GGIL India Cohort Reflections

Wind Palace in Jaipur City. This Palace has 365 windows for the 365 days in the year. Royal women used to peer through the windows to watch street festivals safely from inside the walls of the palace. Photo by Ariana Katz

Course Overview  |  Sahaay Project Overview  |  Week 1 Reflections  |  Week 2 Reflections  |  Final Reflections  |  Meet the Bloggers  |  Project Video

Course Overview

The Gillings Global Implementation Lab (GGIL) is an exciting new three credit hour, graduate-level, interdisciplinary, field-based course in which students apply knowledge and experience to systematically design and implement solutions to complex public health problems in North Carolina and around the world.  Teams of 5-8 students build problem solving and implementation capacity working on a public health project in partnership with governmental, non-governmental or private sector organizations.  Students acquire valuable applied experience and develop generalizable insights and sound implementation practices. This team will be traveling to New Delhi, India to help improve the data collection aspect of FHI 360’s Sahaay Project. The Sahaay Project is implemented by FHI360 through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. The team will be blogging during their time in India to help give you an inside look on the work this new and exciting class is doing.

Sahaay Project Overview

The India Cohort meets before departing for India

The India Cohort meets before departing for India

The Sahaay Project by FHI 360 is a phone helpline for men who have sex with men (MSM).  From the Sahaay Project’s Facebook page, ” Sahaay Helpline is the first dedicated helpline for men who have sex with men (MSM) and transgender (TG) community in India. Anybody from the community can access information and counseling on HIV/AIDS, STI, general health issues and any psycho social and legal issues related to MSM and TG.

The helpline is going to be especially useful for MSM and TG who have not come out in the open or who do not want to access services from government targeted intervention (TI) projects due to different reasons. A caller can receive information and counseling by speaking to a counselor, or hear recorded message on interactive voice response (IVR), or receive message through automated sms. Read more

This helpline is available free of cost (toll free) round the clock on all days and no recording of the call is done; the caller is also not asked personal identifiers like name, address and telephone number.

Currently the helpline is available in Hindi in three states of India, namely, Chhattisgarh, Delhi and Maharashtra. This is being done as a part of a study to determine the effectiveness in reaching out to MSM and promoting HIV/AIDS safe behaviour.

The study is being conducted by FHI360 (an international NGO) with approval from Department of AIDS Control, Government of India. The study is technically and financially supported by PATH and Canadian International Development Agency (CIDA).

If the helpline is found useful, Sahaay Project will advocate with Department of AIDS Control in implementing it across the country.”


Week 1 Reflections

Saturday, March 1, 2014 - Arrival! (Emily M.)

GGG_Prof_dinner_3.1It is not in every class that three faculty members will wait three hours to pick up one student from the airport. But SPHG 690 “Implementation Lab” is no ordinary class and our three professors, Rohit Ramaswamy, Sue Havala Hobbs, and Anita Farel, are far from your 9-5 professors. And so, as I arrived sleep deprived and disoriented at New Delhi airport for our field project, I saw my three professors smiling and waving at me, inhumanly exuberant despite their own 24 hour journeys.

Implementation Lab is a new course developed by Rohit, Sue and Anita as a way to combine implementation science, quality improvement and applied learning in the field. Spring 2014 is our pilot course and this semester we are working with FHI 360 in New Delhi to improvement the data collection aspect of an HIV prevention hotline for men who have sex with men (MSM). The field component of this project is two weeks (March 1-March14) and each of the eight students in the India group (there is a domestic group as well) will contribute to the field blog so that students considering the course in 2015 can get a variety of perspectives on this unique experience.

Since I arrived a bit earlier than my cohort I got to spend a little extra time with Rohit, Sue and Anita, and they are a blast. During the day I discovered the Evergreen Sweet Shop (so delicious!) and in the evening we took an auto-rickshaw to a rooftop bar (Amour) and had tasty drinks and appetizers while I got to hear more of their amazing backstories. Who knew drinking with your profs could be so much fun? Most of the group will arrive tonight and tomorrow we tour Delhi!

Sunday, March 2, 2014 - Delhi Tour (Emily M.)

