Hypertension Diagnosis, Treatment, and Control in India.

Importance: Hypertension is a major cause of morbidity and mortality worldwide. Previous efforts to characterize gaps in the hypertension care continuum-including diagnosis, treatment, and control-in India did not assess district-level variation. Local data are critical for planning, implementation, and monitoring efforts to curb the burden of hypertension. Objective: To examine the hypertension care continuum in India among individuals aged 18 to 98 years. Design, Setting, and Participants: The nationally representative Fifth National Family Health Survey study was conducted in 2 phases from June 17, 2019, to March 21, 2020, and from November 21, 2020, to April 30, 2021, among 1 895 297 individuals in 28 states, 8 union territories, and 707 districts of India. Exposures: District and state of residence, urban classification, age (18-39, 40-64, and ≥65 years), sex, and household wealth quintile. Main Outcomes and Measures: Hypertension was defined as a self-reported diagnosis or a newly measured blood pressure of 140/90 mm Hg or more. The proportion of individuals diagnosed (self-reported), the proportion of individuals treated among those diagnosed (self-reported medication use), and the proportion of individuals with blood pressure control among those treated (blood pressure <140/90 mm Hg [aged 18-79 years] or <150/90 mm Hg [aged ≥80 years]) were calculated based on national guidelines. Age-standardized estimates of treatment and control were also provided among the total with hypertension. To assess differences in the care continuum between or within states (ie, between districts), the variance was partitioned using generalized linear mixed models. Results: Of the 1 691 036 adult respondents (52.6% women; mean [SD] age, 41.6 [16.5] years), 28.1% (95% CI, 27.9%-28.3%) had hypertension, of whom 36.9% (95% CI, 36.4%-37.3%) received a diagnosis. Among those who received a diagnosis, 44.7% (95% CI, 44.1%-45.3%) reported taking medication (corresponding to 17.7% [95% CI, 17.5%-17.9%] of the total with hypertension). Among those treated, 52.5% (95% CI, 51.7%-53.4%) had blood pressure control (corresponding to 8.5% [95% CI, 8.3%-8.6%] of the total with hypertension). There were substantial variations across districts in blood pressure diagnosis (range, 6.3%-77.5%), treatment (range, 8.7%-97.1%), and control (range, 2.7%-76.6%). Large proportions of the variation in hypertension diagnosis (94.7%), treatment (93.6%), and control (97.3%) were within states, not just between states. Conclusions and Relevance: In this cross-sectional survey study of Indian adults, more than 1 in 4 people had hypertension, and of these, only 1 in 3 received a diagnosis, less than 1 in 5 were treated, and only 1 in 12 had blood pressure control. National mean values hide considerable state-level and district-level variation in the care continuum, suggesting the need for targeted, decentralized solutions to improve the hypertension care continuum in India.

Agricultural and Socioeconomic Factors Associated with Farmer Household Dietary Diversity in India: A Comparative Study of Visakhapatnam and Sonipat.

Using primary data from 479 farmer households, this study examined the associations between agricultural and socioeconomic factors and farmer household dietary diversity in Visakhapatnam and Sonipat. Cropping intensity was positively associated with farmers' household dietary diversity score (HDDS), suggesting that higher cropping intensity may expand the gross cropped area and improve food security among subsistence farmers. Distance to food markets was also significantly associated with farmer HDDS, which suggests that market integration with rural households can improve farmer HDDS in Visakhapatnam. In Sonipat, wealth index had a positive association with farmer HDDS, targeting the income pathway by improving farmer HDDS in this region. Considering the relative contribution of these factors, distance to food markets, cropping intensity, and crop diversity were the three most important factors affecting farmer HDDS in Visakhapatnam, whereas wealth index, cropping intensity, and distance to food markets emerged as the top three important factors contributing to farmer HDDS in Sonipat. Our study concludes that the associations between agricultural and socioeconomic factors and farmer HDDS are complex but context- and location-specific; therefore, considering the site- and context-specific circumstances, different connections to HDDS in India can be found to better support policy priorities on the ground.

A Delphi Study to Prioritize Evidence-Based Strategies for Cardiovascular Disease Care in India.

