PhD/DrPH Candidates

PhD Candidate: Vamadevan S Ajay

Institutions:
London School of Hygiene and Tropical Medicine and Public Health Foundation of India
Supervisors:
D. Prabhakaran (India), Sanjay Kinra (UK)
Period:
2010 – 2013
Research Project:
A smart-phone enabled diagnosis and management services for hypertension and diabetes at primary health settings in Kerala, India

The objectives of the study are:

  1. To assess the acceptability and feasibility of a smart-phone enabled detection and management services for hypertension and diabetes at primary health settings in Kerala, India;
  2. To collect information on participant response rate, compliance and follow-up statistics to design an effectiveness trial.

The study will be a multi-site, parallel group, controlled, prospective cluster randomized trial testing a smart phone enabled diagnosis and management service among 3050 adult (30+ age group) subjects, attending out-patient clinics in 4 Primary Health Centres (2 PHCs each arm) over a period of 9 months.

Primary outcome: Proportion of people with hypertension and/or diabetes receiving evidence based clinical management after screening.Secondary outcome:Compliance to therapy and follow-up rate among people with hypertension and/or diabetes.

Decision support software (DSS) tool, which runs on smartphones, will be developed for this study. The health care personnel (physician, nurse and health workers) at the PHC will use this tool as a screening and management aid. The software will compute clinical risk scores (for diabetes and 10-year risk of coronary heart disease) and will generate patient specific drug/lifestyle/referral advice using the guidelines issued by the Government of India. The qualitative research component of the study will assess user requirements, acceptability and practicality of the smart-phone enabled service at the PHCs.

Expected outcome: The study will elicit the feasibility dimensions on the use of smartphone based decision support system for chronic disease care at primary care settings.

PhD Candidate: Sandra Albert

Institutions:
London School of Hygiene and Tropical Medicine and Indian Institute of Public Health, Delhi
Supervisors:
Lalit Dandona (India), Diana Lockwood & John Porter (UK)
Period:
2010 – 2013
Research Project:
The role of khasi indigenous medicine in the primary healthcare of rural Meghalaya

Meghalaya in north east India has some of the poorest health indices in the country. The allopathic stream of health care provision through government networks in rural India has been inadequate, mainly because of lack of manpower and poor infrastructure. Its indigenous people have their own non-codified tribal traditional medicine system that is locally popular.

The objectives of this prject are:

  1. To describe the health-seeking behaviours of Khasi women in rural Meghalaya, with particular reference to the use of Khasi traditional medicine and to identify the social determinants of the health seeking behaviours with respect to availability, accessibility, acceptability, efficacy and cost
  2. To make recommendations and construct a possible model for the integration of Khasi traditional medicine with allopathic medicine services in rural Meghalaya

Method: A descriptive ‘health-seeking behaviour’ survey of women from representative villages in the Khasi Hills will be conducted using both quantitative and qualitative methods for obtaining baseline data. For the qualitative studies, a sample of key informants for in-depth interviews will be identified, and a few focus group discussions will be conducted. Interviews with traditional medicine practitioners in the selected villages will be done, so as to determine general approaches to diagnosis, treatment and referral patterns and also to seek their views on integration.

PhD Candidate: Raghupathy Anchala

Institutions:
Cambridge University and Indian Institute of Public Health, Hyderabad
Supervisors:
D. Prabhakaran (India), John Danesh & Dr. Oscar Franco (UK)
Period:
2010 – 2013
Research Project:
Decision support system for prevention of cardiovascular diseases

The objective of the study is to test the effectiveness, cost effectiveness and cost utility of a decision-support system, in hypertensive patients attending primary health care (PHC) centers in a district of AP, India compared to Usual Care (UC) at the end of 12 months of follow up. Randomly chosen 8 PHCs, homogenous in age and gender distribution, from a district in AP, India would be cluster randomized to receive a DSS or UC. The cluster adjusted sample size is 784 subjects (8 clusters with 125 subjects in each cluster to allow for a 20% loss to follow up) per intervention arm to detect a 4mm Hg difference in Systolic Blood Pressure (SBP) with a power of 90% and an alpha of 0.05. Evaluation, risk stratification, guideline based pharmacological treatment and take home advice (on lifetsyle interventions and treatment adherance) would form the elements of DSS. Data on cardiovascular risk profiling and quality of life will be collected at 0, 6 and 12 months after randomization. The primary end point would be comparison of SBP at 0 and 12 months with comparison of quality of life scores and cost effectiveness (0 versus 12m) as secondary end points.

