Written by: Amanda Ferber
Introduction to the Public Health Research Institute of India
My internship at the Public Health Research Institute of India was the greatest honor of my life so far. For 45 days in July and August 2024, I lived in the Mysuru District of Karnataka, India. From Monday to Saturday, I worked alongside an all-woman group of researchers to collect qualitative data for a study I designed on loss-to-follow-up in cervical cancer screening. I also gained exposure to the different entry points of the health system available to citizens of rural villages in Mysuru. I am incredibly grateful to have been welcomed with such warm, open arms into a robust, dynamic family of researchers who eagerly taught me about key aspects of South Indian culture – food, clothing, religious practices, music, and family life – and demonstrated effective egalitarian, community-based research.
My introduction to the Public Health Research Institute of India (PHRII) started in October 2023 in Toronto, Ontario, Canada. I was a poster presenter at the International Cancer Education Conference, showcasing my previous summer’s work on the use of telemedicine in oncology settings. I listened to a talk given by Dr. Purnima Madhivanan, an Associate Professor at the University of Arizona, who spoke about her study on cancer survivorship among Indian women. I approached her after her talk. I learned that she was the founder of PHRII and she valued student exposure and involvement in the work done at PHRII. We began corresponding by email, and, in December 2023, she told me about an urgent need for data collection regarding loss-to-follow-up in cervical cancer screening. Thus began my journey with PHRII.
Here I am in Toronto at the International Cancer Education Conference with my internship director from the previous summer. She encouraged me to speak with Dr. Madhivanan.
Throughout the Spring 2024 semester, I was tasked with designing the methodology for a study with the following aim: to assess the barriers and facilitators to completing a cascade of cervical cancer screening tests among women living in the Mysore District of Karnataka, India. Cervical cancer is comparatively prevalent in India due in part to the absence of a domestically-produced vaccine for HPV, the virus that causes cervical cancer in over 95% of cases. Screening for cervical cancer is a multi-step process, but PHRII found that women who test positive for HPV were not coming back to complete the rest of the steps needed to confirm a cervical cancer diagnosis or prevent pre-cancer from developing into cancer. With this motivation, I designed a qualitative study involving semi-structured, in-depth interviews with women and community health workers in rural villages in Mysore to speak with them about their perceived barriers to follow up. During that semester, I also built up a team of mentors from the JHU Bloomberg School of Public Health and PHRII, applied for and received over $15000 in funding from the Hopkins Office of Undergraduate Research and the Whiting School of Engineering, and obtained IRB approval from both JHU and PHRII as well as international clearance from the Government of India.
Carrying Out a Qualitative Research Project: Key Activities
I arrived at PHRII on July 5th, 2024, and I was given a tour of the research office, the women’s health clinic, the laboratory, and the on-site dormitory, where I would be living for the duration of my internship. From then on, we went full speed ahead on the cervical cancer screening study. Before we could begin traveling to rural villages and recruiting participants for the study, I spent around two weeks scheduling, gathering teammates, and leading highly collaborative full-team meetings where we assessed the study documents I prepared during the Spring semester before approving them for translation into the local language, Kannada. Even though I mainly worked with two staff members, Fazila and Shivamma, on data collection, the whole PHRII staff was invested in my project and used significant chunks of their time to attend these document assessment meetings despite having other projects of their own. I was extremely moved by the full team’s mobilization and the stake they took in the project. From this point on, this pursuit was no longer my project but our project. Using PHRII’s projector, we viewed the participant information sheet, eligibility screening tool, informed consent form, the sociodemographic questionnaire, and the interview guides for community health workers and for women eligible for screening. PHRII’s manager, Poornima, verbally translated all documents line-by-line into Kannada to facilitate collective understanding. By the conclusion of these meetings, we had fine-tuned our study documents such that their main points could be clearly gleaned by study participants and that they represented PHRII in an authentic manner.
