Household members of diarrhea patients are at higher risk of developing diarrheal diseases (>100 times for cholera) than the general population during the 7 days after the diarrhea patient is ...admitted at a health facility. There is growing evidence demonstrating that theory-driven water, sanitation, and hygiene (WASH) interventions are likely to yield greater behavior change than those based on health education alone. The Cholera Hospital-Based Intervention for 7-Days (CHoBI7) mobile health (mHealth) program is a theory-driven WASH intervention initially delivered to a diarrhea patient by a health promoter during a health facility visit and reinforced through weekly voice and text messages. In the recent randomized controlled trial (RCT) of the CHoBI7-mHealth program in Bangladesh, this intervention significantly reduced diarrheal disease and stunting, and increased handwashing with soap and stored drinking water quality over the 12-month program period. The aim of this study was to assess the underlying mechanism of change of this intervention. Handwashing with soap was measured by 5-hour structured observation. Stored drinking water quality was assessed by the presence of Escherichia coli during unannounced spot checks. Psychosocial factors were measured among 1,468 participants in the CHoBI7-mHealth RCT. Perceived susceptibility, response efficacy, self-efficacy, dirt reactivity, and diarrhea knowledge were mediators of the CHoBI7-mHealth program’s effect on stored drinking water quality at the 1-week follow-up. Self-efficacy, response efficacy, and diarrhea knowledge were mediators of the intervention’s effect on handwashing with soap habit maintenance and stored drinking water quality at the 12-month follow-up. This study demonstrates how theory-driven approaches for intervention design can facilitate WASH behavior change.
The risk for cholera infection is >100 times higher for household contacts of cholera patients during the week after the index patient seeks hospital care than it is for the general population. To ...initiate a standard of care for this high-risk population, we developed Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7), which promotes hand washing with soap and treatment of water. To test CHoBI7, we conducted a randomized controlled trial among 219 intervention household contacts of 82 cholera patients and 220 control contacts of 83 cholera patients in Dhaka, Bangladesh, during 2013-2014. Intervention contacts had significantly fewer symptomatic Vibrio cholerae infections than did control contacts and 47% fewer overall V. cholerae infections. Intervention households had no stored drinking water with V. cholerae and 14 times higher odds of hand washing with soap at key events during structured observation on surveillance days 5, 6, or 7. CHoBI7 presents a promising approach for controlling cholera among highly susceptible household contacts of cholera patients.
Objective To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural ...Bangladesh. Study design Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin. Findings Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child's age ( P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <−2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (−0.34 95% CI −0.68, −0.01 and weight-for-height z score (−0.52 95% CI −0.98, −0.06). Conclusion Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations.
During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general ...population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease.
We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery.
The intervention program was modified based on formative research findings. Pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs.
Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.
Humanitarian workers are at risk of experiencing emotional distress and mental health problems. The COVID-19 pandemic created additional stress and challenges for staff in ongoing emergencies who had ...to continue delivering humanitarian assistance. The primary objective of this study was to assess the mental health status of humanitarian staff working in the Rohingya refugee operation in Cox’s Bazar, Bangladesh, amid the COVID-19 pandemic. A sample of 307 national and international humanitarian staff working in person or remotely within the Rohingya refugee operation in Cox’s Bazar anonymously completed an online questionnaire. Outcome measures included 1) the WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings which measures six symptoms related to mental health problems, 2) the Perceived Social Support Questionnaire and 3) questions about help-seeking. The self-reported mental health burden among humanitarian workers was high. The result demonstrates that most participants felt so afraid and severely upset about the emergency/COVID-19 pandemic that they avoided people or places. One in three respondents felt so angry that they were unable to carry out essential activities at least some of the time. Significant differences between national and international staff were found, with national staff more likely than international staff to feel afraid, angry, hopeless and unable to carry out essential activities (all P-values < 0.05). Nearly three out of 10 humanitarian workers reported a lack of social support. Less than one in five had sought professional help, while around half of all respondents indicated that they would want mental health support. The need for mental health support for humanitarian staff in Cox’s Bazar, Bangladesh, during the COVID-19 pandemic was high. It is important to strengthen strategies to proactively make services for mental health support available and accessible to humanitarians, building upon existing structures and allocating appropriate resources.
