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
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1,64
210
0
50
100
150
200
250
General PopulationAli et al. 2015
Household Contacts ofCholera CasesWeil et al. 2009
Ch
ole
ra In
fec
tio
n In
cid
en
ce
R
ate
pe
r 1
00
0
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
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Enabling Technology and Demonstrations
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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
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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
nta
cts
wit
h C
ho
lera
In
fec
tio
ns
by C
ult
ure
du
rin
g
Inte
rven
tio
n P
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