With the content of our study documents in order, Shivamma translated the documents into Kannada, and Fazila, Shivamma, and I were ready to drive to the rural villages in Mysuru and begin recruitment for our study. We needed to recruit 4-6 ASHAs (Accredited Social Health Activists, or community health workers) as well as 8-10 women eligible for cervical cancer screening (aged between 30 and 65 and not having had a hysterectomy or a cervical cancer diagnosis in the past). My task was to keep track of the various study documents and supply them to Fazila and Shivamma and the women we were recruiting as need. I would also transfer our paper-based recruitment and sociodemographic questionnaire data to a digital spreadsheet, formatting it to allow for production of descriptive statistics during data analysis in the future.
Achieving my Goals of Gaining Exposure to Rural Health Systems in Mysuru
At the beginning of the summer, I set an OKR (objective and key result) to guide my involvement in the data collection process. I made the following goal: “Be present for at least three recruitment sessions and/or interviews with study participants to better understand the needs and circumstances of the participants whose testimonies we will consider during the data analysis phase.” I accomplished this goal, visiting at least six different villages in rural Mysuru. Since I cannot speak or understand Kannada, I did not directly speak to anyone beyond greeting them with “Namaste,” but I took advantage of this backseat role by being fully present and observing the infrastructure and layout of the rural villages as well as the home lives of individual families we met. For the remainder of my internship, we conducted interviews with the participants we recruited and continued recruitment on days where we had no interviews scheduled. Fazila arranged for us to meet with a community health worker each time we visited a rural village. It was critical that a community health worker facilitated our introductions with women who were not familiar with PHRII to reduce discomfort or anxiety. We found it difficult, however, to recruit women who were willing to speak about their experiences with and perceptions of cervical cancer screening, as cancer and reproductive health are heavily stigmatized in the rural villages of Mysuru. In total, we recruited around fifteen potential participants and conducted eight interviews. Five remaining interviews will be completed in late August and early September 2024.
I was incredibly inspired by the ways PHRII staff interacted with women, community health workers, and community leaders when we visited the rural villages in Mysuru. Fazila had a deep network of ASHAs and village-trusted leaders she had through conducting cervical cancer screening programs and public health research projects for over a decade, and she did a lot of behind-the-scenes coordinating to allow us to seamlessly meet with potential participants for our studies. Although I could not understand the conversations between my teammates and community members word-for-word, I perceived that Shivamma and Fazila had an easy-going rapport with everyone we met, which promoted the hit rate of recruitment and reduced power dynamics, especially given their own upbringings in rural villages. Similarly, I attended a data collection visit for another ongoing project involving water quality in rural villages, and I observed how PHRII leveraged their direct connections with village water managers to quickly traverse different water access points in a way that didn’t disturb village residents. Lastly, accompanied by PHRII staff, I visited three different types of healthcare providers: a primary health clinic serving 25 villages, a government hospital offering care at a free or very inexpensive rate, and a private hospital. I observed huge differences in the services provided and the conditions of patient waiting areas. The primary health clinic impressed me in its breadth of medicines available (having tuberculosis pills, birth control pills, and even mental health drugs). The government hospital had a suitable emergency medicine ward that the primary health clinic lacked, but most waiting areas were outside, and the oncology department was non-specialized and only had one radiation therapy room for all cancer types.
Reflections on my Joys and Challenges
The workplace environment at PHRII will directly inform the peer-to-peer and group-wide dynamics I will seek out in my future employment opportunities. In professional and academic settings at JHU and beyond, I notice that employees and students alike seem to adhere to a version of “professionalism” that discourages expression of both the love and the adversity that make us empathetic and distinct individuals. In other words, I observe us putting on our “Goal-Focused Professional” hats at work/school and our “Joy-Seeking, Vulnerable Human” hats strictly outside of work. At PHRII, the fourteen on-site staff treat each other with a warmth and authenticity I had never experienced before. Lunch is eaten as a group. Important life events (like baby showers and family deaths) will not go unacknowledged. Everyone participates in Bollywood Zumba in the afternoons (even me!). And, despite differences in caste, education-level, and life experience, it would be impossible to randomly select two staff members who did not have a well-developed, warm, open camaraderie with one another. I hope to work in similar environments where colleagues value each other’s humanity beyond their professional capacity.
