Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program

BACKGROUND: The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) is a handwashing with soap and water treatment intervention program delivered by a health promoter bedside in a health facility and through home visits to diarrhea patients and their household members during the 7 days after admission to a health facility. In a randomized controlled trial among cholera patient households in Bangladesh, the 7-day CHoBI7 program resulted in a significant reduction in cholera among household members of cholera patients and sustained improvements in drinking water quality and handwashing with soap practices 12 months post-intervention. In an effort to take this intervention to scale across Bangladesh in partnership with the Bangladesh Ministry of Health and Family Welfare, this study evaluates the feasibility and acceptability of mobile health (mHealth) programs as a low-cost, scalable approach for CHoBI7 program delivery. METHODS: Formative research for the development of the CHoBI7 mHealth intervention included 40 semi-structured interviews, 4 mHealth workshops, 2 group discussions, and a pilot study of 52 households to assess the feasibility and acceptability of the developed mHealth program. Thematic analysis of the interviews and group discussions was conducted by two individuals separately based on emergent themes, and then themes were compared and discussed. RESULTS: A theory- and evidence-based approach using qualitative research methods was implemented to design the CHoBI7 mHealth program. Semi-structured interviews with government stakeholders identified perceptions and preferences for scaling the CHoBI7 mHealth program. Group discussions and semi-structured interviews with diarrhea patients and their family members identified beneficiary perceptions of mHealth and preferences for CHoBI7 mHealth program delivery. mHealth workshops were conducted as an interactive approach to draft and refine mobile message content based on stakeholder preferences. The pilot findings indicate that the CHoBI7 mHealth program has high user acceptability and is feasible to deliver to diarrhea patients that present at health facilities for treatment in Bangladesh. Both text and voice messages were recommended for program delivery. Dr. Chobi, the sender of mHealth messages, was viewed as a credible source of information that could be shared with others. CONCLUSION: This study presents a theory- and evidence-based approach that can be implemented for the development of future water, sanitation, and hygiene mHealth programs in low-resource settings.

Correction to: Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program.

It was highlighted that the original article [1] contained an error in the title. Additionally, Table 2 contained a typesetting mistake. This Correction article shows the incorrect and correct article title and Table 2. The original article has been updated.

Reduced Diarrhea Prevalence and Improvements in Handwashing with Soap and Stored Drinking Water Quality Associated with Diarrheal Disease Awareness Measured by Interactive Voice Response Messages in the CHoBI7 Mobile Health Program.

The Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) mobile health program promotes water, sanitation, and hygiene (WASH) behaviors through interactive voice response (IVR), voice, and text messages to reduce diarrheal diseases in Bangladesh. The objective of this study was to investigate the relationship between responses to CHoBI7 WASH IVR quiz messages and subsequent diarrhea and WASH behaviors. Fourteen CHoBI7 IVR quiz messages on handwashing with soap and treatment of stored water were sent to 517 households with 1,777 participants during the 12-month program period. IVR message responses were classified as correct answer, incorrect answer, no response (did not press 1 or 2), and failed (did not answer the phone). Diarrhea prevalence was assessed through self-reported monthly clinical surveillance visits. Handwashing with soap was assessed by a 5-hour structured observation, and stored water quality was defined by Escherichia coli concentration. Households that responded correctly to a CHoBI7 IVR quiz message had significantly lower odds of diarrhea for all age groups (adults and children) at the subsequent visit 1 month later (odds ratio [OR], 0.73; 95% CI, 0.54-0.98), and significantly greater odds of handwashing with soap after stool-related events (OR, 2.48; 95% CI, 1.12-5.49) and E. coli levels < 100 colony forming units (CFU)/100 mL (World Health Organization high-risk cutoff) in the stored household water (OR, 2.04; 95% CI, 1.25-3.33) compared with households that did not answer CHoBI7 IVR quiz calls. Correct responses to CHoBI7 IVR quizzes were associated with decreased diarrhea prevalence and improved stored drinking water quality and handwashing with soap behaviors at the subsequent visits. These findings suggest engagement in the CHoBI7 mobile health (mHealth) program and awareness of diarrheal disease prevention can reduce diarrhea and facilitate changes in WASH behaviors.

Effects of a Water, Sanitation and Hygiene Mobile Health Program on Respiratory Illness in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program.

