Christine Marie George, PhD

Associate Professor

Department of International Health

Water, Sanitation, and Hygiene Mobile Health as an Innovative

Tool to Facilitate Behavior Change in Bangladesh:

CHoBI7 Mobile Health Program

2

1,64

210

0

50

100

150

200

250

General PopulationAli et al. 2015

Household Contacts ofCholera CasesWeil et al. 2009

Ch

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Study Rationale

Household members of cholera patients in Bangladesh are at a 100 times higher

risk of developing a cholera infection than the general population

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Cholera Hospital-Based Intervention for 7 days

CHoBI7 Intervention Program

4

Enabling Technology and Demonstrations

5

Research Site

International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka Hospital

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Randomized Controlled Trial of CHoBI7

Cluster Randomized Controlled Trial 2013-2014Dhaka icddr,b Hospital

Standard Message on Oral Rehydration

Solution

Standard Messageplus

CHoBI7 Intervention

Randomization Based on the Date of Arrival to

Hospital

7

CHoBI7 Intervention Program

Cholera Hospital-Based Intervention for 7 days

George et al. 2016 Emerging Infectious Diseases

13.5%

7.1%

0%

2%

4%

6%

8%

10%

12%

14%

Standard Message Only Arm(N=148)

CHoBI7 Intervention Arm(N=140)

Co

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ho

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In

fec

tio

ns

by C

ult

ure

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g

Inte

rven

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eri

od

47% Reduction in Overall Cholera Infections among Household Members in

CHoBI7 Intervention Arm

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Current Work

Investigating Scalable Approaches for CHoBI7

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Sender of CHoBI7 mHealth Messages: Dr. Chobi

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Example Voice Message: Dr. Chobi

Assalamulalaikum. Dr. Chobi from the Cholera Hospital.

How are you?

Have you been using the soapy water we gave you in the

hospital?

Making more soapy water is easy add six capful of

detergent to a plastic water bottle and then add water.

To protect your family from cholera, make sure your

whole family washes their hands with soapy water after

defecation or urination and before preparing, eating, or

feeding children. Please tell my words to all family

members.

I’ll talk to you again. Take care!

Keep your family healthy and happy!

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Example Voice Messages: Aklima

Peer Role Model

Dr. Chobi: I am with my new patient, Aklima.

Aklima, Can you tell me how to treat water

using chlorine tablets?

Aklima: Yes! Add the chlorine tablet and wait

30 minutes to drink.

Dr. Chobi: Thank you Aklima! That’s

absolutely right!

You and Aklima are starting to become

experts. Do not forget to share the text and

voice messages with others in your family

members!

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Example Voice Messages: Aklima’s Husband

Peer Role Model

Dr. Chobi: How are you brother? How is

Aklima and your children?

Aklima’s Husband: Yes, good! My children

had severe diarrhea. Now, they remain

healthy.

Dr. Chobi: Why do you think they remain

healthy now?

Aklima’s Husband: By drinking chlorinated

water and washing hands with soapy water

at key times as you instructed, our children

are healthy now! You called and texted us

and I have shared these messages with my

family and followed all the instructions.

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CHoBI7 Mobile Health Program Delivery

Voice and Text Messages12 Months

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Health Facility CHoBI7 Program Delivery

Pictorial Module

Delivered by a

Health Promoter

Handwashing

Station and

Drinking Water

Vessel

Cue Cards of

Promoted WASH

Practices

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Study Design: Randomized Controlled Trial

Study Site: Dhaka icddr,b and Mugda General Hospital

Randomization Based on Date and Hospital Ward

Diarrhea PatientsHousehold Members

Randomization

CHoBI7 Health Facility Visit +

Mobile Messages

(No Home Visits)

Standard Recommendation on Oral Rehydration

Solution Only

(Standard Arm)

CHoBI7 Health Facility Visit+

Mobile Messages+

2 Home Visits

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Baseline

Presentation of Diarrheal Patient

in Hospital

9 Months

Study Design

• 5 Hour Structured Observation of Handwashing Practices

• E.coli Counts of Household Stored Drinking Water

6 Months 12 Months7 Days 3 Months

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Findings: Five Hour Structured Observation

