Policy and peeR mentOr intervention proGrams on cardiovasculaR disEase at workSites in 3 South Asian countries.

Lead Research Organisation: St John's National Academy of Health Sci
Department Name: St John's Research Institute

Abstract

We propose a feasibility study and a survey conducted at 6 sites - 2 in India, 2 in Srilanka, and 2 in Bangladesh.

1. The feasibility study will be conducted to understand the feasibility of peer-mentored interventions at the operational, research and policy levels to improve CVD health.

At the operational level, we will identify 6 worksites in Bangladesh (2), India (2) and Sri Lanka (2), obtain acceptance from the management, identify the appropriate personnel as peers to carry out interventions and identify areas at worksites to implement interventions (café, physical exercise, stress reduction, tobacco environment).

At research level, we will choose the best methods to identify individuals at risk for interventions, measure risk factor levels identify & train the peer mentors, design the most appropriate interventions, determine the training goals for the peer mentors, select the training methods, and develop the intervention tools.

At policy level, we will, in discussion with the worksite management and the concerned State Government departments (health and labour departments) determine the need, methods and outcomes of the interventions. This strategy ensures that we have useful insights on the interventions as well as the agreement and investment of key stake-holders in relevant departments

2. A qualitative study will be conducted to understand the priorities for policy level changes to improve the CVD environment at worksites in each country, at the Central and Regional levels; to understand the common barriers for an optimal CVD environment at worksites; and to understannd the most acceptable peer mentor-based interventions for employees to improve CVD health.

We will survey at least three levels of management staff per site on the CVD environment at the workplace. Specifically this will include tobacco policy, food at workplace, opportunities for physical activity, medical care if any provided at worksites, policy on chronic care for employees, bariers for optimal care and possible interventions to improve CV health. We will survey 5 management staff at each level or 15 per worksite for a total of 120 at 8 sites.

We will conduct focussed group discussions and in-depth interviews among management staff and employees to better understand policy issues, barriers for CVD care and acceptable interventions to improve CV health.

If peer mentor mediated interventions prove to be effective in reducing cardiovascular risk factors, such interventions could be scaled up globally. As adults can spend upto 60% of their time at workplaces, interventions such as these could prove to be effective in reducing cardiovascular risks and reap rich dividends by reducing cardiovascular deaths, thus helping to achieve World Hearth Federation's goal of 25 by 25.

Technical Summary

From analysis of the outcomes of this development grant we will (a) assess feasibility and (b) identify barriers and workable interventions for a definitive or full-scale study.

(a) Feasibility: we will analyse feasibility at three levels.
We will establish feasibility at the operational level, when we identify 6 appropriate worksites in Bangladesh (2), India (2) and Sri Lanka (2), obtain written acceptance from the worksite management, identify the right personnel as peers to carry out interventions and identify areas at worksites to implement interventions (café, physical exercise, stress reduction, tobacco environment).

We will establish feasibility at the research level, by identifying the most appropriate method to (a) identify individuals at risk for interventions, (b) identify the appropriate peer mentors, (c) select the most acceptable interventions, (d) determine the training methods and goals for the peer mentors, (e) select the training methods (f) design the training and intervention tools, (g) determine risk factor levels in the worksite population design

We will establish feasibility at the policy level, when in discussion with the worksite management and the respective State Departments (Health and Labour Departments) we will determine the need, methods and outcomes of the interventions and get their buy-in into the programme. This will also ensure that we identify the right interventions and have the agreement of key stake-holders.

(b) Identification of barriers and interventions: through a qualitative study we will determine the barriers for an optimal CVD environment at the workplace and also determine the most acceptable peer-mentored interventions for employees to improve CV health.

Planned Impact

Presently there are no high quality studies done on comprehensive worksite interventions to impact the rising burden of cardiovascular diseases(CVD) in low and middle income countries.

Our proposed trial called PROGRESS will generate evidence on a multilevel policy and individual level interventions to reduce CVD risk at worksites. We will work closely with occupational health associates and the governments in three proposed south Asian countries (Bangladesh, India, and Srilanka). University of Oxford with expertise in these areas will work with investigators in these countries to design, conduct, analyse and disseminate the findings.

PROGRESS will develop tools for worksite interventions (diaries, public signage, training manuals, followup strategies, including periodic text messages, presentations on health promotions and efficient referral systems). The evidence generated and the experience gained in the trial will be novel and useful to adapt and help scale up such work in other worksites in the three countries as well as other countries.

Specifically we anticipate the following impact:

At the worksites:
1. Enhanced awareness among all workers on the importance of preventive care for CVD
2. This awareness will also quite likely extend to their family members
3. The worksite environment will change related to tobacco use, improved diet, increased physical activity, regular checks for BP and blood glucose.
4. The management will consider and implement improved health policy to enhance access ( group health insurance, worksite clinics for CVD) and timely referrals.
5. Overall improved health resulting in reduced absenteeism, improved productivity and better quality of life and worker satisfaction.