Sunday was the first day that we were (almost) all together in Delhi and our professors had arranged a whirlwind guided tour of Delhi. We started the day with a delicious Indian/American buffet breakfast at the hotel and then we met our guide in the lobby. Our first stop was Qutab Minar, a soaring, 240 GGG_Delhi Tour_3.2foot-high tower built in 1193 after the defeat of Delhi’s last Hindu kingdom. At the foot of the tower is the first mosque to be built in India. Next we went to the Red Fort, named for its red sandstone walls. The massive Red Fort was built by the Moghul empire in 1638 and contains British barracks, the Hall of Public Audiences, the white marble Hall of Private Audiences, the Pearl Mosque, the Royal Baths and the Palace of Color. From the Red Fort, we took two auto-rickshaws (three-wheeled motor vehicles) down some very bumpy roads and alleys to get to the Jama Masjid Mosque in Old Delhi.

As an aside, traffic is absolutely crazy in Delhi. Honking is constant, stop signs are guidelines and lane markers and one-way signs are ignored completely. Auto-rickshaws, cars, buses, bicycles, and pedestrians all compete for the same space and as a passenger, the experience is something akin to Mr. Toad’s wild ride (for those Wind in the Willows fans).

Jama Masjid was commissioned by a Mughal Emperor in 1650 and it is the largest and best-known mosque in India. The expansive courtyard of the mosque can hold up to twenty-five thousand worshippers. After a yummy lunch of palek paneer, dal, butter chicken, curry vegetables, naan and tea, we stopped by the impressive presidential palace and the extraordinary Baha’i Lotus Temple. Unfortunately we were unable to go into the Lotus Temple because the line was about a mile long (literally), but we stopped to take pictures. It is a breathtaking building, built in 1986, that is shaped like a lotus flower. One great thing about the Baha’i faith is that it emphasizes that the spirit of the House of Worship be that it is a gathering place where people of all religions may worship God without denominational restrictions.

After a full day of sightseeing, the seven UNC students (the eighth was flying in on Monday) met to discuss our strategies, goals and agenda for our first in-person meeting with the FHI 360 team on Monday. I want to emphasize what a fantastic, collaborative and hard-working team of people are working on this project. They are super fun to hang out with and even better to work with. I am looking forward to seeing what we will produce as a team for this class!

Monday, March 3, 2014- Delhi - Visit with the Community Based Organization (Emily N.)

Today was our first day of work!

After a great Indian breakfast in our hotel, we headed across the street to the FHI 360 office, where we finally got to meet all of the wonderful staff that have been emailing and Skyping with us over the last two months. We also met some new team members, including the project’s Behavior Change Communication (BCC) Specialist and the Community Mobilizer (CM). Most of the morning was spent quickly bringing each other up to speed, with both the UNC and the FHI 360 teams giving presentations on the work they had accomplished since virtual meeting.

After lunch we took taxis 45 minutes across the city to a small community based organization (CBO) where the Saahay counselors take calls. We had planned our visit so that we could observe a counselor speaking to a caller and get a sense of the environment in which they work, but were fortunate to also be able to interview several community mobilizers.

The Saahay project uses community mobilizers, all of whom are gay or transgendered males, to seek out hard-to-reach men who have sex with men (MSM) in the community and make them aware of the helpline. The community mobilizers spoke candidly with us about the pride they have in their job and the enjoyment they receive from helping other MSM access services through the helpline ranging from HIV prevention and treatment to psycho-social support.

Tuesday, March 4, 2014 - Visiting the Sahaay Project (Sarah)

Our action packed second day started with us sitting down with the IT manager for the Sahaay project and getting an in-depth tour of the call monitoring system and data. From the FHI office they are able to determine which counselors are on calls, on breaks, or completing documentation work.  They are also able to assess and help troubleshoot technical problems at each of the three call center sites around India.  With this new information our group was able to extend our previous process mapping to include how calls get routed to counselors and identify additional areas that could be causing performance measures to be lower than we would like.

Following our IT focused session, we were fortunate to have Dr. Bitra Greorge, the FHI360 country director, come and speak with us.  He gave us an excellent and illuminating talk about the state of India’s population health and FHI360’s activities to improve health outcomes.   He highlighted some of the challenges including the enormous population of people living in poverty and the struggles they are still having in meeting the MDGs around maternal and child health.  He also discussed the changing roles of government and NGOs working in India.  The Indian government has taken on the role of regulating incoming international funding, and while NGOs still operate in implementation capacity, they are more and more moving in to research and technical assistance roles for the government health departments.  He described the history of FHI360 in India and their present and future programs.  Since beginning work in the late 1990’s on HIV projects, FHI360 has expanded their work to many other health problems and into other areas such as health systems, education, and nutrition as they try to address root causes of poor health outcomes.  Not only was this talk incredibly helpful in creating a context for our work and the Sahaay program, but Dr. George’s enthusiasm and energy was quite inspiring to our group of emerging public health professionals.