Besides the Wellcome Trust Capacity Building Programme, this doctoral research is also supported partly by the PHFI-Cambridge Scholarship.

PhD Candidate: Panniyammakal Jeemon

Institutions:
University of Glasgow and Public Health Foundation of India
Supervisors:
D. Prabhakaran (India), Sandosh Padmanabhan & Anna F. Dominicza (UK)
Period:
2010 – 2013
Research Project:
Genetic markers of lipids in Indians: a validation study of most relevant findings of genome-wide association studies

Genome-wide association studies (GWAS) have found several potential genetic markers for lipids mainly in the European population. For example, SNPs primarily associated with triglycerides (TAG) were identified near ANGPTL3, APOB, GCKR, MLXIPL, LPL, TRIB1, APOA1/A4/A5/C3, and NCAN-CILP2-PBX4 genes and replicated in many different GWAS. The most replicated loci for HDL-c are LPL, LIPC, CETP, ABCA1, LIPG, APOA1/C3/A4/A5 and GALNT2. To the best of our knowledge, these findings are not validated in the Indian population living in India. It is proposed to validate the most significant findings of GWAS on triglycerides and HDL-c in the Indian population.

The objectives of the study:

  1. To validate the most relevant findings of GWAS in triglycerides and HDL-c in the Indian population;
  2. To test whether environment modifies the genotype-phenotype association by studying rural and urban cohorts. It is proposed to use 1500 each urban and rural samples randomly selected from a surveillance study population in Delhi for the genetic study analysis. The top independent signals of lipid traits (triglycerides and HDL-c) will be identified from the published GWAS literature. In order to identify the most relevant findings, a systematic review of all GWAS in triglycerides and HDL-c are completed. In total, a panel of 30 SNPs will be generated. The DNA samples will be utilized to genotype these 30 SNPs on SEQUENOM platform (available at The Centre for Genomic Application-TCGA, New Delhi, India).

Expected outcomes: The study design will help us to identify environmental factors that modify genotype-phenotype (lipids) association in the Indian population.

This research is being done as part of a PhD at University of Glasgowunder the PHFI-UKC Wellcome Trust Capacity Building Programme.

PhD Candidate: AT Jotheeswaran

Institutions:
Institute of Psychiatry and Indian Institute of Public Health, Hyderabad
Supervisors:
Vikram Patel & Y. Sitamma (India), Martin Prince (UK),
Period:
2009 – 2013
Research Project:
Phase I development and phase II evaluation of a community-based intervention targeting frail dependent older people and their carers

The objective of the study is to develop a multi-component (complex) intervention package for use by non-specialist health workers targeting frail dependent older people and their carers, and carry out initial evaluation, as preparatory work for a definitive randomized controlled trial.

Phase I development:

  1. Carry out a systematic review to gain understanding of the literature especially from developing countries and to assist in identifying active ingredients of the intervention;
  2. Carry out a qualitative study involving community health professionals who will be involved in the administration of the intervention, to explore attitudes and expectations regarding elder care, current practices and perceived issues and problems.

Intervention development: From the completed reviews it is evident that: a)There are simple, cheap and effective interventions available for much common impairment among frail dependent older people; b) In some cases there is evidence that non-specialist healthcare workers can deliver the intervention effectively at community level. The review did not however identify any studies from low or middle income countries. Absence of evidence is not evidence of absence, so with the support from WHO (World Health Organisation) and Dr. John Beard, Director of the Department of Ageing and Life Course at WHO, we will establish an external advisory group to assist us in this task.

Phase II evaluation:

  1. Establish the feasibility of each of the components of the intervention, with respect to the time needed for training and its effectiveness, the time taken to administer by CHWs, and its fidelity, and the acceptability to older people and carers;
  2. Assess the likely efficacy of individual components of the intervention with simple before and after assessment of appropriate outcomes; c) Establish the most active components, and test delivery and implementation factors.