For Society and countries at large
1. The tools developed , trial findings and the experience gainged can be adapted and used for other worksites and at other countries.
2. Occupational health organizations and the governements will consider implementing policy changes at worksites for better CVD health.
3. This scaling up will have significant impact on the health of the workers and their families as well as result in greater productivity in countries that depend on their workforces for economic progress

Publications

10 25 50
 
Description Policy level implementation at worksite (010) in India
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Policy level implementation at worksite (011) in India
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Policy level implementation at worksite (030 & 031) in Sri Lanka
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Policy level implementation at worksites (020 & 021) in Bangladesh
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Title Assessment of knowledge, attitudes, practices and risk factors of employees at work sites in Bangladesh, India and Sri Lanka 
Description INTRODUCTION & PURPOSE: Employees from work sites who are above the age of 35 years were provided with a questionnaire. This was self administered to assess the knowledge, attitudes and practices of employees with regard to Cardiovascular diseases and its risk factors. The employees were categorized in to low, medium and high risk using Framingham risk score. UPDATE FROM THE 3 COUNTRIES. BANGLADESH KAP survey: 1) 1st work site(020) : 100 employees 2) 2nd work site(021): 102 employees, Risk Factor Assessment: 1) 1st worksite(020):224 (High risk-50 Moderate-67 Low risk-107) 2) 2nd worksite(021): 210 (High risk-37 Moderate - 64 Low risk-109) INDIA KAP survey: 1) 1st work site(010) : 115 employees 2) 2nd work site(011): 113 employees, Risk Factor Assessment: 1) 1st worksite(010): 114 (High risk- 30 Moderate-39 Low- 45) 2) 2nd worksite(011): 170 (High risk-22 Moderate-51 Low- 97) SRI LANKA KAP survey: 1) 1st work site(030) : 91 employees 2) 2nd work site(031):50 employees, Risk Factor Assessment:) 1st work site(030) : 300 (High risk- 36 Moderate-71 Low- 193) 2) 2nd work site(031):243 (High risk- 15 Moderate-35 Low- 193) 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact In general, knowledge pertaining to cardiovascular disease prevention was sub-optimal at all 6 workplaces. Practices, pertaining to physical activity and diet are sub-optimal. This was improved through the intervention. The peer mentored, group intervention helped to improve knowledge and practices and thus reduce aggregate cardiovascular risk. 
 
Title Online Learning Management System 
Description Purpose : Engagement of peer mentors and keeping their knowledge updated Content : We have developed this website to keep the mentors engaged and their knowledge updated as much as possible. We update the content of the website continually, with new articles from sources such as the Harvard School of Public Health's Nutrition Source etc. The website also has a discussion forum for mentors to interact and ask questions of each other. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The impact of the learning management system has not been assessed. The learning management system is intended to be tool that helped the peer mentors remain updated with the latest literature, that was updated by the central research office. 
 
Title Participant Intervention Chart 
Description Purpose : This chart is expected to serve as a visual reminder for targets set with respect to body weight, tobacco/alcohol cessation or Blood Pressure (BP) by the mentors Content : This chart contains a tabulation of the values for current blood pressure, BMI and target setting for BMI, BP, tobacco and alcohol consumption as well as targets set for the same. This was given to all participants by the mentors. Utility : The participants displayed chart at their homes a prominent place which served as reminder and motivation to work toward their targets to be attained. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The participant Intervention chart is a tool intended for use by participants to track their visit schedule. The impact of the tool will thus be reflected in impact on the final outcome measures. We did not separately assess the impact of the participant Intervention chart. 
 
Title Participant diary 
Description Purpose : The diary is completed by participant to capture data on cardiovascular risk factors at different time points. Content : The diary has validated questionnaires to assess levels of physical activity, dietary composition, medication adherence levels and tobacco/alcohol consumption status. Utility : The diary serves : i) as a reference for the mentor ii) as source notes for our research staff for transcribing data on to the case report form and then on to the database. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The participant diary was a tool used by participants to track their risk factors and medication adherence. The impact of the tool will thus be reflected in impact on the final outcome measures. We did not separately assess the impact of the participant diary. 
 
Title Peer Mentor Training Manual 
Description Purpose : This manual was developed for training peer mentors. Content : This consolidated manual comprised 7 sections and 91 pages. Contents included the structure and function of the heart, risk factors for ischemic heart disease, the Framingham risk score and its importance, evidence based lifestyle modification for preserving cardiovascular health, medication adherence and its determinants, principles of treating hypertension, diabetes and dyslipdemia (including the basic drugs used in treatment), recognising symptoms of a heart attack/stroke and emergency measures in heart attack, cardiac arrest and stroke. There were a total of 21 tables and 26 figures explaining corresponding topics. Utilility : The manuals were distributed among peer mentors 3 weeks prior to their formal training. The manuals are intended to be a ready reference for mentors. The mentors were trained on the contents of the manual over a duration of 2 days 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact The manuals were used for training the peer mentors. Peer mentor proficiency was assessed by the means of a post test. subsequently the mentors have delivered their intervention. During the intervention the mentors referred back to the manuals incase of any doubts. In total 24 Peer Mentors in India, 14 Peer Mentors in Bangladesh and 30 Peer Mentors in Sri Lanka were trained using the training manuals. 
 