The rest of our morning and our afternoon were spent emerged in understanding the counseling process through observations of the Sahaay counselor on calls, interviewing the counselor herself, and finalizing our cause and effect diagram.  This process was at times a frenzy of brainpower and flying ideas, but ultimately got our team over the hill from a place of confusion to a place of more linear, goal directed thinking.

With a non-stop day of work under our belt we concluded the day by riding the Delhi metro for the first time, partaking in delicious street food, and relaxing on a roof top bar — well earned indulgence.

Wednesday, March 5, 2014 -This call is brought to you by the letter 'I' for Iterative (Cori)

With classes in program planning and qualitative data collection and analysis, the Health Behavior (HB) curriculum is full of iterative processes. So much so that using the phrase “iterative process” around HB students is sure to be followed by at least a light chuckle or a groan. Normally, class assignments that involve an iterative process are conducted over the course of a semester, allowing students substantial time to cycle through the various stages of analysis that are needed to create a polished, final product. Today was a reminder that the “real world” doesn’t always afford such opportunities. This is the story of our team’s speed dating session with the iterative process.


Getting down to business.

While we were given some information on the Sahaay Helpline back in January, analyzing data from afar can only provide a limited picture of how a program works. In order to make sure that we are proposing a change that is appropriate for the FHI 360 staff and counselors and is capable of producing an impact; we had to dedicate our first days in India to finalizing our formative research and testing the feasibility of our quality improvement strategies. This amount of work would have usually been done using two separate rounds of focus groups, but this is not your usual class assignment. We were given one morning and three back-to-back calls with counselors (one focus group per each call center).


IT and BCC Specialists Saving the Day

To do this, we broke the calls into three more manageable phases. The first interview was used to learn about the general landscape of BCC data collection and documentation, the second call was used to gain a deeper understanding of the topics covered in the first interview, and the third call was used to test out any change suggestions proposed during the first and second calls. Yes, this progressive strategy sounds logical and smooth. However, it excludes factors like: dropped calls with counselors, time needed for interpretation, having only 15 minutes to adapt the interview guide based on previous responses, internally communicating/ adding questions during the call via Google Docs, and reconfiguring our plan when Google Docs inevitably cut out.

When we finished the focus groups and lunch arrived, we ate as if we had just run a marathon. This may sound hyperbolic, but I assure you – this analogy is not that far off. The whole experience felt like a thrilling race. I was so proud of the team’s ability to accomplish so much in such a short amount of time. Thanks to resourcefulness of the team and the support of FHI 360’s IT Specialist and BCC Specialist (to whom we are eternally indebted), we received some helpful data that will guide our change proposals.

Now, if only I could use such quick thinking to figure out a strategy for safely crossing the street, but that’s a problem for another day…

Thursday, March 6, 2014 - Prioritizing Solutions (Meagan)

Phew, today was another productive and iterative-filled day!  While yesterday was all about identifying the problems counselors have in collecting BCC information from callers and brainstorming potential solutions, our day today was all about prioritizing these 12 solutions so we can narrow them down to one for implementation next week.


Our impact/effort matrix

We started out by creating a matrix on the whiteboard and placing each of the 12 potential solutions on the graph based on impact and effort. As soon as we started discussing the criteria and identifying the prioritized ones based on these, I instantly got flashbacks to our Health Behavior planning course (Thanks Dr. Moracco!) from my first year.

After reviewing the solution matrix placement with the Sahaay Research Manager, our team got to work combining some of the individual solutions into four comprehensive “packages” of individual options combined to complement one another. Once we had narrowed our potential solutions down to these four packages, we got to work creating a prioritization matrix in Excel so we could systematically evaluate our options based on impact, implementation capability, ease of monitoring, counselor adoptability, and organizational effort/resources.


Prioritization matrix for our final four

The rest of our day was spent developing a presentation revealing the rating of our final four options, and while we had one brief moment of panic when the majority of our google presentation temporarily disappeared less than 10 minutes before our presentation, overall the presentation went really well!  Once work was done, the UNC team and FHI360 staff went out to dinner together to celebrate the progress we’ve made so far. Dinner was in the middle of beautiful Deer Park, which unbeknownst to us, was actually a deer reserve in the middle of the city!

Delicious dinners and cute deer aside, we’ve decided to check in with the counselors tomorrow to get their feedback on the potential solutions before making our final decision tomorrow. I’m really proud of the work our all-star all-female UNC team has complete so far, and I’m incredibly excited to wrap up the week prepared to implement a change next week!