Providing quality cardiovascular disease (CVD) care in low resource setting requires understanding of priority and effective interventions. This study aimed to identify and prioritize evidence-based quality improvement strategies for CVD care in India using a modified two-round Delphi process in which, we asked 46 experts (clinicians, researchers, program implementers and policy makers) to rate 25 proven CVD care strategies grouped into: (1) patient support, (2) information communication technology (ICT) for health, (3) group problem solving, (4) training, and (5) multicomponent strategy on a scale of 1 (highest/best)-5 (lowest/worst) on priority, relative advantage, and feasibility. Subsequently, we convened an expert consensus panel of 32 members to deliberate and achieve consensus regarding the prioritized set of strategies for CVD care. The Delphi study found that group problem solving strategies achieved the best score for priority (1.80) but fared poorly on feasibility (2.88). Compared to others, multicomponent strategies were rated favorably across all domains (priority = 1.84, relative advantage = 1.94, and feasibility = 2.40). The ICT for health strategies achieved the worst scores for priority = 2.01, relative advantage = 2.31, and feasibility = 2.85. Training and patient support strategies scored moderately across all domains. The expert panel narrowed the selection of a multicomponent strategy consisting of (1) electronic health records with clinical decision-support system, (2) non-physician health worker facilitated care, (3) patient education materials, (4) text-message based reminders for healthy lifestyle, and (5) audit and feedback report for providers. Future research will evaluate the real-world feasibility and effectiveness of the multicomponent strategy in patients with CVD in a low- and middle-income country setting. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00087-2.

Correction: Cardiovascular Health in India - a Report Card from Three Urban and Rural Surveys of 22,144 Adults.

[This corrects the article DOI: 10.5334/gh.1137.].

The role of dairy in healthy and sustainable food systems: community voices from India.

BACKGROUND: Managing the role of dairy foods in healthy and sustainable food systems is challenging. Milk production is associated with greenhouse gas emissions and milk-based processed foods can be high in fat, sugar and salt; yet, milk production provides income generating opportunities for farmers and dairy foods provide essential nutrients to young children, with a cultural significance in many communities. This is particularly relevant to India, the world's largest producer of milk. The aim of this study was to use Photovoice, a participatory research method, to explore the experiences and perceptions of communities in India on the role of dairy products in local sustainable and healthy food systems. METHODS: Purposive sampling recruited two women's self-help groups in Visakhapatnam, Andhra Pradesh: one in a rural area and one in an urban area. A total of 31 participants (10-17 urban group and 12-14 rural group), produced photographs with captions to represent their views on how dairy was produced, sold, and consumed in their community. A discussion workshop was held in each area, with prompts to consider health and the environment. Workshop transcripts, photographs and captions were analysed qualitatively using thematic analysis. RESULTS: A range of experiences and perceptions were discussed by the two women's self help groups. Participants had an awareness of their local food system and how stages of dairy food supply chains were non-linear and inherently interconnected. Three main themes were identified: 1) Quality and value matters to producers and consumers; 2) The need to adapt to sustain dairy farmer livelihoods in water scarce areas; 3) It's not only about health. CONCLUSIONS: Moderate milk-producing states such as Andhra Pradesh will continue to develop their dairy industry through policy actions. Including communities in policy discussions through innovative methods like Photovoice can help to maximise the positive and minimise the negative role of dairy in evolving local food systems.

Impact of large-scale, government legislated and funded organic farming training on pesticide use in Andhra Pradesh, India: a cross-sectional study.