Acute respiratory infections are a leading cause of morbidity and mortality among young children globally. The objective of this study was to evaluate the impact of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) handwashing with soap and water treatment mobile health (mHealth) program on respiratory illness among diarrhea patients and their household members in urban Dhaka, Bangladesh. A cluster-randomized controlled trial of the CHoBI7 mHealth program was conducted among diarrhea patient households in Dhaka, Bangladesh. Patients were randomized to three arms: standard recommendation on oral rehydration solution use, health facility delivery of CHoBI7 plus mHealth (weekly voice and text messages for 12 months) (no home visits), and health facility delivery of CHoBI7 plus two home visits and mHealth. Respiratory symptoms were assessed during monthly clinical surveillance over the 12-month surveillance period. Respiratory illness was defined as rapid breathing, difficulty breathing, wheezing, or coughing. Two thousand six hundred twenty-six participants in 769 households were randomly allocated to three arms: 849 participants to the standard message arm, 886 to the mHealth with no home visits arm, and 891 to the mHealth with two home visits arm. Compared with the standard message arm, participants in the mHealth with no home visits arm (Prevalence Ratio [PR]: 0.89 [95% CI: 0.80, 0.98]), and the mHealth with two home visits arm (PR: 0.89 [95% CI: 0.81, 0.99]) had significantly lower respiratory illness prevalence over the 12-month program period. Our findings demonstrate that the CHoBI7 mHealth program is effective in reducing respiratory illness among diarrhea patient households.

Translating, contextually adapting, and pilot testing of psychosocial and mental health assessment instruments for Congolese refugees in Rwanda and Uganda.

BACKGROUND: Forcibly displaced people are at elevated risk of experiencing circumstances that can adversely impact on mental health. Culturally and contextually relevant tools to assess their mental health and psychosocial needs are essential to inform the development of appropriate interventions and investigate the effectiveness of such interventions. METHODS: We conducted two related studies: (1) to translate and contextually adapt the Patient Health Questionnaire (PHQ-9), a measure of depressive symptomatology, along with assessment instruments measuring levels of daily stress (Checklist for Daily & Environmental Stressors; CDES), social capital (Shortened and Adapted Social Capital Assessment Tool; SASCAT) and perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) for use with Congolese refugees; (2) to conduct pilot testing of the assessment instruments (including cognitive interviewing about participants' views of completing them) and a validation of the adapted PHQ-9 using a 'known group' approach by recruiting Congolese refugees from refugee settings in Rwanda (n = 100) and Uganda (n = 100). RESULTS: Study 1 resulted in the translation and adaptation of the assessment instruments. No substantive adaptations were made to the SASCAT or MSPSS, while notable linguistic and contextual adaptations were made in both sites to the CDES and the PHQ-9. The cognitive interviewing conducted in Study 2 indicated that the adapted assessment instruments were generally well received by members of the refugee communities. Participants recruited on the basis that local informants adjudged them to have high levels of depressive symptoms had significantly higher PHQ-9 scores (M = 11.02; SD = 5.84) compared to those in the group adjudged to have low levels of depressive symptoms (M = 5.66; SD = 5.04). In both sites, the adapted versions of the PHQ-9 demonstrated concurrent validity via significant positive correlations with levels of daily stressors. Each of the four adapted assessment instruments demonstrated at least adequate levels of internal consistency in both sites. CONCLUSIONS: The adapted versions of the PHQ-9, CDES, SASCAT and MSPSS are appropriate for use amongst Congolese refugees in Rwanda and Uganda. We recommend further application of the approaches used in the current studies for contextually adapting other assessment instruments in humanitarian settings.

Formative Research for the Design of a Baby Water, Sanitation, and Hygiene Mobile Health Program in Bangladesh (CHoBI7 Mobile Health Program).

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

Risk Factors for Household Transmission of Vibrio cholerae in Dhaka, Bangladesh (CHoBI7 Trial).

AbstractHousehold contacts of cholera patients are at a 100 times higher risk of a Vibrio cholerae infection than the general population. To examine risk factors for V. cholerae infections and investigate intervention strategies among this population, we followed household contacts of cholera patients for the 1-week high-risk period after the index patient obtained care. This study was nested within a randomized controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7), a handwashing with soap and water treatment intervention in Dhaka, Bangladesh. Rectal swab results were available from 320 household contacts of cholera patients at five time points over a 1-week period. Fecal and water samples were analyzed for V. cholerae by bacterial culture. All analyses were stratified by study arm. Within the intervention arm, stored household drinking water with a median free chlorine concentration below 0.5 mg/L was associated with a three times higher odds of a cholera infection (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.32, 6.63). In the control arm, having V. cholerae in stored water was associated with a significantly higher odds of a symptomatic cholera infection (OR: 8.66; 95% CI: 2.11, 35.48). No association was found between observed handwashing with soap at food and stool-related events and V. cholerae infections. Stored household drinking water with detectable V. cholerae and chlorine concentrations below the World Health Organization guideline were found to be important risk factors for cholera infection among household contacts of cholera patients. These findings emphasize the need for water treatment interventions targeting this high risk population.