Title Peer Mentor Training in Bangladesh, India and Sri Lanka 
Description INTRODUCTION & PURPOSE:From a list of 60 employees at a worksite who are at moderate-high risk, 8-9 'peer-mentors' were chosen (on a voluntary/ democratic basis) and trained on CVD risk factors and their control with an emphasis on lifestyle modification and adherence to treatments. These peers were expected to meet and educate their colleagues who are at risk, counsel them (for 10 -20 minutes) and give them an educational diary to record the changes made in 3 months. The topics covered during the training were as follows: - Risk factors for Cardiovascular Diseases and understanding the concept of risk - How to improve heart health through lifestyle modification. - Discussion on how to manage peers during the intervention - Hands on training on blood pressure measurement - Causes and management of: Diabetes, Hypertension, Dyslipidemia, Heart attack and Stroke. - First aid in heart disease and diabetes Peer Mentor Training was held at 6 work sites. Given below are the dates and number of peer mentors that attended the 2 day training program at each of the countries. BANGLADESH: 1)1st Worksite (020)): 7 peer mentors were trained on 17th & 18th April 2016 2)2nd Worksite (021): 7 peer mentors were trained on 20th & 21st April 2016 INDIA: 1) 1st Worksite (010): 12 peer mentors were trained on 28th & 29th October 2015 2) 2nd Worksite (011): 13 peer mentors were trained on 21st September 2016 & 4th October 2016 SRI LANKA: 1) 1st work site (030): 20 peer mentors were trained on 27th & 28th July 2016 2) 2nd work site (031): 10 peer mentors were trained on 6th & 7th February 2017 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact The Peer Mentors were empowered with simplified evidence based measures for CVD prevention. They were also confident with some aspects of self-care, which they disseminated among the fellow mentees, their family and friends. 
 
Title Pictorial flip chart 
Description Purpose : This flip chart serves as a tool intended for use by mentors for educating their peers Content : Heart disease and its risk factors, healthy meal plate and its constitution, physical activity for heart disease prevention, details on tobacco and alcohol cessation. Utility : At the baseline visit, the mentors trained their peers (participants) on various aspects of heart disease prevention using this flip chart. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact Pictorial flip chart was a tool intended for use by Peer Mentors to impart education to their mentees on heart disease & stroke. This also carries the information regarding occurrence, risk factors ( Non modifiable risk factors & Modifiable risk factors) & prevention of heart disease and stroke. The impact of the tool will thus be reflected in impact on the final outcome measures. We do not intend to separately assess the impact of the Pictorial flip chart. 
 
