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The Global Handwashing Partnership

Webinar Summary: Mobile Health (mHealth) Messaging to Facilitate Handwashing with Soap Behavior Change

February 15, 2019

On February 7th, 2019, the Global Handwashing Partnership, in conjunction with USAID and the Johns Hopkins Bloomberg School of Public Health, hosted a webinar discussion on the development and randomized controlled trial of a water, sanitation and hygiene (WASH) mobile health program in Dhaka, Bangladesh.

Background of the CHoBI7 Program

The CHoBI7 (Cholera-Hospital-Based-Intervention for 7 Days) program began as an intervention to reduce the incidence of cholera among household members of cholera patients presenting at the International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b) Hospital in Dhaka, Bangladesh. Dr. Christine Marie George, Principal Investigator for the CHoBI7 study, and Associate Professor in the Department of International Health at Johns Hopkins Bloomberg School of Public Health, presented the study. CHoBI7 was a multi-partner collaboration between Johns Hopkins University, iccdr,b, and the Bangladesh Ministry of Health and Family Welfare.

In Bangladesh, household members of cholera patients are at a 100 times higher risk of developing a cholera infection than the general population. This cholera risk is highest during the 7 days after the index cholera patient in the household presents at a health facility. This led the study team to develop the Cholera Hospital-Based Intervention for 7 days (CHoBI7) WASH Program in 2013. “Chobi” means picture in Bangla for the pictorial module delivered as part of the intervention program.

The initial CHoBI7 program delivered a pictorial module on cholera transmission and prevention bedside to cholera patients and their household members in a health facility and provided a cholera prevention package containing a handwashing station, chlorine tablets, a drinking water storage vessel with a lid, and cue cards to reinforce the promoted WASH practices.  Household members were also encouraged to use soapy water (water and detergent powder) as an alternative to bar soap, as this costs about a twentieth the price of bar soap. Health promoters then made home visits to cholera patient households during the 7-day period after the patient was discharged from the health facility for hardware demonstrations and to deliver a pictorial module to all household members. The initial CHoBI7 intervention program led to a 47% reduction in overall cholera infections among household members of cholera patients. These findings demonstrated that delivery of the CHoBI7 intervention program could significantly reduce cholera among this high-risk population.  

Intervention Development and Findings of the CHoBI7 Mobile Health Program

Following these results, the Bangladesh Ministry of Health and Family Welfare requested the study team investigate scalable approaches for delivery of the CHoBI7 intervention program in health facilities across Bangladesh. This led to a grant submission to USAID that was funded in 2015. The Ministry requested the scope of the CHoBI7 intervention be broadened to include all diarrhea patients since household transmission of diarrhea diseases is high for other enteric pathogens in addition to cholera. Mobile health presents a scalable approach that can serve as nudges to facilitate WASH behaviors promoted in the health facility that can be delivered without the need for home visits. Eight months of qualitative and quantitative formative research was conducted to develop the CHoBI7 mobile health program. The CHoBI7 mobile health program was developed to target the following key behaviors during the 7-day high risk period and to sustain these behaviors over time: increased handwashing with soap at stool and food related events, water treatment with chlorine tablets, and storage of household drinking water in a water vessel with a lid.

A randomized controlled trial was conducted to evaluate the CHoBI7 mobile health program at Dhaka icddr,b and Mugda Hospital. Diarrhea patients and their household members were randomized to be in one of three study arms.

  1. Standard Recommendation Arm– Health promoter recommends the use of Oral Rehydration Solution only (this is standard recommendation delivered at the icddr,b Hospital),
  2. Health Facility Delivery of CHoBI7 plus Mobile Health Messaging Arm– Bedside delivery of the CHoBI7 pictorial module in a health facility, a handwashing station and drinking water storage vessels, and cue cards of promoted WASH practices. Bi-weekly delivery of text and voice mobile messages promoting key WASH behaviors over a 12-month period. There are no home visits in this arm.
  3. Health Facility Delivery of CHoBI7 Arm plus Mobile Health Messaging and Home Visits Arm– Bedside delivery of the CHoBI7 pictorial module in a health facility, handwashing station and drinking water storage vessels, and cue cards of promoted WASH practices. Bi-weekly delivery of text and voice mobile promoting key WASH behaviors over a 12-month period. Two home visits during the 7-day period after the diarrhea patient is discharged from the health facility.