Expected outcome: Evidence based multi-component (complex) intervention package for use by non-specialist health workers targeting frail dependent older people and their carers will be the final output of this project.

This research is being done as part of a PhD at Institute of Psychiatry, King's College Londonunder the PHFI-UKC Wellcome Trust Capacity Building Programme.

PhD Candidate: Nanda Kishore Kannuri

Institutions:
University College London and Indian Institute of Public Health, Hyderabad
Supervisors:
K. Srinath Reddy (India), Sushrut Jadhav (UK),
Period:
2010 – 2013
Research Project:
Clinical ethnography of farmer suicides in Andhra Pradesh: developing a culturally sensitive public health framework for intervention

Approximately 52% of the Indian population are engaged in Agriculture. Recent changes in the agrarian sector have been reflected in socio- cultural domains of farmer’s lives. These include increase in small and marginal landholdings, shift from the subsistence to cash crops, individualization of agrarian practices, and insurmountable debts. Rapid and multiple shifts have led to fractures within family and community bonds, and also caused major ruptures in cultural identities. Many small and marginal farmers caught in these struggles have experienced severe distress. In some states of India, farmer suicide has reached epidemic proportion. A staggering 182,936 Indian farmers have committed suicide over the past ten years. Majority of these have occurred amongst cotton farmers in Maharashtra, Andhra Pradesh, Madhya Pradesh, Chhattisgarh, and Karnataka, in order of severity. Suicide is identified as a preventable public health problem. Every suicide has a devastating impact on the family members and large numbers of suicide amongst farmers has a detrimental impact on their health and social fabric. There is a paucity of interdisciplinary research to understand and address farmer suicides from an integrated medical anthropological and public health perspective.

Objectives:

  1. Profile the social and cultural determinants of suicide among cotton farmers including existing policies and intervention, in an identified community
  2. Elicit local and institutional conceptualization of marginality, distress, trauma, and resilience within the identified community
  3. Develop a culturally sensitive psycho-social model to inform interventions addressing farmer suicides.

Methods include 12 months of field work deploying principles of clinical ethnography including extended periods of stay in affected communities, participant observation, focus group discussions, and semi-structured interviews. The study sample includes identified affected and non-affected subjects, and relevant stakeholders including policy planners, bureaucrats, clinicians, and politicians.

Outcomes:

  1. Generate a holistic understanding of the phenomenon of suicides amongst farmers, from both inter-disciplinary and public health perspectives
  2. Produce a culturally sensitive theory and a practical model that can be field tested in future interventions.

PhD Candidate: Anup Karan

Institutions:
Oxford University and Indian Institute of Public Health, Delhi
Supervisors:
Sakthivel Selvaraj (India), Winnie Yip (UK),
Period:
2010 – 2013
Research Project:
Households' expenditure on health care in India: role of financial risk protection

Increasing cost of health care in India restricts many poor households to seek health care on the one hand and on the other causes severe disruption in the living status of those who go for purchasing even the bare essential health care. Equity in access to health care services and the related financial burden on households, hence, has been one of the major concerns of Indian health system. The challenges are related to reducing the financial burden of health care on poor households and enhance their access to quality health care. To protect the poor from health shocks the Government of India has recently launched the largest ever health insurance plan “Rashtriya Swasthya Bima Yojna (RSBY). After the two-to-three years of implantation of the scheme, present research aims to assess how far the RSBY has been successful, so far, in protecting the poor households from the health shocks. Also what steps are required to improve RSBY and enhance the access to health care for the poor? The study is based on data collected from secondary as well as primary sources and uses techniques of difference in difference method (DID) to assess the impact of the scheme on poor households. The outcome of the research is likely to feed into the policy to improve the functioning of the scheme and finally improve the access to health care by poor without suffering financial hardships.

PhD Candidate: Sonalini Khetrapal

Institutions:
London School of Hygiene and Tropical Medicine and Indian Institute of Public Health, Delhi
Supervisors:
Sanjay Zodpey (India), Anne Mills & Arnab Acharya (UK)
Period:
2010 – 2013
Research Project:
Public private partnership in the health sector: the case of national health insurance for the poorest of the poor in two states of india

The aim of the research is to evaluate the use and provision of health services under Public-Private Partnership contracts in the implementation of Rashtriya Swasthya Bima Yojna (RSBY) scheme, in order to inform policy makers on how to improve scheme design.