Title Policy level intervention at work site 
Description INTRODUCTION/PURPOSE: At the policy level, we discussed with the worksite management, the need, methods and implementation of restricting tobacco use, increasing physical activity, improving diet and enhancing access to treatment. a) What is the feasibility of peer-mentored interventions at the operational, research and policy level to improve CVD health? b) What are the priorities for policy level changes to improve the CVD environment at worksites in each country? Status on policy level intervention at workplaces BANGLADESH : Policy level intervention has been implemented at both the worksites. 1st Worksite(020) • Display of information posters regarding steps toward cardiovascular disease prevention at open spaces within the office To promote healthy dietary habits • Provide zero calorie sugar and discourage the use of sweetened condensed milk while preparing and serving tea at the office,. • Provide healthy food menu by introducing a canteen at the office, which will facilitate healthy food habits. • Visit of dietician and their suggestion about appropriate diet plan for critical cases of diabetic and heart patients. To prohibit tobacco use • Actively ensuring a "smoke free zone" within the office premises. To encourage physical activity • Employees who live near the office may be encouraged to walk to home instead of using office transportation. • Encourage to use the stairs instead of the elevators. To provide more health facilities at office • Provide first aid facilities and initial treatment at the office by a part-time healthcare provider. 2nd Worksite(021) Posters were developed on below subject and displayed at different corners of the office, especially at the canteen, office lobby, entrance and cubicle area. • Warning signs and risk factors for heart attack • Warning signs and risk factors for stroke • Lifestyle modifications that can reduce CVD risks (smoking, diet, physical activity, mental stress) • Behaviours that can reduce CVD risks (medication adherence, reference ranges for blood pressure, blood glucose and cholesterol) INDIA :Policy level intervention has been implemented at both the worksites. 1st Worksite(010) • Height to weight ratio charts including advice on obesity, cholesterol & blood pressure is displayed in strategic locations in all canteens inside the campus. • CVD awareness slides and health tips being displayed on the public LCD displays on a regular basis. • First aid box installed in various locations inside campus and being regularly refilled. • An exclusive health portal has been launched in the intranet and new information being added regularly. • An exclusive room has been provided for Peer Mentoring Measurement apparatus such as BP, Sugar & Weighing scale is available here for use by the employees. The room is set up with various health related posters & awareness pictures to create an environment that motivates a healthy lifestyle. • Posters on importance of healthy diet, medication adherence & physical activity were developed and displayed in the campus . • Various training & development programs are being regularly conducted on health & stress management. Training sessions cover both classroom as well as practical. 2nd Worksite(011) Display of informative posters • To promote healthy dietary habits • To promote medication adherence • To encourage physical activity • Company has declared Non Smoking Zone. There are 3 designated areas for smoking with enclosures. SRI LANKA Policy level intervention has been implemented at both the worksites 1st Worksite(030) • Zumba, yoga and exercise classes are carried out after working hours. • Posters and notices are displayed on notice board informing the benefits of taking the stairs instead of the lift. • Posters with health tips and healthy eating habits are displayed on notice boards. • Health tips are circulated among staff through mail system on a regular basis. 2nd Worksite(031) Notices were posted in the notice boards of each division at worksite including the following short health messages. • Drink at least 6 glasses of water per day • Use at least 3 types of vegetables and two types of fruits for your meal • It is more nutritious having fruits in pieces rather than juice • Stand up at least once per hour while working • Consume more green vegetables • Maintain your weight according to the height Welfare society of worksite were advised to do a regular monitoring of the quality of the service including the meals provided by the Cafeteria. Staff of worksite gained knowledge and motivated to check their BMI. Specially pregnant ladies and officers with any kind of chronic disease were advised to check BMI and blood pressure on regular basis using the equipment given by the "PROGRESS" study team. Started a physical training program for staff on every Wednesday from 3.00 pm onwards under the guidance of a professional trainer from the Ministry of sports. Officers were encouraged to involve in any kind of sports to maintain physical and mental health well. As a result of it, there were more worksite's Officers participated for Government servants' athletic meet held in 2017. Understanding the importance of exercising, considerable number of Staff members used to use staircase apart from the lift. Also most of them have been practicing jogging during leisure hours. Canteen policies have been changed with the guidance of Peer Mentor for more healthy and hygienic eating environment. But all members encouraged bringing home made food for lunch as it is friendlier for heart. As a result of PROGRESS project, a series of awareness programmes were organized by the Training Division of the worksite. All the worksite's staffs were got opportunity to participate in this event. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact Impact of these activities cannot be quantified immediately, however the work-sites have implemented the policy measures. 
 
Title Qualitative Study at Bangladesh, India & Sri Lanka 
Description In-depth interviews was conducted among randomly selected 15-20 employees (men and women at different levels of hierarchy) from the work site. The purpose was to understand the barriers faced by employees at workplaces in following heart healthy lifestyles.The interview was for around 90 minutes and was a one time activity. Employees from different grades/positions and the health care provider in the company were interviewed. Qualitative study completion summary: BANGLADESH: 1) 1st Work site(020) : 22 interviews were conducted. 2) 2nd Work site(021): 19 interviews were conducted. INDIA: 1) 1st Work site(010) : 28 interviews were conducted. 2) 2nd Work site(011): 20 interviews were conducted. SRI LANKA: 1) 1st Work site(030) :18 interviews were conducted. 2) 2nd Work site(031):19 interviews were conducted. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact From the qualitative study, we were able to understand few important modifiable issues which influenced employees from maintaining optimum cardiovascular health. Overall, most of the worksites had a good setup to provide quality healthcare and recreational services to the employees, but, there were also issues with regards to food & lifestyle habits and high stress at work, which were communicated to the management workplaces. From the updated qualitative study results as of 2018, we identified • An urgent need to address dietary and lifestyle practices. • Stress as an evolving entity and the need for strategies to improve quality of life • Peers and seniors at workplace have an important role in their colleagues' health. 
 
Title Refresher training for Peer Mentors 
Description INTRODUCTION AND Purpose: since the intervention was new to the Peer mentors, we had a refresher training for the peer mentors at both the work sites in India & Bangladesh to help them to understand better the intervention, target setting, data collection in the diaries and clarify the followup visit schedule of the study 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2017 
Provided To Others? No  
Impact The refresher training helped to clarify doubts and enhance motivation among the mentors. Skills and knowledge were reinforced. 
 
Title Simplified case management algorithm 
Description Purpose : a step by step algorithm and guide for the Peer mentors to help them deal with different scenarios that they encounter such as hypertension, diabetes, overweight/obesity and post CAD/ stroke. Content : The cards have step by step management algorithms (non-pharmacological) for the conditions mentioned above. Utility : These algorithms are a ready reckoner for mentors to refer to when they are interacting with participants. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact Simplified case management algorithm is a tool, a step by step algorithm and guide for the mentors to help them deal with different scenarios they encounter such as hypertension, diabetes, overweight/obesity and post CAD/ stroke. The impact of the tool will thus be reflected in impact on the final outcome measures. We did not separately assess the impact of the simplified case management algorithm. 
 