Hand Washing with Soap at Stool and Food Related Events

7 Day Follow-up (N=331)

OR (95% CI): Reference 3.32 (1.66, 6.67) 5.67 (2.74, 11.74)

OR: Odds Ratio

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Findings: Stored Household Drinking Water Quality

Water Samples Less than 1 CFU/100 ml of E.coli

7 Day Follow-up (N=487)

OR (95% CI): Reference 11.13 (5.94, 20.86) 22.99 (12.11, 43.63)

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Findings: Five Hour Structured Observation

Hand Washing with Soap at Stool and Food Related Events

9 Month Follow-up (N=203)

OR (95% CI): Reference 3.78 (1.47, 9.71) 7.04 (2.78, 17.85)

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11%20% 15%

13%

16% 16%

26%

27%28%

22%

23%24%

28%13% 17%

0%

20%

40%

60%

80%

100%

Findings: Stored Household Drinking Water Quality

WHO Very High Risk Category > 1000 CFU/100 mL of E.coli

9 Month Follow-up (N=376)

OR (95% CI): Reference 0.39 (0.20, 0.75) 0.53 (0.29, 0.98)

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Summary

•CHoBI7 mobile health program resulted in significantly higher handwashing

with soap and improved water quality which was sustained at our 9 month

follow-up.

•Health facility delivery of the CHoBI7 intervention and the mobile health

program alone with no home visits was sufficient to facilitate WASH behavior

change.

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Conclusion

•These findings demonstrate that mobile health presents a promising

approach to facilitate WASH behavior change during cholera outbreaks in this

setting

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Study TeamPrincipal Investigators

• Dr. Christine Marie George

• Dr. Munirul Alam

• Dr. Shirajum Monira

Ministry of Health and Family Welfare

• Dr. Sanya Tahmina

• Dr. Abul Hashem Khan

Evaluation Team

• Tahmina Parvin (Team Leader)

• Dr. Shwapon Biswas (Team Leader)

• Dr. Saif-Ur-Rahman (Team Leader)

• Dr. Tasdik Hasan (Team Leader)

• Laki Das

• Lubna Tani

• Tahera Taznen

• Ismat Minhaz Uddin

• Rafiqul Islam

• Al-Mamun

• Maynul Hasan

• Kalpona Akhter

• Khandokar Fazilatunnessa

• Sadia Afrin Ananya

• Akhi Sultana

• Laki Das

Intervention Team

• Fatema Zohura (Team Leader)

• Dr. Farzana Begum

• Jahed Masud

• Sohag Sarker

• Abul Bashar Sikder

• Shirin Akter

• Abdul Karim

Johns Hopkins Study Investigators

• Dr. David Sack

• Ronald Saxton

• Dr. Jamie Perin

• Dr. Alain Labrique

• Dr. Peter Winch

• Kelsey Keller

• Camille Morgan

• Khaled Hasan

Data Management Team

• Md. Sazzadul Islam (Team Leader)

Laboratory Team

• Fatema Johura (Team Leader)

• Dr. Marzia Sultana (Team Leader)

• Zillur Rahman (Team Leader)

• Mahamud-ur Rashid (Team Leader)

Laboratory Team (Continue)

• Fatema Tuz Jubyda

• Toslim Mahmud

• Munshi Mustafiz

• Indrajeet Barman

Johns Hopkins Students

• Elizabeth Thomas

• Mirza Velagic

• Gayathri Natarajan

• Anne O‘Connor

• Mirza Velagic

• Xiaotong Zhang

• Danielle Jung

• Lauren Oldja

• Alana Teman

• Vanessa Burrowes

• Sohel Rana

• Hasan Shihab

Funding Sources

• USAID-OAA-F-15-00038 (George PI)

• NIH 1K01AI110526-01A1 (George PI)

• Johns Hopkins

• Center for Global Health (George PI)

• USAID WASHPaLS (George PI and Alam PI)

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Acknowledgements

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Questions