The objectives of this study are:

  1. To map the allocated roles and responsibilities of partners under RSBY including the central, state and district governments, public and private health care providers, the insurance companies, NGOs and the Third Party Administrators (TPAs);
  2. To evaluate the availability of services by mapping the number of enrolled households and the market of empanelled healthcare providers;
  3. To assess the influence of demand side factors (e.g. gender) on utilization patterns across public and private providers for RSBY beneficiaries;
  4. To compare the provision of health care across both public and private providers for RSBY beneficiaries and between RSBY and non-RSBY beneficiaries for a specific type of provider;
  5. To inform policy based on the findings of the study and make recommendations in order to help improve provision of healthcare to the target population.

The study will use both qualitative and quantitative methods to determine the implications of using contractual arrangements in use and provision of health services in the context of health insurance. Both primary and secondary data would be used for quantitative research. Additionally, multiple qualitative methods would be used to allow for the triangulation of data, which will help enhance the rigor of the research and help improve the validity of the data.

This research will directly address various data needs to help improve scheme design and implementation.

PhD Candidate: Manu Mathur

Institutions:
University College London and Public Health Foundation of India
Supervisors:
K. Srinath Reddy (India), Richard Watt & Georgios Tsakos (UK)
Period:
2009 – 2012
Research Project:
Status, gradients and determinants of oral health of adolescents living in the city of New Delhi

The overall aim of this research study is to assess whether there is a socioeconomic gradient in oral health status in adolescents, 12-15 years of age in the city of New Delhi, India and to assess the factors influencing this gradient.

Despite recent gains in reducing poverty and a rapidly expanding, upwardly mobile middle class, India remains distinguished by searing inequalities in social class and health. More than 400 million children and adolescents, the most of any country of the world, call India home. There is a clear and wide divide between those who grow up in more affluent homes in India, compared to those who grow up in less privileged contexts, in low income housing and slums. Various studies conducted across the world have reported that children and adolescents belonging to lower socioeconomic groups compared to higher socioeconomic groups have poorer oral health status. Studies conducted in India conversely are inconclusive and provide conflicting evidence. Most of the studies on oral health inequalities in India have stressed socioeconomic status (SES) as an important determinant of oral health. However very few attempts have been made in assessing the role of other psychosocial, behavioural and cultural factors in determining oral health status among different socioeconomic groups in India especially amongst adolescents living in deprived neighbourhoods.

The proposed study aims to address this gap in scientific literature. A cross sectional survey will be conducted with a sample of adolescents living in 3 diverse areas of New Delhi. A clinical examination will assess the oral health status of the sample and a short interview will gather relevant behavioural and social data. The results of the study will provide useful information for the development of future oral health promotion interventions especially among adolescents in a resource poor setting.

PhD Candidate: Poornima Prabhakaran

Institutions:
University of Bristol and Indian Institute of Public Health, Delhi
Supervisors:
K. Srinath Reddy & KV Radhakrishna (India), George Davey Smith & Yoav Ben-Shlomo (UK)
Period:
2010 – 2013
Research Project:
Andhra Pradesh children and parents study (apcaps): nutritional challenges, abdominal adiposity and type 2 diabetes in indians: parental and offspring cardio-metabolic risk: a trans-generational extension of Hyderabad nutrition trial

Studies linking maternal characteristics and offspring outcomes are very limited as compared to the numerous studies relating birth size and outcomes within a generation. With the current “epidemic” of chronic diseases in India, with increasingly younger populations being affected, it would be of importance to study the trans-generational association and transmission of chronic disease risk, if any, to the next generation.

The objectives of the study are:

  1. To examine the association between parental and offspring cardio-metabolic risk profile and to see if the mother-offspring associations are different from father-offspring associations;
  2. To study if parental deprivation in childhood (assessed from socio-economic data and height and leg length of the parents) is associated with cardio-metabolic risk in the offspring, and if so, whether nutritional supplementation of mothers in pregnancy attenuates this risk;
  3. To see if children born before nutritional supplementation of mothers differ from those born after, in their disease risk profile.

