings [
The DISHA study is a cluster randomised trial in India,
designed to test the effectiveness of ‘task shifting’
interventions involving frontline community health workers
for cardiovascular risk reduction. The final results from
this study will have direct policy relevance in formulating
the health system response to the rising burden of
cardiovascular diseases in low and middle-income countries.
Additional file 1: Study questionnaire. http://www.ccdcindia.org//
Disha_study/DISHA_STUDY_QUESTIONNAIRE.pdf. (DOC 22 kb)
Additional file 2: Intervention tools. http://www.ccdcindia.org//
Disha_study/DISHA_Phase_II_IEC_Tools.zip. (DOC 22 kb)
The authors declare that they have no competing interests.
SM and DP conceived the idea. AB, AP, PN, SL, JS, KS, GT and PJ contributed
to protocol preparation. DJ supervised the data management and data quality
checking. AB, AP, PN, SL, JS, and KS supervised the data collection at each
participating sites. GN, PJ, KK, DK, and NS helped in coordination and project
management. DL and NS participated in the intervention development process.
SD coordinated the biochemical assays. PJ wrote the first draft of the paper.
All authors contributed meaningfully to revise the initial draft and approved
the final version of the manuscript.
This study is financially supported by Indian Council of Medical Research, New
Delhi, India. Panniyammakal Jeemon (PJ) was supported by a career development
fellowship (2014 Feb-2014 June) from the Wellcome Trust, Public Health
Foundation of India and a consortium of UK Universities. PJ is currently
supported by a clinical and public health intermediate fellowship from the
Wellcome Trust-Department of Biotechnology India alliance.
DISHA study investigators and study team
Centre for Chronic Disease Control, Delhi: Dr. Dorairaj Prabhakaran, PI; Dr.
Sathya Prakash Manimunda, Co-PI; Dr. Panniyammakal Jeemon, Co-I; Dr.
Dimple Kondal, Bio Statistician; Ms. Nidhi Sobti, PC; Ms. Kashvi Kahol, PC; Mr.
Mumtaz Ali, Data Manager
Indian Council of Medical Research, Delhi: Dr. Gurudyal Singh Toteja,
Supriya Dwivedi, RA.
Sri Aurbindo Institute of Medical Sciences, Indore: Dr. Jyoti Sanghvi, PI; Dr.
Kuldeep Singh, PI: Dr. Ajeet Despandey, Co-I; Dr. Subodh Banzal, Co-I; Dr. Susmit
Kosta, PC; Ms. Urvi Waghela, Lab Technician; Mr. Dinesh Dalal, DEO; Late Narayan
Suryawanshi, Deceased DEO; Ms. Garima Singh, LT; Mr. Dleep Alawa, FI; Mr.
Kamlesh Patidar, FI; Mr. Shankar Lal Maru, FI; Mr. Shailendra Singh Mandloi,
FI; Mr. Varun Mandoliya, FI; Mr. Rahul Chouhan, FI; Mr. Laxman Singh, FI
Aga Khan Health Services, Mumbai: Dr. Sulaiman Sadruddin Ladhani, PI; Ms.
Harshada Bhalerao, Project Cordinator; Dr. Kranti Laxman Rayamane, Co-I; Ms.
Maitreyee Patwardhan, PC; Mr. Himanshu Narendrabhai Bhatt, FI; Mr. Yogesh
Ratilal Dave, FI; Ms. Nitaben Bharat Koriya, FI; Ms. Ramila Lakha Sondarava, FI;
Ms. Rekhaben Vinod Thakar, FI; Ms. Sabnam Jariya, FI; Ms. Anjana Bhatt, FI;
Ms. Asmita Subhashbhai Vadsariya, FI; Mr. Asheesh Shasuddin Kachi, DEO; Mr.
Reena Yadav, DEO; Mr. Mehul Kariya, Lab Technician; Mr. Hansaben Patel, Lab
Technician; Mr. Sanjay Patel, Lab Technician; Ms. Trupti Sachin Lalya, DEO.
Pondicherry Institute of Medical Sciences, Puducherry: Dr. Anil Jacob Purty,
PI; Dr. Prabhakaran Stalin, Co-I; Dr Ramesh Chauhan, Co-I; Dr (Brig) Z Singh,
Co-I; Dr Yogesh Sharma, Co-I Dr Mark Christopher, Co-I; Ms Maghida Sridhar,
Co-I; Dr. Sangeeta Narayanasamy, Co-I; Dr. Prasanna Sundara Raju, Co-I; Ms
Mehru Sudha, FI; Ms Radhika Devi, FI; Mrs Shanmuga Sundari, FI; Ms. Vanitha
Arulsamy, FI; Mr Chinniah Devadas, FI; Mr Allimuthu Nasudan, FI; Mr Raja
Rajeswaran, DEO; Mr Manglaraj Rajasekar, DEO; Mr Mohan Venkatesh, Lab
technician; Ms Jeyalakshmi Sreenivasan, FI; Ms Baby Rama Balakrishnan, FI; Ms
Bakkiyalakshmi Ranganatha, LT.