I received the same treatment from the staff that they showed each other. Almost every day, they shared traditional South Indian foods with me, such as soan papdi, Mysore pak, maggi, khara bath, kesari bath, roti and chutney, and ragi ball and bamboo chute sambar. Each Friday, they involved me in the weekly Hindu practice of puja, and they brought me to temples and educated me about Hindu gods and values. I was required to adhere to the dress code, comprising a long Kurta and long pants, and the staff always complimented me on my commitment to wearing Indian clothing. A woman’s health counselor, Rani, even helped me drape a saree on myself and adorned me in bangles (bracelets) and a bindi (a circle placed between a one’s eyebrows to help them access inner wisdom). One day after a recruitment session, Shivamma even took me to a field to meet a farmer and taught me how to pick mung beans. I tear up as I reflect on these experiences – I am so deeply moved at how open my teammates were to expose me to their culture and robustly immerse me in their lives for a summer.
The most significant work-related challenge I faced was submitting our document revisions to the JHU IRB while in India. Because we changed the content of our participant-facing documents to better reflect PHRII policies, a resubmission to JHU’s IRB was required in order for our project to remain IRB-compliant. The IRB did not immediately accept the changes we made and required highly specific justifications for our changes as well as some modifications to the revised content to ensure clarity and maintain human subjects protections. I spent many hours working at my desk and asking around the office in order to document our changes in a readable way for the IRB reviewers, draft proper justifications for our changes, and gather Kannada translations and their associated translation certifications for the modifications requested by the IRB. I was sad that I couldn’t use this time to observe happenings around the office, but it was an important practical experience for me as I venture into a global health career where there are bound to be rules and regulations from international bodies that I must adhere to legally, such as IRB compliance.
In previous collaborative pursuits, like past internships and group projects at JHU, I attempted to have minimal reliance on others to complete a task, as I have always felt anxious about imposing on others and adding to one’s to-do list. In a more self-critical sense, I have also struggled with patience and having trust in the collaborative process. During my time at PHRII, translation of English documents into Kannada and explaining key concepts to community members was a major component of the work, so I had no choice but to approach my teammates and delegate tasks that I had no way of completing because I am not Kannada speaker. This experience was an excellent opportunity to shed some of my ego, accept my limitations, and practice clearly explaining to my teammates the requests I could not carry out myself.
I also faced challenges outside of work due to my long-term stay in a country largely unfamiliar to me. While I thankfully had warm running water and a functional toilet, I did not have access to a shower, and I had to adjust to bucket baths (mixing hot water with room temperature water and pouring it on myself for bathing). Ultimately, I am glad I learned this skill because bucket baths conserve a lot of water in comparison to the showers I took in the United States, and I may need to harness this skill during international experiences in the future. In addition, our research office as well as many of the buildings and households I visited in rural villages had a no-shoe policy, so I was barefoot for most of my time in India. I unfortunately developed plantar fasciitis because I was used to the support and cushioning that sneakers provided. In addition, my bank detected “fraud” because I made many charges in a short period of time in a foreign country, so my debit card got canceled and I became unable to use ATMs to withdraw rupees. And, when I was away from my teammates outside of work hours, I struggled to make myself understood as I explored Mysuru – the language barrier I experienced while hailing rickshaws (three-wheeled taxis), eating at restaurants, shopping, and visiting palaces and temples showed me how difficult it can be to travel as a solo woman.
Applying my Experience to my Career in Global Health
I am so thankful to have had my first global public health experience at such a dynamic, well-equipped, and welcoming research institute. In the future, I will be able to recount the leadership I took in the research office, the backseat I took as I observed our involvement in rural communities, and the exposure I had to leveraging resources in a resource-scarce environment when I connect with global health practitioners, interview for roles at NGOs and government organizations, and apply for fellowships. I also plan to publish this work as a First Author and present our findings at international oncology conferences. This experience directly contributes to my career goals as an implementation strategist for health interventions in low-resource settings. Specifically, I have immense interest in strategically procuring and configuring the “staff, stuff, space, and systems” that allow interventions to transcend the conceptualization and “planning stages” and emerge in reality. My next steps are to apply for a Fulbright fellowship to hopefully have more exposure to health systems in West Africa and to earn a Master of Science in Public Health in Health Systems at the Department of International Health at the JHU Bloomberg School of Public Health.
