Integrated care van delivery of evidence-based services for people who inject drugs: A cluster-randomized trial.

BACKGROUND AND AIMS: People who inject drugs (PWID) are at risk for adverse outcomes across multiple dimensions. While evidence-based interventions are available, services are often fragmented and difficult to access. We measured the effectiveness of an integrated care van (ICV) that offered services for PWID. DESIGN, SETTING AND PARTICIPANTS: This was a cluster-randomized trial, which took place in Baltimore, MD, USA. Prior to randomization, we used a research van to recruit PWID cohorts from 12 Baltimore neighborhoods (sites), currently served by the city's mobile needle exchange program. INTERVENTION AND COMPARATOR: We randomized sites to receive weekly visits from the ICV (n = 6) or to usual services (n = 6) for 14 months. The ICV offered case management; buprenorphine/naloxone; screening for HIV, hepatitis C virus and sexually transmitted infections; HIV pre-exposure prophylaxis; and wound care. MEASUREMENTS: The primary outcome was a composite harm mitigation score that captured access to evidence-based services, risk behaviors and adverse health events (range = 0-15, with higher numbers indicating worse status). We evaluated effectiveness by comparing changes in the composite score at 7 months versus baseline in the two study arms. FINDINGS: We enrolled 720 cohort participants across the study sites (60 per site) between June 2018 and August 2019: 38.3% women, 72.6% black and 85.1% urine drug test positive for fentanyl. Over a median of 10.4 months, the ICV provided services to 734 unique clients (who may or may not have been cohort participants) across the six intervention sites, including HIV/hepatitis C virus testing in 577 (78.6%) and buprenorphine/naloxone initiation in 540 (74%). However, only 52 (7.2%) of cohort participants received services on the ICV. The average composite score decreased at 7 months relative to baseline, with no significant difference in the change between ICV and usual services (difference in differences: -0.31; 95% confidence interval: -0.70, 0.08; P = 0.13). CONCLUSIONS: This cluster-randomized trial in Baltimore, MD, USA, found no evidence that weekly neighborhood visits from a mobile health van providing injection-drug-focused services improved access to services and outcomes among people who injected drugs in the neighborhood, relative to usual services. The van successfully served large numbers of clients but unexpectedly low use of the van by cohort participants limited the ability to detect meaningful differences.

Leveraging mHealth and Patient Supporters for African Americans' and Latinxs' Engagement in HIV Care (LEAN): Protocol for a Randomized, Controlled, Effectiveness-Implementation Trial.

BACKGROUND: Despite substantial investments in ending the HIV epidemic, disparities in HIV care persist, and there is an urgent need to evaluate novel and scalable approaches to improving HIV care engagement and viral suppression in real-world settings. OBJECTIVE: This paper aims to describe a study protocol for a pragmatic type II hybrid effectiveness-implementation randomized controlled trial comparing existing standard of care clinic HIV linkage, adherence, and retention (LAR) protocols to a mobile health (mHealth)-enhanced linkage, adherence, and retention (mLAR) intervention. METHODS: The study will enroll 450 participants from clinics in Baltimore City. Eligibility criteria include being ≥18 years of age, having a new HIV diagnosis or being HIV-positive and out of care, or being HIV-positive and deemed by clinic staff as someone who could benefit from linkage and retention services. Participants randomized to the intervention receive mHealth-supported patient navigation for 12 months. Participants in the control group receive the referring clinic's standard of care patient support. The primary outcome is HIV virologic suppression at 12 months. A subset of participants will be interviewed at 12 months to learn about their HIV care experiences and, for those in the intervention arm, their experiences with the mLAR intervention. This protocol was developed in collaboration with the Baltimore City Health Department (BCHD) and the Maryland Department of Health (MDH) and with input from a community advisory board. RESULTS: Enrollment began on February 25, 2020. As of August 11, 2022, 411 of the 450 target participants had been enrolled. CONCLUSIONS: Pragmatic implementation science trials designed with input from key stakeholders, including health departments and community members, can help evaluate the evidence for mHealth interventions to reduce HIV health disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT03934437; https://clinicaltrials.gov/ct2/show/NCT03934437. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42691.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program.

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Coalition of Faith Leaders, Community Organizations, and Governmental Organizations to Implement a COVID-19 Campaign in a Latino Neighborhood, Baltimore, Maryland, 2020-2021.

The disproportionate impact of COVID-19 on low-income Latinos with limited access to health care services prompted the expansion of community-based COVID-19 services. From June 25, 2020, to May 20, 2021, we established a coalition of faith leaders, community organizations, and governmental organizations to implement a Spanish-language hotline and social media campaign that linked people to a COVID-19 testing site at a local church in a high-density Latino neighborhood in Baltimore, Maryland. This retrospective analysis compared the characteristics of Latinos accessing testing in community versus health care facility-based settings. (Am J Public Health. 2022;112(S9):S913-S917. https://doi.org/10.2105/AJPH.2022.307074).