Title Steering Committee Meeting 
Description INTRODUCTION & PURPOSE: The study has formed a steering committee which has the investigators from the 3 countries, investigators from the developed country partner, experts from India. The committee met face to face twice to review the progress with the study. Provided recommendation. Preliminary data from the study for KAP (Knowledge, Attitude & Practice) & risk factor assessment was discussed. The 1st steering committee meeting was held in December 2014 and the 2nd meeting in July 2016. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The impact has not been assessed. 
URL http://www.progress-sjri.in
 
Title SQL Commercial Database 
Description We are using the database management system for managing data in the PROGRESS study. We created the data collection forms, build in edit checks and provided remote access to our collaborators in Bangladesh and Sri Lanka to manage their data. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact The commercial database system has been used to manage the data for the project. The data that have been extracted are in the process of analysis. 
 
Description PROGRESS study collaborations 
Organisation International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
Department Equity and Health Systems
Country Bangladesh 
Sector Public 
PI Contribution We are the principal recipients of the UK-MRC/Wellcome Trust/DFID grant and our office was responsible for disbursing the grant money. All the study materials for both the qualitative and quantitative studies such as the training manuals for mentors, tools for participant engagement, data collection instruments, interview guides for the qualitative study were developed at St. John's and shared with the collaborators. Documentations required for ethics and regulatory submission was supported by St. John's for our collaborators. Dr. Denis Xavier (PI) and Dr Deepak Kamath (Co-I) visited the collaborators in Colombo and Dhaka to train teams at the sites and share experiences of peer mentor training with them. Principal Investigators from Colombo and Dhaka likewise visited the national coordinating office in Bangalore for steering committee meetings.
Collaborator Contribution Oxford University is the developed country partner on this project and advised us on various technical aspects of the peer mentored intervention. The University of Colombo (Sri Lanka) and ICDDR,B (Bangladesh) are the National Co-ordinating sites in their respective countries. They selected workplaces, obtained regulatory approvals, conducted the qualitative studies, trained peer mentors, recruited participants, oversaw interventions and manage data.
Impact The collaboration with different low and middle income countries has strengthened the systems in healthcare delivery at worksites. Employees have been sensitised to heart diseases, its cause and prevention and this was possible, through the translation of knowledge and expertise from our collaborators. Our collaboration was multi-disciplinary involving epidemiologists, global/public health scientists, biostatisticians, implementation research specialists and general physicians.
Start Year 2015
 
Description PROGRESS study collaborations 
Organisation University of Colombo
Country Sri Lanka 
Sector Academic/University 
PI Contribution We are the principal recipients of the UK-MRC/Wellcome Trust/DFID grant and our office was responsible for disbursing the grant money. All the study materials for both the qualitative and quantitative studies such as the training manuals for mentors, tools for participant engagement, data collection instruments, interview guides for the qualitative study were developed at St. John's and shared with the collaborators. Documentations required for ethics and regulatory submission was supported by St. John's for our collaborators. Dr. Denis Xavier (PI) and Dr Deepak Kamath (Co-I) visited the collaborators in Colombo and Dhaka to train teams at the sites and share experiences of peer mentor training with them. Principal Investigators from Colombo and Dhaka likewise visited the national coordinating office in Bangalore for steering committee meetings.
Collaborator Contribution Oxford University is the developed country partner on this project and advised us on various technical aspects of the peer mentored intervention. The University of Colombo (Sri Lanka) and ICDDR,B (Bangladesh) are the National Co-ordinating sites in their respective countries. They selected workplaces, obtained regulatory approvals, conducted the qualitative studies, trained peer mentors, recruited participants, oversaw interventions and manage data.
Impact The collaboration with different low and middle income countries has strengthened the systems in healthcare delivery at worksites. Employees have been sensitised to heart diseases, its cause and prevention and this was possible, through the translation of knowledge and expertise from our collaborators. Our collaboration was multi-disciplinary involving epidemiologists, global/public health scientists, biostatisticians, implementation research specialists and general physicians.
Start Year 2015
 
Description PROGRESS study collaborations 
Organisation University of Oxford
Country United Kingdom 
Sector Academic/University 
PI Contribution We are the principal recipients of the UK-MRC/Wellcome Trust/DFID grant and our office was responsible for disbursing the grant money. All the study materials for both the qualitative and quantitative studies such as the training manuals for mentors, tools for participant engagement, data collection instruments, interview guides for the qualitative study were developed at St. John's and shared with the collaborators. Documentations required for ethics and regulatory submission was supported by St. John's for our collaborators. Dr. Denis Xavier (PI) and Dr Deepak Kamath (Co-I) visited the collaborators in Colombo and Dhaka to train teams at the sites and share experiences of peer mentor training with them. Principal Investigators from Colombo and Dhaka likewise visited the national coordinating office in Bangalore for steering committee meetings.
Collaborator Contribution Oxford University is the developed country partner on this project and advised us on various technical aspects of the peer mentored intervention. The University of Colombo (Sri Lanka) and ICDDR,B (Bangladesh) are the National Co-ordinating sites in their respective countries. They selected workplaces, obtained regulatory approvals, conducted the qualitative studies, trained peer mentors, recruited participants, oversaw interventions and manage data.
Impact The collaboration with different low and middle income countries has strengthened the systems in healthcare delivery at worksites. Employees have been sensitised to heart diseases, its cause and prevention and this was possible, through the translation of knowledge and expertise from our collaborators. Our collaboration was multi-disciplinary involving epidemiologists, global/public health scientists, biostatisticians, implementation research specialists and general physicians.
Start Year 2015
 
