Formative Research for Adapting the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Water Treatment and Hygiene Mobile Health Program for Scalable Delivery in Rural Bangladesh

The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) mobile health (mHealth) program is a targeted water treatment and hygiene (WASH) program for the household members of diarrhea patients, initiated in the healthcare facility with a single in-person visit and reinforced through weekly voice and text messages for 3 months. A recent randomized controlled trial of the CHoBI7 mHealth program in urban Dhaka, Bangladesh, found that this intervention significantly increased WASH behaviors and reduced diarrhea prevalence. The objective of this present study was to conduct formative research using an implementation science framework to adapt the CHoBI7 mHealth program for scalable implementation in rural Bangladesh, and to promote construction of self-made handwashing stations (CHoBI7 Scale-up program). We conducted a 3-month multi-phase pilot with 275 recipients and 25 semi-structured interviews, 10 intervention planning workshops, and 2 focus group discussions with intervention recipients and program implementers. High appropriateness, acceptability, and adoption of the CHoBI7 Scale-up program was observed, with most recipients constructing self-made handwashing stations (90%) and chlorinating drinking water (63%) and 50% of participants observed handwashing with soap in the final pilot phase. At the recipient level, facilitators included weekly voice and text messages with videos on handwashing station construction, which served as reminders for the promoted water treatment and hand hygiene behaviors. Barriers included perceptions that self-made iron filters commonly used in households also removed microbial contamination from water and therefore chlorine treatment was not needed, and mobile messages not always being shared among household members. At the implementer level, facilitators for program implementation included follow-up phone calls to household members not present at the healthcare facility at the time of intervention delivery, and the promotion of multiple self-made handwashing station designs. Barriers included high patient volume in healthcare facilities, as well as the high iron in groundwater in the area that reduced chlorination effectiveness. These findings provide valuable evidence for adapting the CHoBI7 mHealth program for a rural setting, with a lower-cost, scalable design, and demonstrated the important role of formative research for tailoring WASH programs to new contexts.