HIV-related stigma among Spanish-speaking Latinos in an emerging immigrant city following the Solo Se Vive Una Vez social marketing campaign.

HIV-related stigma exacerbates Latino immigrants' risk of HIV infection and delayed care. Following the implementation of the social marketing campaign Sólo Se Vive Una Vez (You Only Live Once) to increase HIV testing that addressed stigmatizing beliefs, we conducted a survey among Latinos in Baltimore, Maryland (N = 357). The aims of this paper are to 1) characterize the sociodemographic characteristics, HIV-related stigma beliefs, and testing behaviors of the survey respondents by campaign exposure, and 2) model the effects of Vive exposure on stigma beliefs and testing behaviors. Comparing post-campaign survey respondents exposed and unexposed to the campaign to survey findings previously obtained and reported before the campaign implementation, respondents to the post-Vive survey continued to hold high levels of stigma beliefs, and compared to the pre-Vive survey sample, were more likely to hold four or more stigmatizing beliefs (from the six survey items). Among the post-Vive survey respondents, those for whom religion was important or very important had an increased odds of 1.6 of holding four or more stigmatizing beliefs. Survey respondents who were exposed to the campaign, however, had an increased odds of 2.25 of reporting ever having been tested for HIV. Our findings demonstrate the importance of the changing social context in addressing stigma within emerging immigrant communities and highlight the critical role of religious leaders in efforts to address HIV-related stigma.

High Uptake and Series Completion of COVID-19 Vaccine at Community-Based Vaccination for Latinos With Limited English Proficiency.

BACKGROUND: Despite the disproportionate impact of COVID-19 on Latinos, there were disparities in vaccination, especially during the early phase of COVID-19 immunization rollout. METHODS: Leveraging a community-academic partnership established to expand access to SARS-CoV2 testing, we implemented community vaccination clinics with multifaceted outreach strategies and flexible appointments for limited English proficiency Latinos. RESULTS: Between February 26 and May 7 2021, 2250 individuals received the first dose of COVID-19 vaccination during 18 free community events. Among them, 92.4% (95% confidence interval [CI], 91.2%-93.4%) self-identified as Hispanic, 88.7% (95% CI, 87.2%-89.9%) were limited English proficiency Spanish speakers, 23.1% (95% CI, 20.9%-25.2%) reported prior COVID-19 infection, 19.4% (95% CI, 16.9%-22.25%) had a body mass index of more than 35, 35.0% (95% CI, 32.2%-37.8%) had cardiovascular disease, and 21.6% (95% CI, 19.2%-24.0%) had diabetes. The timely second-dose completion rate was high (98.7%; 95% CI, 97.6%-99.2%) and did not vary by outreach method. CONCLUSION: A free community-based vaccination initiative expanded access for Latinos with limited English proficiency at high risk for COVID-19 during the early phase of the immunization program in the US.

Diarrheal Disease Awareness Is Associated with Caregiver Handwashing with Soap in the Democratic Republic of the Congo (REDUCE Program).

Diarrhea is one of the leading causes of childhood illness and a major cause of infant and child mortality globally. In the Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) prospective cohort study, we investigated the association between diarrheal disease awareness and handwashing with soap among caregivers of children under 5 years of age. A total of 259 caregivers of children under 5 years of age in Walungu Territory, South Kivu, Democratic Republic of the Congo (DRC), were administered an open-ended questionnaire assessing awareness of diarrheal disease transmission and prevention, and key times to wash hands with soap. An overall diarrhea awareness score was developed based on the responses to these items. Five-hour structured observation of handwashing behaviors was conducted at the 6-month follow-up. Diarrheal disease awareness among caregivers was low. Only 32% of caregivers were able to correctly identify a method of diarrhea prevention. The median diarrhea awareness score was three out of 10 (SD: 1.7, range: 0-9). During structured observation, 9% of caregivers washed their hands with soap at a food-related event and 9% washed their hands with soap at a stool-related event. Higher diarrheal disease awareness was associated with an increased odds of handwashing with soap at food-related events (odds ratio: 1.40, 95% confidence interval: 1.03, 1.90). Our findings emphasize the need for targeted water, sanitation, and hygiene interventions to increase diarrhea awareness to facilitate handwashing with soap among caregivers of children under 5 years in rural DRC.

Latino Household Transmission of Severe Acute Respiratory Syndrome Coronavirus 2.

We assessed temporal changes in the household secondary attack rate of severe acute respiratory syndrome coronavirus 2 and identified risk factors for transmission in vulnerable Latino households of Baltimore, Maryland. The household secondary attack rate was 45.8%, and it appeared to increase as the alpha variant spread, highlighting the magnified risk of spread in unvaccinated populations.

Mobile low-threshold buprenorphine integrated with infectious disease services.

INTRODUCTION: In 2018, the Baltimore City Health Department launched a mobile clinic called Healthcare on The Spot, which offers low-threshold buprenorphine services integrated with health care services to meet the needs of people who use drugs. In addition to buprenorphine management, The Spot offers testing and treatment for hepatitis C, sexually transmitted infections, and HIV, as well as pre-exposure prophylaxis for HIV, wound care, vaccinations, naloxone distribution, and case management. METHODS AND MATERIALS: This cohort analysis includes clinical service data from the first 15 months of The Spot mobile clinic, from September 4, 2018, to November 23, 2019. The Spot co-located with the Baltimore syringe services program in five locations across the city. Descriptive data are provided for patient demographics and services provided, as well as percent of patients retained in buprenorphine treatment at one and three months. Logistic regression identified factors associated with retention at three months. RESULTS: The Spot mobile clinic provided services to 569 individuals from September 4, 2018, to November 23, 2019, including prescribing buprenorphine to 73.8% and testing to more than 70% for at least one infectious disease. Patients receiving a prescription for buprenorphine were more likely to be tested for HIV, hepatitis C, and sexually transmitted infections, as well as receive treatment for hepatitis C and preventive services including vaccination and naloxone distribution. The Spot initiated HIV treatment for four patients and HIV pre-exposure prophylaxis for twelve patients. More than 32% of patients had hepatitis C; nineteen of these patients initiated treatment for hepatitis C with eight having a documented cure. Buprenorphine treatment retention was 56.0% at one month and 26.2% at three months. Patients who were Black or receiving treatment for hepatitis C were more likely to be retained in buprenorphine treatment at three months. CONCLUSIONS: Increasing access to integrated medical services and drug treatment through low-threshold, community-based models of care can be an effective tool for addressing the effects of drug use.

Utilizing telemedicine during COVID-19 pandemic for a low-threshold, street-based buprenorphine program.

BACKGROUND: Changes in federal policy during the COVID-19 pandemic allowing for the use of telemedicine to treat opioid use disorder (OUD) have facilitated innovative strategies to engage and retain people in treatment. Since 2018, the Baltimore City Health Department has operated a mobile street medicine program called Healthcare on The Spot (The Spot) that provides treatment for OUD and infectious diseases. This study describes the transition of The Spot's buprenorphine service to telemedicine during the COVID-19 pandemic and one year treatment retention. METHODS: Patients actively engaged in care at the time of transition to telemedicine and patients newly engaged in buprenorphine services through telemedicine were included in this descriptive analysis and assessed at one year for retention. RESULTS: From March 16, 2020 to March 15, 2021, The Spot provided voice-only buprenorphine treatment services to 150 patients, 70.7% (n = 106) male and 80.0% (n = 120) Black; 131 were patients who transitioned from in person services and 19 were newly engaged via telemedicine. 80.7% (n = 121) of patients remained engaged in treatment at one year, 16.0% (n = 24) were lost to follow-up, and 3.3% (n = 5) were deceased. Patients newly engaged via telemedicine were more likely to be female and white than those retained from in person services. CONCLUSION: The Spot's transition of patients from a street medicine program to telemedicine during the COVID-19 pandemic has implications for future practice. Increased flexibility of service delivery, extended prescription length, and decreased UDT likely contributed to high retention rates and should inform the future structure of low-threshold buprenorphine programs.

Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program).

Diarrheal disease remains a leading cause of child mortality, globally. In the Democratic Republic of the Congo (DRC), each year there are an estimated 45 million episodes of diarrhea in children under five years of age. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to develop theory-driven, evidence-based approaches to reduce diarrheal diseases among young children. The REDUCE prospective cohort study in Walungu Territory in Eastern DRC took guidance from the risks, attitudes, norms, abilities, and self-regulation model, the integrated behavioral model for water, sanitation, and hygiene (WASH), and other behavior change theories to identify psychosocial factors associated with WASH behaviors. Psychosocial factors were measured among 417 caregivers at baseline and caregiver responses to child mouthing of dirty fomites and handwashing with soap was assessed by 5-hour structured observation at the 6-month follow-up. Caregivers who agreed that their child could become sick if they put dirt in their mouth (perceived susceptibility) and caregivers that agreed they could prevent their child from playing with dirty things outside (self-efficacy) were significantly more likely to stop their child from mouthing a dirty fomite. Higher perceived susceptibility, self-efficacy, and disgust, and lower dirty reactivity, were associated with higher handwashing with soap behaviors. This study took a theory-driven and evidence-based approach to identify psychosocial factors to target for intervention development. The findings from this study informed the development of the REDUCE Baby WASH Modules that have been delivered to over 1 million people in eastern DRC.

Community Testing and SARS-CoV-2 Rates for Latinxs in Baltimore.

INTRODUCTION: Latinxs have been disproportionately impacted by COVID-19. Latinx immigrants, in particular, face significant barriers to SARS-CoV-2 testing, including lack of insurance, language barriers, stigma, work conflicts, and limited transportation. METHODS: In response to a disproportionately high SARS-CoV-2 positivity rate among Latinxs at the Johns Hopkins Health System, investigators implemented free community-based testing by partnering with religious leaders and leveraging the skill of trusted community health workers. Data were extracted from the electronic health record and a Research Electronic Data Capture database. SARS-CoV-2 positivity was evaluated per event stratified by race/ethnicity. Total rates of SARS-CoV-2 positivity and categorical patient characteristics were compared between groups using chi-square tests. RESULTS: Between June 25, 2020 and October 15, 2020, a total of 1,786 patients (57.5% Latinx, 31.2% non-Hispanic White, 5.9% non-Hispanic Black, and 5.3% non-Hispanic other) were tested for SARS-CoV-2 in 18 testing events. Among them, 355 (19.9%) tested positive. The positivity rate was 31.5% for Latinxs, 7.6% for non-Hispanic Blacks, 3.4% for non-Hispanic Whites, and 5.3% for patients of other races/ethnicities. Compared with Latinxs who tested negative, Latinxs who tested positive were more likely to report Spanish as their preferred language (91.6% vs 81.7%, p<0.001), be younger (30.4 vs 33.4 years, p<0.008), and have a larger household size (4.8 vs 4.3 members, p<0.002). CONCLUSIONS: Community-based testing identified high levels of ongoing SARS-CoV-2 transmission among primarily Latinxs with limited English proficiency. During this period, the overall positivity rate at this community testing site was almost 10 times higher among Latinxs than among non-Hispanic Whites.

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.

BACKGROUND: The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh. METHODS: Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat. RESULTS: Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61-.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69-.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31-.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31-.96]) compared with children in the standard message arm. CONCLUSIONS: The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households. CLINICAL TRIALS REGISTRATION: NCT04008134.

Child Mouthing of Feces and Fomites and Animal Contact are Associated with Diarrhea and Impaired Growth Among Young Children in the Democratic Republic of the Congo: A Prospective Cohort Study (REDUCE Program).

OBJECTIVE: To identify exposure pathways to fecal pathogens that are significant contributors to diarrheal diseases and impaired growth in young children, and to evaluate scalable interventions to reduce fecal contamination from these pathways. STUDY DESIGN: Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) was a prospective cohort study of 370 children <5 years of age was conducted in Walungu Territory, South Kivu, Democratic Republic of the Congo. Child mouthing behaviors were assessed through caregiver reports and 5-hour structured observations. Caregiver reports of child contact with animals and child diarrhea were also obtained. Anthropometric measurements were collected at baseline and at a 6-month follow-up. RESULTS: Children observed putting soil in their mouth during structured observation at baseline had a significantly higher odds of diarrhea at the 6-month follow-up (OR, 1.79; 95% CI, 1.04 to 3.07). Children observed mouthing feces during structured observation had a significant reduction in height-for-age z-score (HAZ) from baseline to the 6-month follow-up (ΔHAZ, -0.69; 95% CI, -1.34 to -0.04). A significant reduction in HAZ was also observed for children with caregiver reports of touching guinea pigs (-0.33; 95% CI, -0.58 to -0.08) and rabbits (-0.34; 95% CI, -0.64 to -0.04) and children with feces in their sleeping space during unannounced spot checks (-0.41; 95% CI, -0.74 to -0.09). CONCLUSIONS: These findings emphasize the urgent need for infant water, sanitation, and hygiene interventions targeting child mouthing behaviors, fecal contamination in child living spaces, and child contact with domestic animals to reduce exposure to fecal pathogens among susceptible populations.

Child hand contamination is associated with subsequent pediatric diarrhea in rural Democratic Republic of the Congo (REDUCE Program).

OBJECTIVE: The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program focuses on identifying exposure pathways to faecal pathogens for young children in the Democratic Republic of the Congo (DRC) and on developing scalable interventions to reduce faecal contamination from these pathways. METHODS: A prospective cohort study of 690 participants was conducted to investigate the association between hand, food, and environmental faecal contamination and diarrhoeal disease prevalence among young children in Walungu Territory, South Kivu, DRC. A total of 1923 hand rinse, soil, food, object, surface, stored water and water source samples were collected during unannounced spot checks after baseline enrolment and analysed for Escherichia coli. Caregiver reports of diarrhoea were obtained from children < 5 years at a 6-month follow-up. RESULTS: E.coli was detected in 73% of child and caregiver hand-rinse samples, 69% of soil samples from child play spaces, 54% of child food samples, 38% of objects and surfaces children were observed putting in their mouths, 74% of stored water samples, and 40% of source water samples. Children < 5 years with E. coli on their hands had significantly higher odds of diarrhoea at the 6-month follow-up (odds ratio: 2.03 (95% confidence interval: 1.05, 3.92)). CONCLUSION: The cohort study findings from the REDUCE program have shown that child hand contamination is associated with diarrhoeal disease in rural DRC, and that there is high faecal contamination in child plays spaces and food. These findings provide evidence demonstrating the urgent need to provide clean play spaces for young children and interventions targeting hand hygiene to reduce paediatric exposure to faecal pathogens.

OBJECTIF: L'étude REDUCE (Réduire l'Entéropathie, la Dénutrition et la Contamination à partir de l'Environnement) se concentre sur l'identification des voies d'exposition aux pathogènes fécaux pour les jeunes enfants en République Démocratique du Congo (RDC) et sur le développement d'interventions évolutives pour réduire la contamination fécale par ces voies. MÉTHODES: Une étude de cohorte prospective de 690 participants a été menée pour étudier l'association entre la contamination fécale des mains, des aliments et de l'environnement et la prévalence des maladies diarrhéiques chez les jeunes enfants dans le Territoire de Walungu, dans le Sud-Kivu, en RDC. Un total de 1.923 échantillons de rinçages des mains, de sol, d'aliments, d'objets, de surfaces, d'eau stockée et de sources d'eau ont été collectés lors de contrôles ponctuels inopinés après l'inscription de base et analysés pour Escherichia coli. Les rapports des soignants concernant la diarrhée ont été obtenus pour les enfants de moins de 5 ans à un suivi de 6 mois. RÉSULTATS: E. coli a été détecté dans 73% des échantillons de rinçage des mains des enfants et des soignants, 69% des échantillons de sol des aires de jeux pour enfants, 54% des échantillons d'aliments pour enfants, 38% des objets et des surfaces que les enfants mettaient en bouche, 74 % des échantillons d'eau stockée et 40% des échantillons de sources d'eau. Les enfants de moins de 5 ans avec E. coli sur leurs mains avaient un risque de diarrhée significativement plus élevé au suivi de 6 mois (rapport de cotes: 2,03 (intervalle de confiance à 95%: 1,05, 3,92)). CONCLUSION: Les résultats de l'étude de cohorte du programme REDUCE ont montré que la contamination des mains des enfants est associée aux maladies diarrhéiques dans les régions rurales de la RDC et à une forte contamination fécale dans les aires de jeux et les aliments pour enfants. Ces résultats fournissent des données démontrant le besoin urgent de fournir des espaces de jeu propres aux jeunes enfants et des interventions ciblant l'hygiène des mains pour réduire l'exposition pédiatrique aux pathogènes fécaux.

Effect of a water, sanitation and hygiene program on handwashing with soap among household members of diarrhoea patients in healthcare facilities in Bangladesh: a cluster-randomised controlled trial of the CHoBI7 mobile health program.

OBJECTIVE: The Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7) is a water treatment and handwashing with soap intervention for diarrhoea patients and their household members which is initially delivered in a healthcare facility setting. This study evaluated the effectiveness of CHoBI7 program delivery in increasing handwashing with soap in a healthcare facility setting among diarrhoea patients and their household members. METHODS: A randomised controlled trial of the CHoBI7 program was conducted among 404 diarrhoea patients and their accompanying household members in healthcare facilities in Dhaka, Bangladesh. The 'Standard Message' Arm received the standard message given in Bangladesh to diarrhoea patients on the use of oral rehydration solution. The 'Health Facility Visit + Soapy Water' Arm received the standard message, the CHoBI7 communication module delivered bedside to the patient; and a soapy water bottle in the healthcare facility. The 'Health Facility Visit + Handwashing Station' Arm received this same intervention plus a small plastic handwashing station. Within 24 h of intervention delivery, three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhoea patients and their accompanying household members. RESULTS: Compared to the Standard Message Arm, there was significantly more handwashing with soap at key events in both the Health Facility Visit + Soapy Water Arm (51% vs. 25 %) (Odds Ratio: 3.02; (95% Confidence Interval (CI): 1.41, 6.45) and the Health Facility Visit + Handwashing Station Arm (58% vs. 25%) OR: 4.12; (95% CI: 1.86, 9.14). CONCLUSION: These findings demonstrate that delivery of the CHoBI7 communication module and provision of a soapy water bottle to diarrhoea patients and their accompanying household members presents a promising approach to increase handwashing with soap among this high risk population in a healthcare facility setting in Bangladesh.

OBJECTIF: Le programme (CHoBI7Cholera-Hospital-Based-Intervention-for-7-days) est une intervention de traitement de l'eau et de lavage des mains avec du savon pour les patients et les membres de leur famille qui est initialement administrée dans un établissement de santé. Cette étude a évalué l'efficacité du programme CHoBI7 pour augmenter le lavage des mains au savon dans les établissements de santé. MÉTHODES: Un essai contrôlé randomisé du programme CHoBI7 a été mené auprès de 404 patients atteints de diarrhée et des membres de leur famille qui les accompagnent dans des établissements de santé à Dhaka, au Bangladesh. Le bras "Message standard" a reçu le message standard donné au Bangladesh aux patients atteints de diarrhée sur l'utilisation de la solution de réhydratation orale. Le bras "Visite de l'établissement de santé + eau savonneuse" a reçu le message standard, le module de communication CHoBI7 a été délivré au chevet du patient et une bouteille d'eau savonneuse dans l'établissement de santé. Le bras "Visite de l'établissement de santé + station de lavage des mains" a reçu la même intervention, ainsi qu'une petite station de lavage des mains en plastique. Dans les 24 heures suivant l'intervention, une observation structurée de trois heures des pratiques de lavage des mains lors d'événements liés aux selles/vomis et à la nourriture (événements clés) a été menée dans les établissements de santé. RÉSULTATS: Par rapport au bras 'Message standard', le lavage des mains au savon était significativement plus fréquent lors des événements clés dans le bras 'Visite de l'établissement de santé + Station de lavage des mains' (58% contre 25%) (rapport de cotes (OR): 4,12 ; (intervalle de confiance (IC) de 95%: 1,86-9,14) et dans le bras 'Visite de l'établissement de santé + Eau savonneuse' (51% contre 25%) (OR: 3,02 ; (IC95% : 1,41-6,45). CONCLUSION: Ces résultats démontrent que l'implémentation du module CHoBI7 constitue une approche prometteuse pour augmenter le lavage des mains au savon dans un établissement de santé au Bangladesh.

Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program).

OBJECTIVE: To characterise childhood mouthing and handling behaviours and to assess the association between hand-to-object and object-to-mouth contacts and diarrhoea prevalence in young children in urban Dhaka, Bangladesh. METHODS: A prospective cohort study was conducted among 494 children under 5 years of age in Dhaka, Bangladesh. This study was nested within the randomised controlled trial of the Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program. The CHoBI7 mHealth program focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members through mobile messages and a single in person visit. Mouthing and handling of faeces and fomites among young children was measured by five-hour structured observation and caregiver reports. Diarrhoea surveillance data was collected monthly for 12 months. RESULTS: Fifty five percent of caregivers reported that their child put a visibly dirty fomite (object or soil) in their mouth in the past week. Caregivers reported that 50% of children had mouthed visibly dirty objects, 26% had mouthed dirt, and 2% had mouthed faeces. Forty five percent of children were observed mouthing a visibly dirty fomite during structured observation, 40% of children were observed mouthing a visibly dirty object, 10% were observed mouthing soil, and one child (0.2%) was observed mouthing faeces. Mouthing of visibly dirty fomites was highest for children 12-18 months of age with 69% of these children having caregiver reports and 54% having observed events. Children with caregiver reports of mouthing faeces had a significantly higher odds of diarrhoea over the subsequent month (Odds Ratio: 4.54; 95% Confidence Interval: 1.06, 19.48). CONCLUSION: These findings demonstrate that mouthing of contaminated fomites among young children is frequent in urban environments in Bangladesh, and that mouthing faeces is associated with a significantly higher odds of diarrhoea. Interventions are urgently needed to protect young children from faecal pathogens in their play spaces.

OBJECTIF: Caractériser les comportements de mâchouillement et de manipulation par les enfants et évaluer l'association entre les contacts main-objet et objet-bouche et la prévalence de la diarrhée chez les jeunes enfants dans la ville de Dhaka, au Bangladesh. MÉTHODES: Une étude de cohorte prospective a été menée auprès de 494 enfants de moins de 5 ans à Dhaka, au Bangladesh. Cette étude s'inscrivait dans le cadre de l'essai contrôlé randomisé du programme CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-days) de santé mobile (mHealth. Le programme de santé mobile CHoBI7 se concentre sur la promotion du traitement de l'eau et du lavage des mains avec à l'eau et au savon aux patients atteints de diarrhée et aux membres de leur foyer par le biais de messages mobiles et de visites de face à face. Le mâchouillement et la manipulation des excréments et des fomites chez les jeunes enfants ont été mesurés par des observations structurées de cinq heures et par les rapports des personnes s'occupant d'enfants (soignants). Les données de surveillance de la diarrhée ont été recueillies chaque mois pendant 12 mois. RÉSULTATS: 55% des soignants ont déclaré que leur enfant avait mis un fomite visiblement sale (objet ou terre) dans sa bouche au cours de la semaine précédente. Les soignants ont indiqué que 50% des enfants avaient mâchouillé des objets visiblement sales, 26% avaient mâchouillé de la terre et 2% avaient mâchouillé des excréments. 45% des enfants ont été observés en train de mâchouiller un fomite visiblement sale au cours d'une observation structurée. 40% des enfants ont été observés en train de mâchouiller un objet, 10% ont été observés en train de mâchouiller de la terre et un enfant (0,2%) a été observé en train de mâchouiller des excréments. Le mâchouillement de fomites visiblement sales était le plus fréquent chez les enfants de 12 à 18 mois; 69% de ces enfants ont été signalés par les soignants et 54% ont été observés en train de le faire. Les enfants dont les soignants avaient signalé un mâchouillement d'excréments présentaient un risque de diarrhée nettement plus élevé au cours du mois suivant (rapport de cotes: 4,54; intervalle de confiance à 95%: 1,06-19,48). CONCLUSION: Ces résultats démontrent que le fait de mâchouiller des fomites contaminés chez les jeunes enfants est fréquent en milieu urbain au Bangladesh et que le fait de mâchouiller des excréments est associé à un risque de diarrhée nettement plus élevé. Des interventions sont urgemment nécessaires pour protéger les jeunes enfants des agents pathogènes fécaux dans leurs espaces de jeu.

Process evaluation for the delivery of a water, sanitation and hygiene mobile health program: findings from the randomised controlled trial of the CHoBI7 mobile health program.

OBJECTIVE: The Cholera-Hospital-Based Intervention for 7-days (CHoBI7) mobile health (mHealth) program delivers mobile messages to diarrhoea patient households promoting water treatment and handwashing with soap. The randomised controlled trial (RCT) of the CHoBI7 mHealth program demonstrated this intervention was effective in significantly reducing diarrhoea and stunting amoung young children. The objective of this study was to assess the implementation of the CHoBI7 mHealth program in delivering mHealth messages during this RCT. METHODS: 517 diarrhoea patient households with 1777 participants received weekly text, voice and interactive voice response (IVR) messages from the CHoBI7 mHealth program over the 12-month program period. The program process evaluation indicators were the following: the percentage of CHoBI7 mHealth messages received and fully listened to by program households (program fidelity and dose), and household members reporting receiving and sharing an mHealth message from the program in the past two weeks (program reach). RESULTS: Ninety two percent of text messages were received by program households. Eighty three percent of voice and 86% of IVR messages sent were fully listened to by at least one household member. Eighty one percent of IVR quiz responses from households were answered correctly. Program households reported receiving a CHoBI7 mHealth message in the past two weeks at 79% of monthly household visits during the 12-month program. Seventy seven percent of participants reported sharing a program message with a spouse, 55% with a neighbour and 49% with a child during the program period. CONCLUSION: There was high fidelity, dose and reach of mobile messages delivered for the CHoBI7 mHealth program. This study presents an approach for process evaluation that can be implemented to evaluate future mHealth programs.

OBJECTIF: Le programme CHoBI7 (Cholera-Hospital-Based-Intervention-for-7-days) de santé mobile (mHealth) délivre des messages mobiles aux ménages avec patients atteints de diarrhée pour promouvoir le traitement de l'eau et le lavage des mains au savon. L'essai contrôlé randomisé (ECR) du programme mHealth CHoBI7 a démontré que cette intervention était efficace pour réduire de manière significative la diarrhée et le retard de croissance chez les jeunes enfants. L'objectif de cette étude était d'évaluer la mise en œuvre du programme CHoBI7 mHealth dans la diffusion des messages mHealth au cours de cet ECR. MÉTHODES: 517 ménages avec des patients atteints de diarrhée ont reçu chaque semaine des messages SMS, vocaux et de réponse vocale interactive (RVI) du programme mHealth de CHoBI7 pendant les 12 mois du programme. Les indicateurs d'évaluation du processus du programme étaient les suivants: le pourcentage de messages mHealth du programme CHoBI7 reçus (fidélité au programme et dose) et entièrement écoutés par les ménages participant au programme (fidélité au programme et dose) et les bénéficiaires déclarant avoir reçu et partagé un message mHealth du programme (portée du programme) au cours des deux dernières semaines. RÉSULTATS: 92% des SMS ont été reçus par les ménages participant au programme. 83% des messages vocaux et 86% des messages RVI envoyés ont été entièrement écoutés par au moins un membre du ménage. 81% des réponses aux quiz RVI des ménages ont été correctement répondues. Les ménages du programme ont déclaré avoir reçu un message CHoBI7 mHealth au cours des deux dernières semaines dans 79% des visites mensuelles des ménages pendant les 12 mois du programme. 77% des participants ont déclaré avoir partagé un message du programme avec un conjoint, 55% avec un voisin et 49% avec un enfant pendant la durée du programme. CONCLUSION: La dose et les messages délivrés dans le cadre du programme mHealth de CHoBI7 l'ont été avec une fidélité élevée. Cette étude présente une approche d'évaluation des processus qui peut être mise en œuvre pour évaluer les futurs programmes mHealth.

Piloting a low-cost hardware intervention to reduce improper disposal of solid waste in communal toilets in low-income settlements in Dhaka, Bangladesh.

BACKGROUND: Bangladesh faces daunting challenges in addressing the sanitation needs of its urban poor. Maintaining the cleanliness and functionality of communal toilets is dependent upon periodic emptying of fecal sludge, and cooperation between users of communal toilets. Trash disposal into latrines can block the outflow pipes, rendering the toilets non-functional. METHODS: Pre-intervention: We conducted in-depth interviews with five operators of fecal sludge emptying equipment and five adult residents who were also caregivers of children. We identified factors contributing to improper disposal of trash into communal toilets, a barrier to operation of the equipment, in low-income communities of Dhaka, Bangladesh. Intervention design: We developed behavior change communication materials to discourage waste disposal in toilets, and promote use of waste bins. We conducted six focus group discussions with adult male, female, landlord and children to select the preferred design for waste bins to be placed inside toilets, and finalize communication materials. Post-intervention: We then pilot-tested an intervention package to promote appropriate trash disposal practices and thus facilitate periodic removal of fecal sludge when the latrine pits become full. We conducted 20 in-depth interviews and four focus group discussions with community residents, landlords and cleaners of communal toilets. RESULTS: Barriers to appropriate waste disposal included lack of private location for disposal of menstrual hygiene products, limited options for formal trash collection and disposal, and the use of plastic bags for disposing children's feces. A pilot intervention including behavior change communication and trash bins was implemented in two urban slum communities. Spot checks confirmed that the bins were in place and used. Respondents described positive improvements in the appearance of the toilet and surrounding environment. CONCLUSION: The current practice on the part of local residents of disposing of waste into toilets impedes the safe removal of fecal sludge and impairs toilet functionality. Residents reported positive changes in toilet cleanliness and usability resulting from this intervention, and this both improves the user experience with toilets, and also promotes the sustainability of the entrepreneurial model of Vacutug operators supported by WSUP.

If I do not have enough water, then how could I bring additional water for toilet cleaning?! Addressing water scarcity to promote hygienic use of shared toilets in Dhaka, Bangladesh.

OBJECTIVES: Provision of toilets is necessary but not sufficient to impact health as poor maintenance may impair toilet function and discourage their consistent use. Water in urban slums is both scarce and a prerequisite for toilet maintenance behaviours. We describe the development of behaviour change communications and selection of low-cost water storage hardware to facilitate adequate flushing among users of shared toilets. METHODS: We conducted nine focus group discussions and six ranking exercises with adult users of shared toilets (50 females, 35 males), then designed and implemented three pilot interventions to facilitate regular flushing and improve hygienic conditions of shared toilets. We conducted follow-up assessments 1 and 2 months post-pilot including nine in-depth interviews and three focus group discussions with adult residents (23 females, 15 males) and three landlords in the pilot communities. RESULTS: Periodic water scarcity was common in the study communities. Residents felt embarrassed to carry water for flushing. Reserving water adjacent to the shared toilet enabled slum residents to flush regularly. Signs depicting rules for toilet use empowered residents and landlords to communicate these expectations for flushing to transient tenants. Residents in the pilot reported improvements in cleanliness and reduced odour inside toilet cubicles. CONCLUSIONS: Our pilot demonstrates the potential efficacy of low-cost water storage and behaviour change communications to improve maintenance of and user satisfaction with shared toilets in urban slum settings.