Title Interventions at 6 worksites in 3 countries completed 
Description Description of intervention - We developed a peer mentor led, group intervention implemented at work sites, to improve physical activity, diet and adherence to medication, and reduce aggregate cardiovascular risk. This was a pilot study to develop the intervention components. We invited 6 work sites, 2 each from Bangladesh, India and Sri Lanka to participate. We had a mix of government owned, private companies and a labour force comprising of white and blue collar workers. We held screening sessions at the workplaces and used the Framingham non-laboratory equivalent risk score to compute aggregate risk of the employees. We then invited those aged => 35 years of age and a risk score of > 10% (i.e, at moderate to high risk of CVD) to participate in the study. Company human resource departments were tasked with identifying the mentors. The mentors were then trained at the national leaders offices in the respective countries. We developed modules to train mentors. Mentors were trained on cardiovascular disease risk factors, aspects related to cardiovascular disease prevention, measuring blood pressure and capillary glucose (using a glucometer) and interpreting essential investigation parameters). We also created special tools - such as show and tell charts to educate individual participants, referral algorithms and a diary for the individual participant detailing an individual's risk factors and subsequent goals/targets to be achieved. We allocated mentees to each mentor in an approximately 6:1 ratio. At baseline, the mentors first identified an individual's risk factors, educated mentees on risk factors and set targets for subsequent follow-ups. There were subsequent formal follow-ups at monthly intervals. Mentors were also encouraged to informally meet with the mentees regularly. Current stage of development - We have completed the pilot phase of the intervention. We have tested the intervention among 300 participants from 6 work sites, and the follow up has been completed. Most recent principle source of funding - UK-MRC/Wellcome trust/Department for International Development. 
Type Preventative Intervention - Physical/Biological risk modification
Current Stage Of Development Initial development
Year Development Stage Completed 2017
Development Status Closed
Impact We now have experience in developing a peer mentor led, group intervention to reduce cardiovascular risk at worksites. Through this study, we have developed training modules for peer mentors and developed tools that the mentors can use to educate their colleagues, family and friends. Our intervention delivered by trained peer mentors has proved to be feasible at medium to large worksites and also led on to a significant reduction in the aggregate cardiovascular risk factors, which was assessed by Framingham (non-lab based) risk score (FRS). There was a significant reduction in the FRS at 3 months from baseline by [19.7 (+/- 8.2) vs 17.5 (+/- 8.1); p < 0.001]. Apart from the change in the aggregate risk factor levels at 3 months, we also observed a significant change in the mean systolic BP [133.3 (+/- 17.8) vs 130.0 (+/- 15.6); p < 0.001]. We believe this model can be scaled up to include other organised work-sites across India and across South Asia. This model, if found successful in larger controlled trials, can also be adopted by the governments to implement in national programs and at government owned companies. 
 
Title Peer mentoring for risk reduction 
Description The project aimed to reduce cardiovascular risk at a workplace by behavioural modification facilitated through a trained 'Peer Mentor'. The peer mentor was a person chosen among the employees at a workplace, who was motivated enough to bring about a difference in the health of their colleagues. The mentor was then trained on various aspects of heart health by a team of investigators (Physicians). The mentors then assessed their colleagues' risk using a validated risk assessment tool (Framingham risk score) and then intervened, through education and systematic follow-up and tried to bring about a change in their diet/physical activity levels and improved or maintained medication compliance to reduce cardiovascular disease risk. This was a pilot study and we explored the feasibility of running a trained peer mentor led intervention to reduce aggregate CVD risk at workplaces. The UK-MRC/ Wellcome trust/ DFID was the principle source of funding for this development. 
Type Preventative Intervention - Physical/Biological risk modification
Current Stage Of Development Initial development
Year Development Stage Completed 2016
Development Status Closed
Impact The Peer Mentors had completed the intervention at all 6 workplaces. They had successfully completed the baseline educational intervention, helped set goals and followed up participants every month, for 3 months.. We have received favourable feedback from the research participants about the acceptability of the intervention and this pilot feasibility project could be developed as a sustainable model which further can be scaled up to many other organised worksites in south Asia. 
 