Friday, March 7, 2014- Success!! (Rachel)

Another incredibly exhausting and rewarding day! We spent another full day today in the conference room at FHI 360, the one we can almost call home at this point.  The frenetic work pace was set early, our efforts fueled by the lovely staff members who graciously bring us coffee and Chai tea on a cycle that can be timed by the hour. Yesterday, we came up with a slew of change packages based on Helpline problems and recommendations identified by the counselors; today was the day to vet the packages and select one for implementation. After a crazy morning of throwing together an interview guide and having it translated into Hindi by the ever-amazing IT Specialist, we were finally ready to present our options to the Delhi counselors. They unanimously chose one package they felt was easiest to implement and would be most effective in solving the documentation problem. Success!!

The work day ended with us scrambling back to the hotel to gather our gear for a ROAD TRIP!! We piled into our tour bus and braved Delhi traffic, zipping around cars, motorcycles, and bicycles at a frenzied pace before crossing into Uttar Pradesh. At the “border” – I use this term loosely, as there was nothing to signify we’d crossed over outside of a quick stop our driver made to hand money over to a gentleman in a sports coat – traffic eased a bit and we made our way along a privately-owned highway toward Agra, home of the Taj Mahal. Here are some things I learned in the 5 hours it took to make our way across India:

1. This community LOVES its Formula One – Greater Noida in Uttar Pradesh is the site of the annual Formula One Indian Grand Prix. Judging by the way people drive here, I’m not at all surprised.

2. Construction, construction, construction! Everything is either in the process of being built or being torn down. Parts of the countryside are littered with buildings that look like they’ve been bombed – wires stick out, concrete is exposed. People are packed into cities yet these buildings remain unfinished and unpopulated. The disconnect is striking. The only finished buildings house American companies like Metlife. Depressing.

3. Once out of Delhi, the landscape is beautifully green and lush. Wheat and mustard plants grow in neatly sectioned plots. There are narrow smoking chimneys dotting the terrain. It turns out these are kilns for baking bricks – piles of bricks line the sides of the road, and in the distance you can see women laboring or taking naps in the grass.


Photo by Rachel Clad

4. Highway driving is BANANAS

Once we arrived in Agra, all manner of vehicles converged, squeezing into narrow, ancient streets. Huge trucks vied for space, their clown car horns belting out tunes that are almost comical in their gaiety. These trucks are amazing – they are beautifully painted with bright colors and festooned with tassels and charms. They are hard to miss. I was struck by how much busier Agra is than Delhi, and how much older. Decrepit, colonial-era homes abound, their architecture at odds with the monuments to Mughal kings that seem to pop up every few feet. As we went over a bridge, our tour guide pointed out the Taj Mahal in the distance, its symmetrical sides glowing in the moonlight. I can’t describe how inviting that glow is, or how excited I am for tomorrow’s itinerary. On to the next adventure!!

Saturday, March 8, 2014- Trip to Agra and the Taj Mahal (Sayaka)

After a whirlwind week in the FHI 360 office deciding on and planning for our change, we were all really excited for our weekend trip to Agra and Jaipur.  The first day in Agra to see the Taj Mahal did not disappoint! We woke up to a beautiful morning, ready to do some sightseeing and to get to spend some time together outside of the office.

GGG_sphg_Group at Taj Mahal

The 7th World Wonder, the Taj Mahal. Photo by Ariana Katz

Our first trip of the day was to the 7th World Wonder, the Taj Mahal, a landmark that needs no introduction, but does need a disclaimer: it is practically impossible to accurately capture one’s experience! The Taj Mahal was built by a Mughal Emperor named Shah Jahan in memory of his third wife, Mumtaz Mahal, who died giving birth to their 14th child. Mumtaz itself means “beautiful crown,” and Mahal means “palace,” providing a fitting name to such an awe-inspiring mausoleum. It took 22 years and 20,000 workers to construct the Taj Mahal, and no wonder – it is full of intricate inlay marble work. One interesting tidbit we learned is that Shah Jahan was also planning to build a black version of the Taj Mahal across the river, until his son imprisoned him, apparently for spending too much money! The foundation is still present and visible from the back of the Taj, and it was humbling to see how such a grand monument could start with such a basic and simple foundation.