Mobile messaging was delivered in Bangla over a 12-month period, through voice and text messaging on the Viamo platform. The mobile messages were designed around the character of a Medical Doctor from the iccdr,b Hospital, Dr. Chobi. In the voice messages, she has discussions with a female peer role model, and a male peer role model, around key WASH behaviors promoted. Text messages were found during the formative research to complement voice messages by serving as important reminder that could be shared with others.

“Have you made a habit of drinking chlorinated water and washing your hands with soapy water to create a shield for good health?  If not, you can start now! Please tell my words to all family members.”

-Example Text Message from Dr. Chobi

The changes in WASH behaviors were measured at 7 days and 9 months after intervention delivery using 5-hour structured observation of handwashing practices and E. coli counts in household stored drinking water. The CHoBI7 intervention was found to significantly increase handwashing with soap and stored water quality at both the Day 7 and 9 Month follow-up visits. Furthermore, home visits did not provide a significant benefit compared to delivery of CHoBI7 in the health facility and through mobile messages alone. These findings indicate that mobile health presents a promising approach to facilitate WASH behavior change in this setting which can be delivered without home visits.

Question and Answer Session Overview

Following this presentation, Dr. George and Nga Nguyen of USAID engaged the audience in a discussion. Nga Nguyen opened this section by highlighting the CHoBI7 program as a good example of implementing continuous learning and adaptation in program design. The program began as initial randomized controlled trial and underwent further formative research to design a scalable WASH mobile health program evaluated in a second randomized controlled trial.  Several key discussion points emerged, highlighted below:

Mobile Health Applications in WASH

This is considered a new area with no published randomized controlled trials to date on WASH mHealth programs.

System 1 and System 2 Drivers

The CHoBI7 mobile health program targets both System 1 (S1) Drivers (relatively automatic, cue-driven drivers) and System 2 (S2) Drivers (relatively conscious and motivational factors) of behavior change. This includes S1 drivers on context change and piggybacking on existing behaviors, and S2 drivers focused on behavioral intentions.

Timing of Message Delivery and Gender Dynamics of Mobile Phone Access

The formative research revealed that the households had a preference for receiving mobile health messages during the evenings, and therefore these messages were subsequently delivered shortly before dinner time. The majority of primary mobile phone owners in households were males. This led the study team to include of a male peer role model in the mobile health program, and to encourage sharing of mobile health messages within the household.

Costs Incurred in Mobile Health Program

One of the participants shared the barriers of cost and poor network access in the implementation of a mobile health program in a similar setting in Sub-Saharan Africa. In Bangladesh, the costs incurred are much lower. Bi-weekly mobile messaging per household for 12 months cost 2 USD. Additional research in settings with lower phone coverage than Bangladesh is necessary.

Another participant highlighted a case study from a program in Haiti, where text messaging was used to send reminders around chlorination of drinking water, and voice messaging was used for handwashing with soap behavior change.

Potential for Scale to Non-High-Risk Members of the Population  

The study team is currently investigating the effectiveness of mass media approaches to deliver this WASH mHealth program.

Inclusion of Call Centers as a Route to Scale

Dr. George highlighted that the Bangladesh government operates a call center for the general population to call in and ask general health questions, for a small fee. This segued into Nga Nguyen explaining a similar approach in the U.S, encouraging patients to call in and speak with healthcare providers over minor illnesses that can be treated with over-the-counter medications.

Webinar recording

A recording of the webinar is available here. If you have questions or feedback about the webinar; or if you have resources related to leveraging mobile health messaging for behavior change at critical times for handwashing, please visit our Resources Hub, or email contact@globalhandwashing.org.

Ask the GHP Series

At this webinar, the Global Handwashing Partnership launched our #AsktheGHP knowledge series. This is an opportunity to leverage the technical expertise the Global Handwashing Partnership offers, to answer pressing questions about handwashing with soap behavior change. To participate, please submit questions using the hashtag #AsktheGHP on Twitter or contact us.

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