Objective To determine the relationship between geophagy (mouthing of dirt, sand, clay, or mud) and growth faltering in young children. Study design We examined linear growth as height and weight ...standardized by age and sex, and weight standardized by height, in a cohort of children aged 6-36 months in rural Mirzapur, Bangladesh. We determined geophagy behavior at baseline through caregiver report. Anthropometric measurements were assessed at baseline and at a 1-year follow-up. Results We found that among children not stunted at baseline, those with caregiver-reported geophagy at baseline grew less over 1 year compared with their peers, with a difference in the change of standardized height for age and sex of −0.31 (95% CI, −0.61 to −0.01). Conclusion These findings show that caregiver-reported geophagy was associated with growth faltering in a pediatric population in rural Bangladesh. Future studies are needed to learn more about this exposure pathway and its relevance to child growth.
Cholera can result in the expulsion of important microbiota from the gut and result in death if left untreated. The disease transmits mainly via drinking water carrying Vibrio cholerae; and household ...contacts (HHC) of cholera patients are at elevated risk during the first week of infection. The gut microbiota profiles of HHC-children of cholera patients at Dhaka city slums were investigated before (day 0) and after (day 8) delivery of chlorinated water as part of the major study 'CHoBI7 trial (cholera-hospital-based intervention for 7 days)'.
Results of sequencing and analysis of bacterial community DNA revealed the predominance of two bacterial phyla: Bacteroidetes and Firmicutes at day 0 with a relative abundance of 62 ± 6 (mean ± SEM%) and 32 ± 7, respectively. The pattern reversed at day 8 with a decreased relative abundance of Bacteroidetes (39 ± 12; p = 0.034) and an increased abundance of Firmicutes (49 ± 12; p = 0.057). Of 65 bacterial families confirmed at day 0, six belonging to Proteobacteria including Vibrionaceae disappeared at day 8. Interestingly, the relative abundance of four Firmicutes families-Lachnospiraceae, Bifidobacteriaceae, Clostridiaceae, and Ruminococcaceae was increased in all five study children at day 8.
The observed exclusion of pathogenic Proteobacteria and enhancement of beneficial Firmicutes in the gut of children delivered with chlorinated water as part of WASH intervention reflect a great promise of the CHoBI7 program in preventing cholera and improving child health.
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.
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.
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.
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.
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.
Household contacts of cholera patients are at a 100 times higher risk of developing cholera than the general population. The objective of this study was to examine the incidence of V. cholerae ...infections among household contacts of cholera patients in a rural setting in Bangladesh, to identify risk factors for V. cholerae infections among this population, and to investigate transmission pathways of V. cholerae using multilocus variable-number tandem-repeat analysis (MLVA).
Stool from household contacts, source water and stored water samples were collected from cholera patient households on Day 1, 3, 5, and 7 after the presentation of the index patient at a health facility. Two hundred thirty clinical and water V. cholerae isolates were analyzed by MLVA. Thirty seven percent of households had at least one household contact with a V. cholerae infection. Thirteen percent of households had V. cholerae in their water source, and 27% had V. cholerae in stored household drinking water. Household contacts with V. cholerae in their water source had a significantly higher odds of symptomatic cholera (Odds Ratio (OR): 5.49, 95% Confidence Interval (CI): 1.07, 28.08). Contacts consuming street vended food had a significantly higher odds of a V. cholerae infection (OR: 9.45, 95% CI: 2.14, 41.72). Older age was significantly associated with a lower odds of a V. cholerae infection (OR: 0.96, 95% CI: 0.93, 0.99). Households with both water and clinical V. cholerae-positive samples all had isolates that were closely related by MLVA.
These findings emphasize the need for interventions targeting water treatment and food hygiene to reduce V. cholerae infections.
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