The Great Gateway of the Taj Mahal. Photo by Ariana Katz

The Great Gateway of the Taj Mahal. Photo by Ariana Katz

After the Taj Mahal we made our way to the Agra Fort, a huge walled city that is now mostly occupied by the Indian Army. Despite the fact that we were only seeing a small part of it, we still spent a considerable amount of time admiring the architecture, views, and inlay marble work. It would have been very easy for us to get distracted after having seen the Taj Mahal, but our guide did a great job weaving in the long history of the fort to keep us engaged and to truly appreciate the mix of Hindu and Islamic architecture that is found there.

Our visit in Agra concluded with a delicious lunch and trips to an inlay marble and carpet-making shop, where we learned how those pieces of artwork were traditionally created. We then headed out towards Jaipur, the next city up on our itinerary, as a group of happy and slightly more tanned public health students. Like everything on this trip, the day flew by in the blink of an eye. Being able to share this lifetime experience with 7 other amazing ladies (and one very tolerant and patient tour guide) was such a treat, and I feel incredibly fortunate to have had this opportunity! Not only has the sightseeing portion been eye opening (pun absolutely intended), but it has given us a lot of insight into the culture and history of the country where we’re making our change, which will undoubtedly be helpful for when we plan our implementation on Monday.

Sunday, March 9, 2014-Jaipur, the Pink City, and the Amber Fort (Ariana)

Amber Fort Panorama. Photo by Meagan Brown

Amber Fort Panorama. Photo by Meagan Brown

I thought Saturday’s visit to the Taj Mahal would make all future tourist sites seem lacking in comparison. Yet Sunday’s tour of Jaipur continued to wow with its ancient palaces, forts, temples and exciting street markets.

Wind Palace in Jaipur City. This Palace has 365 windows for the 365 days in the year. Royal women used to peer through the windows to watch street festivals safely from inside the walls of the palace. Photo by Ariana Katz

Wind Palace in Jaipur City. Royal women used to peer through the windows to watch street festivals safely from inside the walls of the palace. Photo by Ariana Katz

In Jaipur City, also called the “Pink City,” all of the walls of the buildings are painted pink and no one is allowed to paint their house or shop differently. The result is striking. The architecture and earth tone coloring reminds me a bit of adobe houses in the Southwest United States, with more decoration. After a quick visit to a small palace in the depths of the city, we headed to the main attraction of the day, the Amber Fort, located about 7 miles outside of Jaipur City in Rajasthan.

Chalk-painted elephants and their drivers. Photo by Ariana Katz

Chalk-painted elephants and their drivers. Photo by Ariana Katz

There’s only one proper way to enter the Amber Fort — by elephant. Sitting atop a paddled metal bench on the backs of chalk-painted elephants, we ambled up the cobbled path toward the Sun Gate and took in the majestic views of Maota Lake and the city of Jaipur. At the top of the hillside sits the Amber Palace, an incredible man-made feat built in the late 16th century. The Rajput King, who was a Commander Chief in the Mogul Army, built the palace for his family and we spent the morning learning about what palace life was like back then in Rajasthan. After hearing about the natural water-cooling system, Jacuzzi bathtubs with piped hot water, different rooms for winter and summer seasons and pulley system to bring water to the top of the palace – I came to the conclusion that life was pretty good for the ancient Maharajas! Even their latrines were fancier than some of the modern squat toilets I’ve seen.

The weekend had been filled with learning about the deep and varied history of India. So of course, we finished it off with some speed shopping for pashminas at the local street market before making the long, traffic-heavy, 7-hour drive back to Delhi. Many scarves heavier and our adventure needs satisfied (for the time being), we got back to Delhi refreshed and ready to get back to work and begin developing our implementation plan.


Week 2 Reflections

Monday, March 10, 2014- Back to work! (Emily M.)

After an amazing weekend in Agra and Jaipur, we were ready to get back to work at FHI 360 in Delhi. We started by brainstorming on the whiteboard what we needed to accomplish today. Then we went back over transcripts from calls with counselors so that we could remind ourselves how we had proposed the solutions and how the counselors had responded in order to develop standardize language. As a reminder, the counselors had selected “standardized BCC staging language” as the change that they preferred. So our priority for the day was to develop and vet that language as well as map out monitoring and evaluation.

Once we were all back on the same page, we broke up into two groups to come up with standardized language for 1. The rationale for asking BCC questions and 2. Questions about BCC staging (condom use/intention). Since group 1 finished early, they also put together a one day and week agenda with blue stars denoting documents that needed to be created.

In the afternoon (after a delicious bento box-like Indian lunch) we met with the BCC specialists (2) and the senior program officer to present the standardized language we had developed in the morning. They offered a lot of contextual insight into our proposal and we modified accordingly.

