Our Collaborations

Rishi Valley Study

The Rishi Valley study is a collaborative project between Monash University and the Rishi Valley Rural Health Centre.

Although the most common causes of disease burden in countries such as India include malnutrition and infectious disease, vascular disease is being increasingly recognized as an emerging epidemic. In urban Indian populations, changes in lifestyle exposures (resembling those seen in high income countries) may underlie this phenomenon. However, even less is known about the burden of vascular disease in those living in rural communities. We sought to identify risk factors for hypertension in this rural region where people do not exhibit the traditional risk factors for stroke, i.e. they are young, thin, and physically active. We also sought to obtain important baseline data on the extent of vascular disease (heart disease and stroke) and its risk factors in this typical rural Indian community.

This survey conducted in the Rishi Valley, an area situated in the interior of rural Andhra Pradesh, is a major South Indian State. It is home to the villages of a stable rural community of approximately 35,000 residents. The population consists primarily of shepherds and marginal subsistence farmers, with landholdings of less than one acre.

Major outputs to date

  • Among 277 individuals in rural India with hypertension, awareness, treatment and control of hypertension was poor. Geographic access and/or utilisation of health services were associated with awareness and treatment, but not control of hypertension in this population. Greater per cent body fat was the only factor independently associated with control of hypertension. Further details of this study can be accessed in:
  • Among 1479 adults living in a disadvantaged rural community in India, men were particularly prone to the effects of relative socioeconomic advantage and salt intake on their risk of hypertension. Traditional risk factors may play a greater role in the development of hypertension in men living in poverty than in women. Further details of this study can be accessed in:
  • In this cross sectional study conducted in rural India, farming was an important risk factor associated with chronic energy deficiency, while low dietary iron was not the main cause of anaemia. Better farming practice may help to reduce chronic energy deficiency in this population. Further details of this study can be accessed in:

The Global Alliance for Chronic Diseases

  • The Global Alliance for Chronic Diseases (GACD) is a collection of the world’s largest public research funders. The inaugural joint research programme of the GACD (Hypertension) was launched in 2012 with an investment of US$23 million into 15 implementation science projects. The aim of the programme is to generate the scientific evidence to inform the implementation and scale-up of policies and programmes at local, national and regional levels to reduce the prevalence of CVD as a result of high blood pressure (BP). As indicated in the projects above, this collaboration sought to improve the control of hypertension in rural India.
  • Among more than 1400 people with hypertension, we showed that a simple group-based education strategy was effective in reducing blood pressure and in controlling hypertension. This highly novel approach could be extended to the >100 million people with hypertension in rural India, and modified for rural and remote Australia and other settings where doctors are unavailable and distance to health services is great.
  • Development of a training program for trained health workers to teach people in their communities about hypertension, and empower them to self-manage their hypertension. The resources include a training manual, flipcharts to aid in teaching, record keeping and handouts for patients to use at home. Additionally, we have developed resources to evaluate training of healthcare workers about hypertension. The resources include questionnaires, focus group discussion questions, and forms for record keeping and evaluation. Details of the training program and its evaluation are described in:
  • Cluster randomised feasibility trial to improve the Control of Hypertension In Rural India (CHIRI) is a multi-centre trial in which the investigators evaluate the feasibility of a community-based intervention to improve the control of blood pressure. The intervention is provided by Accredited Social Health Activists (ASHAs), and consists of group-based health education and support for individuals to improve their self-management of blood pressure. Details of the trial protocol are described in:

Mashhad Stroke Incidence Study

The Mashhad Stroke Incidence Study is a research collaboration drawing upon the expertise of stroke and medical scientists at Mashhad University of Medical Science, the University of Melbourne, Baker IDI Heart and Diabetes Institute, Monash University. Collectively, the investigators sought to examine the epidemiology of stroke in the Middle East, in particular the incidence of stroke in Mashhad, north-eastern Iran. During a 12-month period (2006-2007), 624 patients who experienced a first-ever stroke were identified and their outcomes examined.