BACKGROUND: The use of pesticides in agriculture has been associated with the destruction of biodiversity and damage to human health. A marked reduction in pesticide use is urgently required globally, but whether this can be achieved rapidly and at scale is unclear. We aimed to assess whether government-legislated and funded organic farming training in Andhra Pradesh, India, reduced pesticide use by farmers and sales of pesticides by pesticide retailers. METHODS: We did a cross-sectional survey between Aug 11 and Nov 26, 2020, among farmers and pesticide retailers in Kurnool District of Andhra Pradesh (India). We assessed the impact of the Andhra Pradesh Community Managed Natural Farming (APCNF) programme, which aims to transition 100% of the agricultural land of Andhra Pradesh (population approximately 49 million, 6 million of whom are farmers) to organic farming practices by 2030. We did cross-sectional phone interview surveys of farmers and face-to-face surveys of pesticide retailers. We used multivariable Poisson regression models to estimate relative risks (RRs) and logistic regression models to estimate odds ratios (ORs). FINDINGS: 962 farmers were invited to participate, of whom 894 (93%) consented (709 conventional farmers and 149 APCNF farmers). 47 pesticide retailers were invited to participate, of whom 38 (81%) consented. APCNF farmers had practised APCNF for a median of 2 years (IQR 1-3). APCNF farmers were less likely to use pesticides than conventional farmers (adjusted RR 0·65 [95% CI 0·57-0·75]), although pesticide use remained high among both APCNF and conventional farmers (73 [49%] of 148 APCNF farmers vs 695 [99%] of 700 conventional farmers; p<0·0001). APCNF farmers had lower pesticide expenditures than conventional farmers (median US$0 [IQR 0-170] for APCNF farmers vs $175 [91-281] for conventional farmers; p=0·0001). Increased frequency of meeting with agricultural extension workers was associated with reduced pesticide use among ACPNF farmers. Seven (18%) of 38 retailers reported a decrease in sales of pesticides in the past 4 years; no difference in the odds of reporting a decrease in pesticide sales in the past 4 years was identified between APCNF retailers and conventional retailers (OR 0·95 [95% CI 0·58-1·57]). INTERPRETATION: Despite a major government drive for organic agriculture, about half of APCNF farmers continued to use pesticides and no impact on pesticide sales at local retailers was observed. A combination of policy instruments (eg, bans on highly hazardous pesticides), not solely training for farmers, might be needed to eliminate pesticide use in agriculture. FUNDING: Scottish Funding Council and UK Research and Innovation.

Environmental risk factors for reduced kidney function due to undetermined cause in India: an environmental epidemiologic analysis.

BACKGROUND: An epidemic of chronic kidney disease is occurring in rural communities in low-income and middle-income countries that do not share common kidney disease risk factors such as diabetes and hypertension. This chronic kidney disease of unknown etiology occurs primarily in agricultural communities in Central America and South Asia. Consequently, environmental risk factors including heat stress, heavy metals exposure, and low altitude have been hypothesized as risk factors. We conducted an environmental epidemiological analysis investigating these exposures in India which reports the disease. METHODS: We used a random sample population in rural and urban sites in Northern and Southern India in 2010, 2011, and 2014 (n = 11,119). We investigated associations of the heat index, altitude, and vicinity to cropland with estimated glomerular filtration rate (eGFR) using satellite-derived data assigned to residential coordinates. We modeled these exposures with eGFR using logistic regression to estimate the risk of low eGFR, and linear mixed models (LMMs) to analyze site-specific eGFR-environment associations. RESULTS: Being over 55 years of age, male, and living in proximity to cropland was associated with increased risk of low eGFR [odds ratio (OR) (95% confidence interval (CI) = 2.24 (1.43, 3.56), 2.32 (1.39, 3.88), and 1.47 (1.16, 2.36)], respectively. In LMMs, vicinity to cropland was associated with low eGFR [-0.80 (-0.44, -0.14)]. No associations were observed with temperature or altitude. CONCLUSIONS: Older age, being male, and living in proximity to cropland were negatively associated with eGFR. These analyses are important in identifying subcommunities at higher risk and can help direct future environmental investigations.

A model for national assessment of barriers for implementing digital technology interventions to improve hypertension management in the public health care system in India.