The is a cross-sectional study of the parents and siblings of the subjects born in an earlier controlled, randomized, clinical trial which evaluated the impact of the nutritional supplementation component of the ICDS programme in India. Parents are in the age range of 35-60 years and siblings are 16 – 30 years of age. In order to study the associations between parental anthropometry and cardiometabolic risk markers in the offspring, data including questionnaires (evaluating diet, physical activity and socio-economic status), anthropometry, body composition, arterial stiffness and carotid scan, pulmonary function tests and fasting bloods for glucose, lipids, insulin and DNA is being collected on all members of the family in study households located in 29 villages of Rangareddy District in Hyderabad, South India.

The findings from this study, if suggestive of a trans-generational influence on chronic disease risk, modulated by a nutritional intervention, will be of important relevance to public health policy.

PhD Candidate: Bidyut Sarkar

 
Institutions:       University College London and Indian Institute of Public Health, Delhi    
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Supervisors:      K. Srinath Reddy & Monika Arora (India), Robert West & Lion Shahab (UK)
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Period:               2010 – 2013
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Research project:   A Cluster Randomized Trial of a brief tobacco cessation intervention in low income communities in India
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There is a continued need to develop and evaluate interventions to promote cessation of tobacco use. In India there is an urgent need for low cost interventions that can be delivered to the 275 million tobacco users.

This study is a community-based cluster randomised trial in tobacco users with two arms. The intervention arm is: brief advice and training in yogic exercises; the control arm is very brief advice simply stressing the importance of stopping tobacco use .  Tobacco users will be identified actively by a household survey and offered either YA or VBA. The inclusion criteria will be:  23+ years of age, current self-reported use of any tobacco-containing product and willingness to provide consent.

 The participants will be followed up one month and 7 months after the intervention.

The study will be conducted in 28 low income slum areas in India. Each slum area would be considered as a cluster. Fourteen clusters will be randomly allocated to the yogic exercises arm (YA) and fourteen randomly allocated to very brief advice (VBA) arm. Each slum area belongs to either a “Jhuggi-Jhopri” (J.J) (not government sanctioned) category or ‘resettlement’ (government sanctioned) category. Therefore, within each arm seven clusters will be from JJ slum clusters category and seven from slum resettlement category.

The primary outcome measure will be self report of abstinence for the 6 months preceding 7-month follow up together with a saliva cotinine concentration estimation at that point using an ELISA assay. The findings will be used to inform regional and national policy for tobacco use cessation.

PhD Candidate: Reetu Sharma

 
Institutions:                  University of Oxford and Indian Institute of Public Health, Delhi
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Supervisors:                Sanghita Bhattacharya (India), Premila Webster (UK)
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Period:                         2009 – 2012
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Research project:         Coordination of frontline workers of ICDS and RCH (NRHM) of government of India: a case study of Rajasthan
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 The research study aims to : 1) Identify areas and nature of coordination between the three frontline workers of two national programs, 2) Assess the current status of this coordination, 3) Understand factors that affect this coordination and suggest ways towards better coordination.

The study uses Content Analysis to accomplish the first study objective.  Based on the findings, in order to assess the current status of coordination, primary data will be collected from eight data sites/villages from the three frontline workers. For this, the study adopts a Case Study Approach and the data on various identified areas of coordination are collected through In-depth interviews using Interview schedules and guides. Participant Covert Observation is used to triangulate the findings and content analysis for reviewing registers and records will also be used.  For assessment of the coordination of workers in service delivery and events/meetings, more participatory methods of data collection will be used. Short interviews with the beneficiaries are also planned.  To answer the factors affecting coordination, data at two levels will be collected using interviews i.e. 1) first from the respondent frontline workers using questionnaire and observations on their socio-economic status, geographical barriers, inter-personal barriers, village politics, departmental barriers etc. 2) from the officials higher-up to reflect on the programmatic factors, larger administrative and technical issues etc. 

By the end of the study, it will be able to establish a clarity on operational meaning of coordination, areas of duplication of tasks and hence the areas that need better coordination, reflect on the current status of coordination for the first time, present reflections of the factors-inter-departmental, structural issues, interpersonal issues, larger administrative issues, issues of politics, caste, class and gender etc that affect the coordination of frontline workers and some possible solutions to  better inter-departmental/inter-program coordination.