Major findings

  • The age-specific stroke incidence was greater in younger patients than is typically seen in high income countries. Comparison of age-specific incidence rates between regions revealed that stroke in Mashhad occurs approximately 1 decade earlier than in Western countries. Ischemic stroke incidence was also considerably greater than reported in other regions. Further details of this study can be accessed in:
  • A substantial number of our patients either died or had stroke recurrences during the study period. The cumulative incidence of stroke recurrence was 14.5% by the end of 5 years, with the largest rate during the first year after first-ever stroke (5.6%). Case-fatality was poorer in those having a first stroke recurrence than in those with a first-ever stroke. Advanced age and the severity of the index stroke significantly increased the risk of recurrence. This is an important finding for health policy makers and for designing preventive strategies in people surviving their stroke. Further details of this study can be accessed in:
  • The 5-year cumulative risk of death among 624 patients with first-ever stroke in Iran, was 53.8% for women and 60.5% for men. The most frequent causes of death were stroke (41.2%) and myocardial infarction/vascular disease (16.4%). Cox proportional hazard analysis indicated that being male, having a stroke of greater severity, having atrial fibrillation and having <12years of education were associated with greater 5-year case fatality. The long-term case fatality following stroke in Iran is greater than that observed in many high-income countries. Targeting strategies to reduce the poor outcome following stroke, such as treating atrial fibrillation, is likely to reduce this disparate outcome. Further details of this study can be accessed in:
  • We found that significant disability and functional dependency after stroke in Northeast Iran were largely attributable to the effects of stroke severity and prior dependency. Patients with a history of stroke (before the study period) were more likely to be disabled at one year than patients who had a first ever stroke. Advanced age, severity of stroke at the time of admission, diabetes mellitus, and educational level (<12 years) were independently associated with greater disability and functional dependency. Further details of this study can be accessed in:

INternational STroke oUtComes sTudy (INSTRUCT)

Following publication of our article on sex differences in presentation, severity and acute management of stroke. NEUROLOGY 2010; 74:975 (+ accompanying editorial), the INSTRUCT collaboration arose. This collaboration was aimed at identifying sex differences in stroke occurrence, treatment, and outcomes. This collaboration, led by A/Prof Gall, provided the largest available dataset on sex differences in stroke. A number of publications have already arisen from this international collaboration from the Principal Investigators of 13 high quality incidence studies.


  1. Phan H, Blizzard CL, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, Heeley E, Otahal P, Vemmos K, Anderson C, Parmar P , Krishnamurthi R, Barker-Collo S, Feigin V, Bejot Y, Cabral N, Carolei A, Sacco S, Chausson N, Olindo S, Rothwell P, Silva C, Correia M, Magalhães R, Appelros P, Korv J, Vibo R, Minelli C, Gall S (2017). Sex differences in long-term mortality after stroke in the INternational STroke oUtComes sTudy (INSTRUCT): a meta-analysis of individual patient data. Circulation: Cardiovascular Quality and Outcomes 10(2):e003436. DOI: 10.1161/CIRCOUTCOMES.116.003436
    1. This collaboration arose from some novel findings in the North East Melbourne Stroke Incidence Study, led by Professor Thrift, where women appeared to do more poorly after stroke than men. Pooled data provided strong evidence for underlying contributors to the disparities in stroke between men and women, and better knowledge of outcomes following stroke in women..
  2. Phan H, Blizzard CL, Reeves M, Thrift AG, Cadilhac DA, Sturm J, Heeley E, Otahal P, Vemmos K, Anderson C, Parmar P, Krishnamurthi R, Barker-Collo S, Feigin VL, Bejot Y, Cabral N, Carolei A, Sacco S, Chausson N, Olindo S, Rothwell P, Silva C, Correia M, Magalhães R, Appelros P, Korv J, Vibo R, Minelli C, Gall SL (2018). Factors contributing to sex differences in functional outcomes and participation after stroke: a meta-analysis of individual participant data from the INternational STRoke oUtComes sTudy (INSTRUCT). Neurology 90(22):e1945–e1953. DOI: 10.1212/WNL.0000000000005602.
    1. In this study we found that the worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency. This provides important knowledge about using these factors as potential targets to improve the outcomes after stroke in women.
  3. Phan HT, Reeves MJ, Blizzard CL, Thrift AG, Cadilhac DA, Sturm J, Otahal P, Rothwell P, Bejot Y, Cabral NL, Appelros P, Kõrv J, Vibo R, Minelli C, Gall SL (2019). Sex differences in severity of stroke in the INternational STRoke oUtComes sTudy (INSTRUCT): a meta-analysis of individual participant data. Journal of the American Heart Association 18(1):e010235. DOI: 10.1161/JAHA.118.010235.
    1. We identified that women had more severe ischemic stroke than men. As much of the difference was attributable by pre‐stroke factors, strategies to improve pre‐stroke health in the elderly could improve outcome for women.
  4. Phan HT, Blizzard CL, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, Heeley H Otahal P, Rothwell P, Anderson C, Parmar P, Krishnamurthi R, Barker-Collo S, Feigin V, Gall SL (2019). Sex differences in long-term quality of life among survivors after stroke in the INternational STroke oUtComes sTudy (INSTRUCT). Stroke 50(9):2299-2306. doi: 10.1161/STROKEAHA.118.024437
    1. We found that women consistently exhibited poorer HRQoL after stroke than men. These disparities were largely explained by advanced age in women, the fact that women had more severe strokes, a greater pre-stroke dependency, and more post-stroke depression than men. This suggesting that these may be potential targets to reduce the differences in outcome between women and men.