BACKGROUND: There is substantial interest in leveraging digital health technology to support hypertension management in low- and middle-income countries such as India. The potential for healthcare infrastructure and broader context to support such initiatives in India has not been examined. We evaluated existing healthcare infrastructure to support digital health interventions and examined epidemiologic, socioeconomic, and geographical contextual correlates of healthcare infrastructure in 544 districts covering 29 states and union territories across India. METHODS: The study was a cross-sectional analysis of India's Fourth District Level Household and Facility Survey (DLHS-4; 2012-2014), the most up-to-date nationally representative district-level healthcare infrastructure data. Facilities were the unit of analysis, and analyses accounted for clustering within states. The main outcome was healthcare system infrastructural context to implement hypertension management programs. Domains included diagnostics (functional BP instrument), medications (anti-hypertensive medication in stock), essential clinical staff (e.g., staff nurse, medical officer, pharmacist), and IT specific infrastructure (regular power supply, internet connection, computer availability). Descriptive analysis was conducted for infrastructure indicators based on the Indian Public Health Standards, and logistic regression was conducted to estimate the association between epidemiologic and geographical context (exposures) and the composite measure of healthcare system. RESULTS: Data from 32,215 government facilities were analyzed. Among lowest-tier subcenters, 30% had some IT infrastructure, while at the highest-tier district hospitals, 92% possessed IT infrastructure. At mid-tier primary health centres and community health centres, IT infrastructure availability was 28 and 51%, respectively. For all but sub-centres, the availability of essential staff was lower than the availability of IT infrastructure. For all but district hospitals, higher levels of blood pressure, body mass index, and urban residents were correlated with more favorable infrastructure. By region, districts in Western India tended towards having the best prepared health facilities. CONCLUSIONS: IT infrastructure to support digital health interventions is more frequently lacking at lower and mid-tier healthcare facilities compared with apex facilities in India. Gaps were generally larger for staffing than physical infrastructure, suggesting that beyond IT infrastructure, shortages in essential staff impose significant constraints to the adoption of digital health interventions. These data provide early benchmarks for state- and district-level planning.

Assessment of Studies of Quality Improvement Strategies to Enhance Outcomes in Patients With Cardiovascular Disease.

Importance: Clinical care quality improvement (QI) strategies are critical to prevent and control cardiovascular disease (CVD). However, there is limited evidence regarding which components of the health system-, clinician-, and patient-based QI strategies contribute to their impact on CVD. Objectives: To identify, map, and organize evidence on the effectiveness and implementation of cardiovascular QI strategies that seek to improve outcomes in patients with CVD. Evidence Review: Eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, ProQuest, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform) were searched for studies published between January 1, 2009, and October 25, 2019. Eligible study designs included randomized trials and preintervention and postintervention evaluations. Descriptive findings of included studies were reported using several frameworks to map the intervention components stratified by target population, setting, outcomes, and overall results. Findings: From 8066 screened titles and abstracts, 456 unique studies with 150 148 unique patients (38.1% women and 61.9% men; mean [SD] age, 64.6 [7.1] years) were identified, including 427 randomized trials, 21 quasi-randomized studies, and 8 preintervention and postintervention studies. Of 336 studies from 45 countries that were classified, 255 (75.9%) were from high-income countries; 68 (20.2%), upper-middle-income countries; 13 (3.9%), lower-middle-income countries; and 0, low-income countries, with diverse clinical settings and target patient populations (post-myocardial infarction, stroke, heart failure). Patient support (311 studies), information communication technology (ICT) for health (78 studies), community support (18 studies), supervision (15 studies), and high-intensity training (14 studies) were the most commonly evaluated QI strategies. Other strategies were group problem-solving (7 studies), printed information (5 studies), strengthening infrastructure (4 studies), and financial incentives (3 studies). Patient support, ICT for health, training, and community support were strategies that had been evaluated the most for clinical end points and showed modest associations with several clinical outcomes. The other strategies did not have outcome-driven evaluations reported. Group problem-solving was associated with improved patient self-care and quality of life. Strengthening infrastructure was associated with improved treatment satisfaction. Printed information and financial incentives showed no meaningful effect. Conclusions and Relevance: This systematic review found that substantial variations exist in the types, effectiveness, and implementation of QI strategies for patients with CVD. A comprehensive map of QI strategies created by this study would be useful for researchers to identify where new knowledge is needed to improve cardiovascular outcomes. Outcome-driven evaluations and long-term studies are needed, particularly in low-income settings, to better understand the effects of QI strategies on prevention and control of CVD.

Patient experiences and perceptions of chronic disease care during the COVID-19 pandemic in India: a qualitative study.