Finally, we put together a process map and our final packet for the counselors, sent it to the senior program officer (who has been an amazing partner in our work) for translation, and then presented to the PI/project director who gave us the go ahead to work with the counselors tomorrow morning to implement our change.

After a long day, a few of us picked up some street food (Momos: Tibetan dumplings) and then got cracking on our other school work.

Tuesday, March 11, 2014- Devising a plan (Emily N.)

This morning our team began by devising a plan for how to present the finalized change to the Delhi counselors, which included creating several scenarios for them to practice using the new language we developed.  We went back and forth on how this mini-training session would be implemented and, with the help of our FHI 360 colleagues, decided to ask them to engage in a short role play to demonstrate their understanding of how the new language was to be used.

We presented the rationale for asking the BCC questions first, which reads as follows:

“To better assist you, I would like to ask you some personal questions which we ask of all callers. As a reminder, anything you say will be kept confidential. Your responses will help us guide you to additional resources as needed and help us improve our services.”

The counselors initially indicated that the text was too long, but were pleased with it once our FHI 360 colleagues told them that they could incorporate the parts of the language that they found helpful into their conversations as they saw fit. We ran into a bit more difficulty rolling out the BCC staging questions, which are used to determine the current “stage of change” of the caller.

Throughout the course of the training today it became clear that our understanding of the purpose of the BCC questions differed from that of the counselors. While we had been viewing ‘stage of change’ as an indicator of a caller’s intention to use a condom, the counselors view it as an indicator of the frequency and consistency with which callers are using condoms. Though this difference is subtle, it underscored for the team how information can get lost in translation when working across cultures.

We concluded our call with an agreement that the counselors would try out this new language for several days, and we would check in with them on Thursday to get their feedback. The FHI 360 team requested some time to think about how we could best monitor the use of this new language, so we decided to break early for the day and do some more exploring.

After a delicious meal of fried rice and samosas from a street vendor, several students set off to visit local markets, including Khan Market, while others stayed back to work on reading and homework for their other courses.

Though our work today did not proceed in the ways we had planned, many valuable lessons were learned about the difficulties inherent in global health and we were reminded us that implementation is not a perfect science.

Wednesday, March 12, 2014- Planning our Process Evaluation (Sarah)

Today was the first day of wrapping up our in country activities and setting the stage for beginning our evaluation and handover.  After rolling out our change with a counselor training session yesterday and agreeing upon an evaluation and monitoring plan with the FHI 360 team yesterday afternoon, we set about developing the tools we would need moving forward to the “study” portion of our PDSA cycle.

The morning began with a group effort to create a rubric for evaluating the mystery calls that will be conducted next week with each of the callers.  By conducting mystery calls we hope to evaluate the fidelity, reach, and context of our implemented change.  The rubric we created will be used by the FHI 360 staff listening to recordings of the mystery calls to evaluate each counselor’s use of the new techniques for asking the important questions regarding condom use and provide us with feedback on how well the implementation has gone.

After finishing our evaluation rubric we split our group in half to work on an interview guide and our final presentation.  The interview guide will be used by the FHI 360 team in one-on-one calls with each of the 4 counselors from Delhi who were instructed in the new standardized language on Tuesday.  In this part of our process evaluation we hope to also assess fidelity, reach, and context, but also understand the counselor’s perceptions of the change and get their feedback in the event that something is not working as hoped.

In the afternoon, we met as a large group along with and Professor Ramaswamy the Sahaay project’s research manager to finalize the language of our interview guide.  We also hammered out our plan for post-implementation data analysis, as well as analysis of data after our small change is scaled up to reach all counselors and be applied to sexually transmitted infection (STI) related calls in addition to HIV calls. The FHI 360 staff is very excited and hopeful that our change will prove to be beneficial to their counseling services and data collection efforts and are already planning to begin scale up next week!

Thursday, March 13, 2014- Staying in the moment (Cori)

Delhi in the morning.  Photo by Ariana Katz

Delhi in the morning. Photo by Ariana Katz


Barbie- sponsoring water balloon fights around the world. Photo by Cori Fordham

Barbie- sponsoring water balloon fights around the world. Photo by Cori Fordham

It can be difficult to stay in the moment when living in a new environment. Even the simplest of events can make my brain start to wander. A ride on the metro can quickly turn into an internal debate on the merits and unintentional consequences of the women-only passenger car. When walking to work, I find myself considering the poor air quality in Delhi and its impact on infant health. Every time I see something that vaguely resembles a relic from my time in Burundi, I reflect on the role that globalization and international development plays in shaping the look and feel of a country. All this thinking can be exhausting – especially when paired with a multitude of smaller everyday challenges, such as “How much does that cost in dollars?” “Where will I get lunch today?” and “How can I avoid the small children who are trying to peg me with water balloons (a Holi tradition)?”

