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International Health

October 2, 2020

Digital Health Program Reduces Diarrhea and Stunting Among Young Children in Bangladesh, New Study Finds

The program also led to improved household drinking water quality and handwashing with soap behaviors

Dr. Chobi with patient
Dr. Papri (left), a doctor at a diarrhea hospital in Bangladesh, with
a mother and her child who was a patient. Dr. Papri was the 
face of
CHoBI7’s messages. She was known in the program as Dr. Chobi so
participants could easily identify phone messages originating from the 
program. Chobi means picture in Bangla. Photo Credit: Dr. Papri 

A digital health program in Bangladesh that sent weekly voice and text mobile phone messages to diarrhea patients and their household members significantly reduced the prevalence of diarrhea and stunting in children under 2 years of age, according to a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health.

Researchers conducted a randomized controlled trial to evaluate the digital health program called the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) Mobile Health Program, based in Dhaka, Bangladesh. For 12 months, the program sent weekly reminders about the importance of handwashing with soap and boiling drinking water. The study enrolled 2,626 participants who were diarrhea patients admitted to health facilities and members of their households. During this time period, researchers monitored diarrhea prevalence, height and weight measurements for children under 5, presence of E.coli in drinking water, and handwashing practices.

The study was published in August in Clinical Infectious Diseases

“Our findings demonstrate that mobile phones are a promising tool for delivering health communication programs that can improve child health by reducing diarrhea and stunting. This is particularly valuable now when our ability to conduct in-person visits is limited due to the coronavirus pandemic,” says Christine Marie George, PhD, an associate professor in the Department of International Health at the Bloomberg School and lead author of the study.

In Bangladesh, there are an estimated 28 million diarrhea episodes every year among children under the age of 5.1 Thirty-one percent of children under 5 years of age are estimated to be stunted in the country.2 Stunting, or being too short for one’s age, is associated with many negative developmental outcomes, including cognitive impairments such as delayed motor development, impaired brain function and poor school performance. The first two years of life are when children are most susceptible to impaired growth; therefore, interventions targeting reductions in diarrheal disease and stunting are needed for this critical window of child development. Intervention targeting handwashing with soap and promoting the use of safe drinking water have been shown to have the potential to reduce diarrheal diseases and improve growth in young children.

The study recruited 769 diarrhea patients admitted to government and private health facilities. Researchers randomly assigned them and members of their respective households to one of three groups. One group was not part of the CHoBI7 Mobile Health Program. Neither they nor members of their household received any program mobile messages or materials.

Patients in the other two groups were met in the health facility by a health promoter from the CHoBI7 Mobile Health Program. Using a set of visual aids developed by the program, the health promoter shared diarrhea prevention information with the patients, including the importance of washing their hands with soap and boiling drinking water. Patients in these two groups also received a diarrhea-prevention package to take home that contained a one-month supply of chlorine water treatment tablets, a handwashing station, and a container to help insure safe water storage. For the next 12 months, the program sent text and voice messages to patients and members of their households reminding them of the importance of handwashing and boiling drinking water. In one of these two groups, health promoters also visited patients’ homes twice during the week after their discharge from the health facility.

The prevalence of diarrhea among children under 2 years old was 31% lower in households receiving phone messages and two home visits and 22% lower in households receiving only phone messages compared to the prevalence in households that were not part of the CHoBI7 Mobile Health Program. There was a 27% reduction in stunting among children under 2 years old in households receiving phone messages and two home visits and a 29% reduction in households receiving only phone messages, compared to the prevalence in households not part of the CHoBI7 program.

People living in households receiving program messages were two times more likely to wash their hands with soap before eating, feeding a child, and preparing meals, thus reducing the chance for pathogen transmission. The prevalence of E.coli in drinking water stored in the home was also lower in both groups that were part of the digital health program compared to households that were not.

 “Our findings suggest that digital health programs can lead to reductions in diarrhea and stunting comparable to those of more expensive programs in which households are visited weekly by community health workers,” says George. Most diarrhea-prevention programs in Bangladesh involve frequent in-person visits conducted weekly, she explains. These programs often cost over $60 per household each year, whereas weekly messages to a mobile phone cost around $2 per phone per year in Bangladesh. With a population of 163 million and 160 mobile phone subscriptions registered with the government in the country, George believes this presents an ideal environment to use mobile phones to deliver disease control programs across Bangladesh.

The CHoBI7 Mobile Health Program was developed in partnership with the government of Bangladesh through a participatory approach which included input from diarrhea patients and their household members. The program’s original objective was to reduce cholera among households with members who had recently been treated for the disease. Cholera, which causes severe diarrhea and can result in death if untreated, is transmitted through water and contaminated food—similar to how many other diarrhea-causing pathogens infect people. The program’s original success, therefore, led USAID to fund an evaluation of its expansion to households of patients treated for diarrhea from any cause.

As a result of these promising findings, the government of Bangladesh has decided to expand the CHoBI7 Mobile Health Program beyond Dhaka to serve the entire country. Given the number of people affected in Bangladesh from diarrheal diseases, the program has the potential to help 10 million people every year. George is currently partnering with the government to develop plans for scaling up the program and to evaluate its effectiveness in rural areas of the country. She is also leading a team of researchers to conduct a randomized controlled trial evaluating the health impacts of delivering a similar program in the Democratic Republic of the Congo.

Effects of a Water, Sanitation, and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-randomized Controlled Trial of the Cholera Hospital-based Intervention for 7 Days (CHoBI7) Mobile Health Program was written by Christine Marie George, Shirajum Monira, Fatema Zohura, Elizabeth D. Thomas, M. Tasdik Hasan, Tahmina Parvin, Khaled Hasan, Mahamud-ur Rashid, Nowshin Papri, Aminul Islam, Zillur Rahman, Raisa Rafique, Md. Sazzadul Islam Bhuyian, Ronald Saxton, Alain Labrique, Kelsey Alland, Indrajeet Barman, Fatema Tuz Jubyda, Farzana Afroze, Marzia Sultana, Fatema-Tuz Johura, Md. Abul Hasem Khan,3 Sanya Tahmina, Farzana Munmun, David A. Sack, Jamie Perin, and Munirul Alam

The study was supported by a United States Agency for International Development (USAID), Development Innovation Ventures grant awarded to the Johns Hopkins Bloomberg School of Public Health.