OBJECTIVE: People with chronic conditions are known to be vulnerable to the COVID-19 pandemic. This study aims to describe patients' lived experiences, challenges faced by people with chronic conditions, their coping strategies, and the social and economic impacts of the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: We conducted a qualitative study using a syndemic framework to understand the patients' experiences of chronic disease care, challenges faced during the lockdown, their coping strategies and mitigators during the COVID-19 pandemic in the context of socioecological and biological factors. A diverse sample of 41 participants with chronic conditions (hypertension, diabetes, stroke and cardiovascular diseases) from four sites (Delhi, Haryana, Vizag and Chennai) in India participated in semistructured interviews. All interviews were audio recorded, transcribed, translated, anonymised and coded using MAXQDA software. We used the framework method to qualitatively analyse the COVID-19 pandemic impacts on health, social and economic well-being. RESULTS: Participant experiences during the COVID-19 pandemic were categorised into four themes: challenges faced during the lockdown, experiences of the participants diagnosed with COVID-19, preventive measures taken and lessons learnt during the COVID-19 pandemic. A subgroup of participants faced difficulties in accessing healthcare while a few reported using teleconsultations. Most participants reported adverse economic impact of the pandemic which led to higher reporting of anxiety and stress. Participants who tested COVID-19 positive reported experiencing discrimination and stigma from neighbours. All participants reported taking essential preventive measures. CONCLUSION: People with chronic conditions experienced a confluence (reciprocal effect) of COVID-19 pandemic and chronic diseases in the context of difficulty in accessing healthcare, sedentary lifestyle and increased stress and anxiety. Patients' lived experiences during the pandemic provide important insights to inform effective transition to a mixed realm of online consultations and 'distanced' physical clinic visits.

Changes in take-home aerated soft drink purchases in urban India after the implementation of Goods and Services Tax (GST): An interrupted time series analysis.

OBJECTIVES: Taxes on sugar-sweetened beverages (SSB) are increasingly being implemented as public health interventions to limit the consumption of sugar and reduce associated health risks. In July 2017, India imposed a new tax rate on aerated (carbonated) drinks as part of the Goods and Services Tax (GST) reform. This study investigates the post-GST changes in the purchase of aerated drinks in urban India. METHODS: An interrupted time series analysis was conducted on state-level monthly take-home purchases of aerated drinks in urban India from January 2013 to June 2018. We assessed changes in the year-on-year growth rate (i.e. percentage change) in aerated drink purchases with controls for contextual variables. RESULTS: We found no evidence of a reduction in state-level monthly take-home aerated drink purchases in urban India following the implementation of GST. Further analysis showed that the year-on-year growth rate in aerated drink purchases increased slightly (0.1 percentage point per month, 95%CI = 0.018, 0.181) after the implementation of GST; however, this trend was temporary and decreased over time (0.008 percentage point per month, 95%CI = -0.015, -0.001). CONCLUSIONS: In India, a country currently with low aerated drink consumption, the implementation of GST was not associated with a reduction in aerated drink purchase in urban settings. Due to the lack of accurate and sufficiently detailed price data, it is not possible to say whether this finding is driven by prices not changing sufficiently. Furthermore, the impact of GST reform on industry practice (reformulation, marketing) and individual behaviour choices (substitution) is unknown and warrants further investigation to understand how such taxes could be implemented to deliver public health benefits.

Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India: a mixed methods study.

BACKGROUND: People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India. METHODS: Between July 29, to September 12, 2020, we telephonically surveyed adults (n = 2335) with chronic conditions across four sites in India. Data on participants' demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient's experiences during the COVID-19 lockdowns and data analyzed using thematic analysis. RESULTS: One thousand seven hundred thirty-four individuals completed the survey (response rate = 74%). The mean (SD) age of respondents was 57.8 years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90-5.53), having diabetes (2.42, 1.81-3.25) and hypertension (1.70,1.27-2.27), and loss of income (2.30,1.62-3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52-5.35), and job loss (1.90,1.25-2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services. CONCLUSION: People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.

Implementation of the new integrated algorithm for diagnosis of drug-resistant tuberculosis in Karnataka State, India: How well are we doing?