Title PROGRESS Online learning management system 
Description This online learning management website has been created for 2 reasons : i) to help peer mentors update their knowledge levels ii) help peer mentors discuss and share strategies. A curator from the national coordinating office will periodically update information and upload interesting evidence based information related CVD prevention for mentors to access. There will be a discussion forum where mentors can post questions/ queries and share their experiences. 
Type Of Technology Webtool/Application 
Year Produced 2016 
Impact We have not directly quantified the impact of the learning management platform. The platform has been used by the mentors to post questions or doubts related to the interventions. The platform has also been used by the national coordinating office in India to post updates on evidence related to diet, physical activity or heart disease risk reduction. 
URL http://www.progress-sjri.in
 
Description Health Awareness Talk at the work sites in Bangladesh, India and Sri Lanka 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Health Awareness Talk at work sites in Bangladesh, India and Sri Lanka focused on creating awareness among the employees at worksite regarding the Cardiovascular Diseases, its risk factors and prevention .
Topics covered during the talk : 1) Why is heart disease, stroke and diabetes increasing in our country and how can we prevent it 2) Why conduct a project to improve health at worksites , 3) What will be done as part of the PROGRESS project at the worksite, and how will it benefit the employees and followed by discussion with the employees.

Outcome/impact: The health awareness talks were well received by the worksite audience. The session was an interactive one which kindled interest about evidence based preventive measures for cardiovascular disease prevention. This interest also resulted in participation in the peer mentor mentored intervention study. There has been increased demand for more health awareness sessions on chronic cardiovascular disease prevention.

BANGLADESH :
1) Held at 1st worksite(020) on 27th October 2015
Attendees from 1st worksite : A total of 50 managerial officers were present at the talk. Majority of them were Managers (24%). Other attendees had various top-level designations such as Deputy Managers (20%), Assistant Managers (22%), Deputy General Managers (10%), Assistant General Managers (8%), General Managers (6%) and others (10%).
Attendees from National Leader Office : Dr. Ashique Haider Chowdhury (Senior Research Investigator and the Principal Investigator of PROGRESS in Bangladesh), Shyfuddin Ahmed (Research Investigator and Coordinator of PROGRESS in Bangladesh) and Syeda Novera Anwar (Research Officer), Cardiologist Dr. M. A. Hasnat, MD

2) Held at 2nd worksite(021) on 17th October 2015
Attendees from 2nd worksite : The Managing Director (MD) of the company, along with the Executive Director, Senior General Manager, General Manager, Senior Manager and Director of the company had attended the talk. A total of 23 senior level employees were present; most of them were Managers of different departments (around 40%).
Attendees from National Leader Office : Dr. Aliya Naheed (Interim Head, Non-Communicable Diseases, under Health Systems and Population Studies), Dr. Ashique Haider Chowdhury (Senior Research Investigator and the Principal Investigator of PROGRESS in Bangladesh), Dr. Ali Tanweer Siddique (Senior Research Investigator and the Co-investigator of PROGRESS in Bangladesh), Shyfuddin Ahmed (Research Investigator and Coordinator of PROGRESS in Bangladesh), Dr. Tauhidul Islam (Research Investigator) and Syeda Novera Anwar (Research Officer) were present to conduct the Health Awareness Talk. icddr,b invited one of its collaborating cardiologist Dr. M. A. Hasnat, MBBS, FCPS(Medicine), MD (Cardiology).

INDIA:
1) Held at 1st worksite (010) on 27th May 2015
Attendees from worksite: 70 participants attended the session
Team from St. John's : Dr. Prem Pais, MD; Dr. Denis Xavier, MD; Dr. Deepak Kamath, MD; Dr. Padmini Devi, MD;
2) Held at 2nd worksite on 24th Aug 2015
Attendees from worksite: 35 participants attended the session
Team from St. John's: Dr. Prem Pais, MD; Dr. Denis Xavier, MD; Dr. Deepak Kamath, MD; Dr. Padmini Devi, MD;
3) Held at 3rd worksite (011) on 27th April 2016
Attendees from worksite:175 participants attended the session
Team from St. John's: MD; Dr. Denis Xavier, MD; Dr. Deepak Kamath, MD; Dr. Padmini Devi, MD;
SRI LANKA:
1) Held at 1st Worksite(030) on 8th Sep 2015
Team from National Leader Office: Dr. Prasad Katulunda (Principal Investigator of PROGRESS in Sri Lanka), Dr. Ranil ( Co-investigator of PROGRESS in Sri Lanka), Ms. Achini (Research Officer) 2) Held at 2nd worksite on 9th March 2016
Attendees from worksite: 100 participants attended the session
Team from National Leader Office: Dr. Prasad Katulunda (Principal Investigator of PROGRESS in Sri Lanka),
Dr. Ranil ( Co-investigator of PROGRESS in Sri Lanka), Ms. Achini (Research Officer)
3) Held at 3rd worksite(031) on 28th Oct 2016
Attendees from work site : 126 participants attended the session
Team from National Leader Office : Dr. Prasad Katulunda (Principal Investigator of PROGRESS in Sri Lanka), Dr. Ranil ( Co-investigator of PROGRESS in Sri Lanka), Ms. Achini (Research Officer)
Year(s) Of Engagement Activity 2015,2016
 