Research Manager and IT Specialist disguise their voices to conduct process evaluation calls with counselors. Photo by Cori Fordham

Research Manager and IT Specialist disguise their voices to conduct process evaluation calls with counselors. Photo by Cori Fordham

At the top of my brain are questions about our intervention. I’ve been itching to know to what extent the counselors are actually using our way of taking a call and if it will actually lead to an improvement in documentation. When designing our change, we became so invested in the data collection and documentation and analyzed the processes down to their miniscule details, but now it’s out of our hands. It’s time to take a step back, take a deep breath, and let go.

Behold, our beautiful Gantt chart. Photo by Cori Fordham

Behold, our beautiful Gantt chart. Photo by Cori Fordham

Today’s monitoring call with the counselors facilitated this process. While some counselors still seemed hesitant about the change, others were clearly on board and had even internalized the suggestions. One counselor provided us with some great antidotal evidence, demonstrating how the change allowed them to draw out some essential information from the caller, which resulted in a more personal and influential call. I am comforted to see counselors like this, as they give me hope that someone will advocate for our change once we return to North Carolina (if in fact, it proves to be an improvement). With this hand-over in mind, we spent today putting the finishing touches on our work by creating our final presentation for FHI 360, a Gantt chart depicting our outcome evaluation plan, and a rubric for assessing intervention fidelity.

Learning the tricks to succeeding in Delhi has also helped us relax and stay present. Yesterday night, we discovered our hotel’s rooftop deck, which allowed me to start today off with yoga, good music, and a skyline view of the city. Today, we located a market with tasty samosas, mangos, and oranges within walking distance from the FHI 360 office. We also found the vendors who are selling super soakers and water balloons, should we take the low road and decide to retaliate against those scoundrels who keep attacking us.

Our team ended the day by eating a delicious dinner, piling into cars, and sharing some lighter questions – in the form of mindless knock-knock jokes. Despite the fact that these weeks have required a significant amount of work, we all seemed hopeful about the potential fruits of our labor. Orange you glad…

Friday, March 14, 2014- Last day! (Meagan)

The FHI360 Sahaay project staff and UNC team take a final photo together - photo by Ariana Katz

The FHI360 Sahaay project staff and UNC team take a final photo together. Photo by Ariana Katz

Today was the big day – our final presentation for the FHI360 staff on our Sahaay project work so far and proposed plans moving forward. Our day started off bright and early with two run-throughs of the presentation making tweaks and edits to perfect our delivery. Although all eight of us worked on the presentation, half the group presented while the other half fielded questions afterwards. We’ll be making an additional final presentation back in the states next month, and at that point we’ll switch roles to make sure everyone gets a chance to present.

Despite presenting first thing in the morning on a Friday, we had a great turnout – over 10 FHI360 staff came to listen in addition to the staff we had been working with over the past two weeks. Afterwards the staff had some great questions and input. I think my favorite moment was when the New Delhi office director, who has been very involved in the project, took a moment and explained the quality improvement process flawlessly!

After our presentation, we sat down with the FHI360 Sahaay team to plan for monitoring and evaluation. Even though we’ll be leaving India soon, our work is nowhere near completed! In addition to the counselor interviews conducted on Thursday, next week mystery calls will be conducted with the New Delhi counselors to monitor how they are implementing the new change. We’ll also be getting call data for the month of March so we are able to analyze it and see if our change had an impact!

The Sahaay research project manager presents research on gender roles in Indian culture. Photo by Ariana Katz

The Sahaay research project manager presents research on gender roles in Indian culture. Photo by Ariana Katz

We wrapped up our two weeks with a great presentation from the Sahaay project research manager on gender roles in Indian culture. He studied this extensively for his PhD dissertation and presented a couple of really interesting studies on the influence of perceptions of masculinity on gender-based violence. Once his presentation was finished, our group split up to squeeze in a few days of spring break before heading back to North Carolina! A few of us are headed to a nature reserve a few hours outside of Delhi before returning for the Holi festival on Monday, while the rest of the group heads to Jim Corbett tiger reserve and Rishikesh for some time at the base of the Himalayas.