Indira Gandhi Medical College, Shimla: Dr Prakash Chand Negi, PI; Dr Anjali
Mahajan, Co-I; Dr Rajeev Merwaha, Co-I; Dr Virendra Mohan Singh Jaiswal,
Co-I; Ms Sucheta Sharma, DEO; Mr Raminder Dhiman, DEO; Mr Ravinder
Kumar, FI; Ms Reeta Sharma, LT; Mr Ravindra Thakur, FI; Ms Ashu Kanwar, FI;
Ms Rama Kumari, FI; Ms Pratibha Sharma, FI; Ms Kiran Sharma, FI; Mr Saurabh
Rajendra Prasad Government Medical College, Tanda: Dr Ashok Bhardwaj,
PI; Dr Dinesh Kumar, Co-I; Mr Sanjiv Kumar, DEO; Mr Parkash Singh, LT; Mr
Kulwinder Singh, FI; Mr Sohan Mal, FI; Mr Kritesh Thakur, FI; Mr Anil Kumar,
FI; Mr Mohinder Pal, FI; Mr Rajinder Singh, FI; Ms Binta Devi, FI; Mr Sahil Kumar,
FI, Mr Anup Kumar, FI
Regional Medical Research Centre, Bhubaneswar: Dr Santanu Kumar Kar,
PI; Dr Bhagirathi Dwibedi, Co-I; Mr Madhab Chandra Mandal, LT; Mr Raghumani
Sa, FI; Mr Bharati Sahu, FI; Mr Tuna Naik, FI; Mr Jubaraj Gahir, FI; Mr Anil Kumar,
FI; Mr Manjush Kumar, DEO
National Institute of Nutrition, Hyderabad: Dr Avula Laxmaiah, PI; Dr.
Mallikharjuna Rao, Co-I; Dr. Indrapal Ishwar Meshram, Co-I; Dr Nagalla Balakrishna,
Co-I; Mr Sree Ramakrishna, Co-Investigator; Mr. Manchalla Ravindranath, Co-I; Mr
Shankar Kookutla, LT; Mr. Raut Anmol, DEO; Mr Palem Vereesh, FI; Ms Rama Devi,
FI; Mr Ravi Bhaskar, FI; Mr Madasi Suresh, FI; Mr Padadala Manikumar, LT; Mr Neella
Desert Medicine Research Centre, Jodhpur: Dr. Raman Sachdev, PI; Dr
Shalabh Sharma, Co-I; Dr Raghavendra Rai, Co-I; Mr Anil Purohit, PC; Mr
Ramesh Chandra Sisodiya, LT; Mr Dolat Singh Shekhawat, FI; Ms Sonika
Parmar, FI; Mr. Kishan Gopal Sharma, FI; Ms. Preeti Mangal; FI; Mr. Mahendra
Singh Chouhan, FI
Rajendra Memorial Research Institute of Medical Sciences, Patna: Dr
Pradeep Das, Project Head; Dr Neena Verma, PI; Dr Roshan Kumar Topno,
Co-I; Dr Vidya Nand Ravi Das, Co-I; Dr Krishna Pandey, Co-I; Dr Chandra Sekar
Lal, Co-I; Mr Abhay Kumar, LT; Mr Animesh Kumar, DEO; Anushil Anand; FI.
Rajendra Institute of Medical Sciences, Ranchi: Prof (Dr) Shamim Haider, PI;
Prof (Dr) Vivek Kashyap, Co-I; Dr Shalini Sunderam, Co-I; Mr Shashi Bhushan
Singh, Co-I; Dr Mithilesh Kumar, Co-I; Mr Gunjan Kumar, FI; Mr Arvind Kumar,
FI; Mr Lalit Ekka, FI; Mr Raja Ram Ahir, FI; Mr Kuldip Mahto, FI; Mr Raju Pramanik,
FI; Mr Kashim Ali, FI; Ms Sita Devi, FI.
Regional Medical Research Centre, Dibrugarh: Dr Prafulla Dutta, PC;
Dr Jagadish Mahanta, PI; Dr Prasanta Kumar Borah, Co-I; Dr. Gojendra Kumar
Medhi, Co-I; Dr. Hiranya Kumar Das, Co-I; Mr Ankur Borgohain, LT; Mr Chaitanya
Narayan Chetia, FI; Mr Rintu Das, FI; Mr Dipjyoti Ahom, FI; Mr Gaurav Goswami,
FI; Mr Pritam Boruah, FI; Mr Arif Haque, FI; Ms Munmi Rajkhowa, DEO.
PI = Principal Investigator, Co-I = Co-investigator, PC = Project Coordinator, FI = Field
Investigator, DEO = Data Entry Operator, LT = Lab Technician, RA = research Assistant.
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