Description Policy level intervention at work site 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Industry/Business
Results and Impact INTRODUCTION/PURPOSE:
At the policy level, we discussed with the worksite management to determine the need, methods and implementation of restricting tobacco use, increases physical activity, improving diet and enhancing access to treatments.
Given below are the updates of policy level intervention at workplaces in Bangladesh, India and Sri Lanka.
BANGLADESH : Policy level interventions have been implemented at both the worksites.
1st Worksite(020): • Display of information posters regarding steps toward cardiovascular disease prevention at open spaces within the office To promote healthy dietary habits • Provide zero calorie sugar and discourage the use of sweetened condensed milk while preparing and serving tea at the office,. • Provide healthy food menu by introducing a canteen at the office, which will facilitate healthy food habits. • Visit of dietician and their suggestion about appropriate diet plan for critical cases of diabetic and heart patients. To prohibit tobacco use • Actively ensuring a "smoke free zone" within the office premises. To encourage physical activity • Employees who live near the office may be encouraged to walk to home instead of using office transportation. • Encourage to use the stairs instead of the elevators. To provide more health facilities at office • Provide first aid facilities and initial treatment at the office by a part-time healthcare provider. 2nd Worksite(021): Posters were developed on below subject and displayed at different corners of the office, especially at the canteen, office lobby, entrance and cubicle area. • Warning signs and risk factors for heart attack • Warning signs and risk factors for stroke • Lifestyle modifications that can reduce CVD risks (smoking, diet, physical activity, mental stress) • Behaviours that can reduce CVD risks (medication adherence, reference ranges for blood pressure, blood glucose and cholesterol) INDIA :Policy level intervention has been implemented at both the worksites. 1st Worksite(010): • Height to weight ratio charts including advice on obesity, cholesterol & blood pressure is displayed in strategic locations in all canteens inside the campus. • CVD awareness slides and health tips being displayed on the public LCD displays on a regular basis. • First aid box installed in various locations inside campus and being regularly refilled. • An exclusive health portal has been launched in the intranet and new information being added regularly. • An exclusive room has been provided for Peer Mentoring Measurement apparatus such as BP, Sugar & Weighing scale is available here for use by the employees. The room is set up with various health related posters & awareness pictures to create an environment that motivates a healthy lifestyle. • Posters on importance of healthy diet, medication adherence & physical activity were developed and displayed in the campus . • Various training & development programs are being regularly conducted on health & stress management. Training sessions cover both classroom as well as practical.
2nd Worksite(011) • Display of informative posters - To promote healthy dietary habits , to promote medication adherence ,to encourage physical activity • Company has declared Non Smoking Zone. There are 3 designated areas for smoking with enclosures.
SRI LANKA: The Policy level intervention has been implemented at both worksites 1st Worksite(030): • Zumba, yoga and exercise classes are carried out after working hours. • Posters and notices are displayed on notice board informing the benefits of taking the stairs instead of the lift. • Posters with health tips and healthy eating habits are displayed on notice boards. • Health tips are circulated among staff through mail system on a regular basis.
2nd Worksite(031)

Notices were posted in the notice boards of each division at worksite including the following short health messages.
• Drink at least 6 glasses of water per day
• Use at least 3 types of vegetables and two types of fruits for your meal
• It is more nutritious having fruits in pieces rather than juice
• Stand up at least once per hour while working
• Consume more green vegetables
• Maintain your weight according to the height

Welfare society of worksite were advised to do a regular monitoring of the quality of the service including the meals provided by the Cafeteria.

Staff of worksite gained knowledge and motivated to check their BMI. Specially pregnant ladies and officers with any kind of chronic disease were advised to check BMI and blood pressure on regular basis using the equipment given by the "PROGRESS" study team.

Started a physical training program for staff on every wednesday from 3.00 pm onwards under the guidance of a professional trainer from the Ministry of sports.

Officers were encouraged to involve in any kind of sports to maintain physical and mental health well. As a result of it, there were more worksite's Officers participated for Government servants' athletic meet held in 2017.

Understanding the importance of exercising, considerable number of Staff members used to use staircase apart from the lift. Also most of them have been practicing jogging during leisure hours.

Canteen policies have been changed with the guidance of Peer Mentor for more healthy and hygienic eating environment. But all members encouraged bringing home made food for lunch as it is friendlier for heart.

As a result of PROGRESS project, a series of awareness programmes were organized by the Training Division of the worksite. All the worksite's staffs were got opportunity to participate in this event.
Year(s) Of Engagement Activity 2016,2017,2018
 
Description Results dissemination visit to worksite 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Industry/Business
Results and Impact The results dissemination visit to the 2nd worksite in India was held on 6th Jul 2018. There were 15 participants, which included the team from Global Co-ordinating Office along with Management staff and Peer Mentors, in this meeting.
The results specific for the worksite were discussed during the meeting.
Year(s) Of Engagement Activity 2018
 
Description Study Close Out Meeting at Bangladesh for 2 worksites 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact The study close out meeting was held at the first work site on 20th Feb 2018 and at the 2nd work site on 6th Nov 2017.
Year(s) Of Engagement Activity 2017,2018