BACKGROUND: As per national policy, all diagnosed tuberculosis patients in India are to be tested using Xpert® MTB/RIF assay at the district level to diagnose rifampicin resistance. Regardless of the result, samples are transported to the reference laboratories for further testing: first-line Line Probe Assay (FL-LPA) for rifampicin-sensitive samples and second-line LPA(SL-LPA) for rifampicin-resistant samples. Based on the results, samples undergo culture and phenotypic drug susceptibility testing. We assessed among patients diagnosed with tuberculosis at 13 selected Xpert laboratories of Karnataka state, India, i) the proportion whose samples reached the reference laboratories and among them, proportion who completed the diagnostic algorithm ii) factors associated with non-reaching and non-completion and iii) the delays involved. METHODS: This was a cohort study involving review of programme records. For each TB patient diagnosed between 1st July and 31st August 2018 at the Xpert laboratory, we tracked the laboratory register at the linked reference laboratory until 30th September (censor date) using Nikshay ID (a unique patient identifier), phone number, name, age and sex. RESULTS: Of 1660 TB patients, 1208(73%) samples reached the reference laboratories and among those reached, 1124(93%) completed the algorithm. Of 1590 rifampicin-sensitive samples, 1170(74%) reached and 1104(94%) completed the algorithm. Of 64 rifampicin-resistant samples, only 35(55%) reached and 17(49%) completed the algorithm. Samples from rifampicin-resistant TB, extra-pulmonary TB and two districts were less likely to reach the reference laboratory. Non-completion was more likely among rifampicin-resistant TB and sputum-negative samples. The median time for conducting and reporting results of Xpert® MTB/RIF was one day, of FL-LPA 5 days and of SL-LPA16 days. CONCLUSION: These findings are encouraging given the complexity of the algorithm. High non-reaching and non-completion rates in rifampicin-resistant patients is a major concern. Future research should focus on understanding the reasons for the gaps identified using qualitative research methods.

Towards the Three Dimensions of Sustainability for International Research Team Collaboration: Learnings from the Sustainable and Healthy Food Systems Research Programme.

This paper highlights the potential for learning and virtual collaboration in international research teams to contribute towards sustainability goals. Previous research confirmed the environmental benefits of carbon savings from international virtual conferences. This paper adds the social and economic dimensions by using a combination of qualitative and quantitative methods to measure the constraints and benefits for personal development, economic costs, efficiency and team learning of holding international virtual conferences (VCs). Using the Sustainable and Healthy Food Systems (SHEFS) research programme as a case study, we analysed VC participant survey data to identify strengths, weaknesses, opportunities, and threats of VCs. We estimated 'saved' GHG emissions, costs, and time, of using VCs as an alternative for a planned in-person meeting in Chennai, India. Hosting VCs reduced North-South, gender, and researcher inclusivity concerns, financial and travelling time costs, and substantially reduced emissions. For one international meeting with 107 participants, changing to a virtual format reduced the per capita GHG emissions to half the annual global average, and avoided 60% of travel costs. The benefits of VCs outweighed weaknesses. The main strengths were inclusivity and access, with 20% more early/mid-career researchers attending. This study identified opportunities for international research partnerships to mitigate their carbon footprint (environmental benefit) and enhance inclusivity of early/mid-career, women and Global South participants (social benefit), whilst continuing to deliver effective collaborative research meetings (economic benefit). In doing so, we present a holistic view of sustainability opportunities for virtual collaboration.

UDAY: A comprehensive diabetes and hypertension prevention and management program in India.

INTRODUCTION: Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted. METHODS AND ANALYSIS: UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about diabetes and hypertension, the proportion treated and controlled; the patient knowledge and self-management skills; healthcare providers' management practices; the level of access and barriers to obtaining care.The interventions will include: tailored health promotion for improving public knowledge; screening of adults aged ≥ 30 years for identifying those at high risk of diabetes and/or hypertension for linkage to the healthcare system; patient education using technology enabled community health workers, geographic information system (GIS) based mapping of the communities, healthcare provider training on management guidelines, community based diabetes registry and; advocacy to improve access to healthcare. The baseline surveys have been completed, the study areas mapped using GIS and the interventions are being implemented. UDAY is expected to increase over baseline the levels of: public knowledge about diabetes and hypertension; those treated and controlled; patient self-management skills; the use of guideline based management by providers and; access to healthcare, leading to improved health outcomes and inform development of a India relevant chronic care model. ETHICS AND DISSEMINATION: Ethical clearance for conduct of the study was obtained from the Institutional Ethics Committee (IEC) of the Public Health Foundation of India. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities.