Formative research to scale up a handwashing with soap and water treatment intervention for household members of diarrhea patients in health facilities in Dhaka, Bangladesh (CHoBI7 program)

The program was originally developed for cholera patients and their household members, but it has been modified to target a broader population of diarrhea patients and their household members. The CHoBI7 program was designed to be delivered by health promoters during the seven-day period after a patient is admitted to a health facility for treatment, which is considered a high-risk period for the transmission of diarrheal diseases. The program includes a pictorial module, delivered at the patient's bedside, that depicts how diarrheal diseases spread and can be prevented. Behavioral recommendations are reinforced via daily household visits during the week following admission to the health facility. The original CHoBI7 intervention program included a range of enabling technologies and supplies, such as a sealed drinking water vessel, chlorine tablets for water treatment, a handwashing station, and a bottle of soapy water. The program was informed by the Risk, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model of behavior change and the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH). A randomized controlled trial of the original CHoBI7 intervention program showed significantly fewer symptomatic cholera infections and a 47% reduction in overall cholera infections among those in the intervention arm versus the control arm. The program also showed that intervention household members had significantly higher instances of handwashing with soap and significantly less E.coli in stored drinking water when compared to control households 6-12 months post-intervention delivery. The CHoBI7 program was modified based on formative research findings, which included 60 semi-structured interviews, 2 group discussions, and a pilot study. The pilot study participants recognized the benefits of the CHoBI7 intervention program and made suggestions to improve the acceptability and feasibility of the intervention. Modifications included providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility. Considerations for scalability of the CHoBI7 program include the local availability and marketing of enabling technologies and supplies, staff for program delivery in health facilities, and potential integration into existing government or health promotion programs. The program has the potential to be scaled up to other settings, including government and private health facilities in Bangladesh, and could be tailored to meet the needs of different populations and contexts. The CHoBI7 program has been shown to be effective in reducing the transmission of diarrheal diseases and promoting safe drinking water and handwashing with soap behaviors. The program's success is attributed to its use of behavior change theories and its focus on multiple behavioral determinants. The program's scalability and potential for adaptation to different settings make it a promising intervention for reducing diarrheal diseases in low- and middle-income countries.