As our trip and two weeks in the field wraps up, this will be the last post for awhile. We’ll be back later this spring to present our final results, so stay tuned for more soon!

Final Reflections

Monday, April 28, 2014-Final Post! (Emily M.)

Emily M. giving opening remarks for the final presentation.

Emily M. giving opening remarks for the final presentation.

As I think back on my experience in the Implementation Lab, the words that come to mind are “intense” and “rewarding”. This class required an incredible amount of time, energy, creativity, flexibility, patience, and faith. It asked me to work and travel with seven colleagues whom I’d never met before, and trust the three professors who were themselves piloting this concept class. Together, we traveled to India to apply our classroom knowledge to a real-world problem for which there was no answer key. To add to the complexity, we were in a place that had different values, different cultures, and different languages than those with which we were familiar. And while we had absolutely excellent partnership from the organization, it was not a static environment, meaning that they were making changes at the same time as we were trying to understand this issues and make our own improvements. Between us, we spent 640 (wo)man-hours in Delhi, and probably the same amount of time in the US, meticulously and thoroughly examining the issues, getting organizational buy-in, designing improvements, and designing ways to implement, monitor, and evaluate those improvements. Every step we took and conversation we had was thoroughly vetted and planned by the whole team. As I said, intense. And ultimately we did not get the results we had hoped for, which is not unexpected given the nature of the PDSA cycle which emphasizes testing and refining small changes.


The group answers questions from the audience and fellow classmates. (The audience is hiding from the camera. They are there…we swear…).

Despite these challenges, or perhaps because of them, I found this class incredibly rewarding. This class pushed me beyond my comfort zone and taught me tangible, translatable new skills that I can use for quality improvement in the future. It also helped me understand big picture concepts and small scale problem-solving. And though I went through every possible emotion that one can feel about teamwork, I am exceptionally grateful to all of those with whom I worked. I learned at least as much from my peers as I did from the didactic portion of the class.

I would tell students who are considering participating in the international section of this class that they are making a significant commitment that will not always be easy or fun, but that in the end they will have the satisfaction and skills that come with achieving something in the world beyond the classroom.


Meet the Bloggers

Meet the women who keep you informed about their daily activities on the Sahaay Project for the Gillings Global Implementation Lab!

Meagan Brown – Meagan is a second year MPH student in the Health Behavior department interested in adolescent obesity prevention and collaborative capacity building in community based organizations. Prior to UNC-Chapel Hill, Meagan worked for Communities In Schools of Chicago connecting free health programs and services to over 20,000 low-income students each year.

Rachel Clad – Rachel is a second year MPH student in the Health Behavior department. She has spent her career addressing barriers to HIV prevention among disenfranchised communities worldwide, and is excited to learn quality improvement techniques through this course as a way to improve HIV programming in India.

Cori Fordham – Corinne (Cori) Fordham is a second year MPH student in the Health Behavior department. She is passionate about improving access to health care and education through capacity building, monitoring and evaluation, and health communication projects. Prior to coming to the Gillings School, Cori worked in Burundi as a Global Health Corps Fellow for an HIV organization, which ran an anonymous hotline for LGBT populations.

Sayaka Hino – Sayaka is a second year MPH student in the Health Behavior department who is currently working as a graduate research assistant at Peers for Progress. She is interested in applying the implementation research skills learned through this course to improving child health and global mental health outcomes.

Ariana Katz – Ariana is a second year MPH student in the Health Behavior department. She has spent over 8 years working in the field of HIV/AIDS and is passionate about working toward harm reduction solutions with high-risk populations.

Emily Mangone – Emily is a first year PhD student in Health Policy and Management with a focus on Decision Sciences. Emily received her MSc in Global Health Sciences from UCSF in 2011 and she is interested in mobile health applications, women’s health and empowerment, and systems thinking.

Emily George Nicholson – Emily is a second year MPH student in the Public Health Leadership Program (PHLP) who serves as the GRA in the Gillings Global Gateway, where she administers the residential Global Health Certificate. Emily’s previous experience in global health includes TB and neglected tropical diseases (NTD) projects at FHI 360 and service as a Peace Corps Volunteer in Bolivia.

Sarah Smiley – Sarah is a UNC medical student and health care and prevention MPH student. She plans to pursue a career as an OBGYN and to apply the quality improvement knowledge and skills gained through this class in her future clinical career.

Project Video

The video below was created by the Sahaay Project to promote the program.  The project has also had press coverage in India.

If you have any questions or comments about the course, please contact Anita Farel, Suzanne Hobbs, and Rohit Ramaswamy.