Background
CHoBI7 program
Previous randomized controlled trial of the CHoBI7 intervention
Theory based approach for development of the CHoBI7 intervention program
Rationale for the development of the CHoBI7 mobile health program
Methods
Formative research activities
Intervention development
Psychosocial Factor | Factor Definition | Behavior Change Technique | IBM-WASH Dimension | Example Messages | Hypothesized Change with Intervention |
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Self-Efficacy | The belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations. (Bandura et al. 1997) | mHealth messages providing information on actionable tasks | Structural (Gender Roles)/ Individual | Voice Message
Dr. Chobi Apa: How are you brother? How is Aklima and your children?
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Higher acceptability of WASH behavioral recommendations among men
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Husband: Yes, good! My children got frequent diarrhea and sometimes we needed to hospitalize them before. Now, they remain healthy.
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Higher self-efficacy among male household members
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Dr. Chobi Apa: Why do you think they remain healthy now?
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Husband: Because my family and I now boil and safely store our drinking water and wash our hands with soapy water after defecation, after cleaning a child’s feces and anus, before preparing food, and before eating or feeding children. See, you phoned and texted me which I have shared with my family and followed all the instructions.
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mHealth messages encouraging the use of enabling technology | Habitual | Text Message To keep your water safe to drink, always put your boiled water in the blue bucket with the lid on. Never put your hands into this water, always use the tap. Keep your family happy and healthy! |
Higher self-efficacy and convenience of WASH behavioral recommendations
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Descriptive Norms | Perceptions about which behaviors are typically performed by others (Cialdini et al. 2006) | mHealth messages describing the proportion of others in the community performing the same behavior | Community | Voice Message
I am Dr. Chobi Apa from Mohakhali Cholera Hospital. How are you? We have found that 80% of individuals in your neighbourhood reported washing their hands with soap before feeding their child this week. Like others in your neighborhood, always wash your hands with soap before preparing food and feeding your child. Make sure there is always soapy water present within 10 steps of your cooking area. Keep your family healthy and happy!
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Higher descriptive norms of WASH behavioral recommendations
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mHealth messages from Aklima, a woman who brought her child to a health facility for diarrhea treatment, and who learned proper handwashing and water treatment behaviors from Dr. Chobi. | Interpersonal | Voice Message
This is Dr. Chobi Apa. Aklima is here with me again today and wants to share her story with you. Aklima: My son was very sick; he almost died. We took him to the hospital and the doctors gave him treatment. Before I left the hospital, they gave me a nice red handwashing bucket and blue water bucket. Dr. Chobi Apa told me about washing my hands with soap at four key times: before I prepare food, before I eat, and after I use the toilet or clean my child’s feces or anus. I have followed all these instructions all the time, and my family is now healthy and happy!
Dr. Chobi: Thank you Aklima for sharing your story! Did you hear how well Aklima is doing now? Are you also practicing these safe practices and staying healthy?
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Higher descriptive norms of WASH behavioral recommendations
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Emotion of Nurture | The desire to care for someone, and see them develop or grow. | mHealth messages encouraging nurture of young children as a motivator to practice the key behaviors promoted | Interpersonal | Voice Message
Diarrhea especially hurts small children.
To protect your child from these germs, make sure your whole family washes their hands at 4 key times: after defecation, after cleaning a child’s feces and anus, before preparing food, and before eating or feeding children. Use soapy water each time!
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Higher nurture for young children
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Emotion of Disgust | Revulsion that is occasioned by the sight of excreta, rotten food, slime, and bugs. (Curtis et al. 2001) | mHealth messages encouraging the emotion of disgust as a motivator to practice the key behaviors promoted | Individual | Text Message
If you don’t wash your hands after using the toilet, you’re eating feces when you’re eating your food. There are lots of germs in feces, and you may have diarrhea again.
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Higher disgust
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Remembering | To perform a behavior, it has to be remembered at the right time/situation. (Tobias et al. 2009) | mHealth messages reminding households to perform the key behaviors promoted | Habitual | Text Message
Have you made a habit of drinking safe water and washing your hands with soap to create a shield for good health? If not, you can start now!
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Higher daily remembering of behavioral recommendations
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IBM-WASH Dimension | Contextual Factors | Psychosocial Factors | Technological Factors |
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Structural/ Societal | • Existing government mobile health programs send out health-related messages on government health days, these include voice and text mobile messages • Potential inclusion of CHoBI7 intervention in the National Operational Plan in Bangladesh • Potential integration of CHoBI7 in existing mobile health programs in Bangladesh | • Government commitment to mobile health as a method to deliver public health information | • Existing government mobile platform has the potential to be used for CHoBI7 intervention delivery at reduced cost • Health Education Bureau in the Ministry of Health and Family Welfare currently develops mobile health messages, and can be potentially engaged for CHoBI7 intervention development |
Community | • High household mobile phone access and ownership in Bangladesh | • Sharing of mHealth messages with neighbors | • High mobile network coverage in Dhaka, Bangladesh |
• Most feature phones available in Bangladesh allow for viewing of Bangla script | |||
Interpersonal | • Females in the households are often the ones responsible for caring for young children • Male household members may not want female household members to receive text and voice messages from an unknown sender | • Female caregivers requesting access to CHoBI7 mHealth messages to allow them to better care for their children | • Text messages allow for sharing with others at a later time • Male household members do not always share mobile messages or their mobile phones with other household members • Timing for mobile message delivery when all household members are present • Adult male household members typically have primary mobile phone ownership in household • Lower female access to mobile phones |
Individual | • Literacy rate of household members • Limited mobile message sharing by those working outside of the home | • Self-efficacy to open text messages, and respond to interactive voice response messages | • Concerns about being charged a fee for viewing or listening to mobile messages |
Habitual | • Frequency of exposure to mobile messages | • Outcome expectancy that following recommendations contained in mobile messages will reduce disease | • Voice and text messages as reminders to perform the promoted water, sanitation, and hygiene behaviors |
CHoBI7 mHealth pilot
Semi-structured interview and group discussions
Results
Bangladesh Government’s use of mobile health
Government stakeholders
Acceptability of mobile phone messages for CHoBI7 program delivery
Government stakeholders
In my country right now 90% of our people are connected with mobile phones. Using mobile phones is a very smart behavior for sharing information and knowledge. My people starting from the very poor to the high [wealthy] people you just give them the message, it is not a big challenge. They will take it.
For generating text messages, funding will be required. Since the funding is not big, if external funding is available, then better. But it is possible to do [this] by the government funding.
Request the Health Education Bureau, they will form the message, taking the participation [of] you and other experts … who [will] prepare this message. And [they] will disseminate this message through [out] the whole country and [the] funding required for this message will be, given from this [National] Operational Plan.
Patient households
Both IVR [voice] and [text] messages are good. Many people can learn from this and by saying this information is from the hospital, we can let other people know about this information as well.
It was really good to get a call after coming from hospital.
Voice of the CHoBI7 program mHealth messages: Dr. Chobi and Aklima
Government stakeholders
Character development
Patient households
I could feel her [Dr. Chobi’s] words from my heart.
Aklima was a patient like me and it is good that she is taking help from Chobi apa [sister] like us … She should promote all this knowledge to others.
Text and voice messages for delivery of CHoBI7 program
Government stakeholders
Patient households
Both voice and text [messages] are good. From calls we can learn and if sometimes we forget, we can see the [text] message or tell others to read them for us. That is why both together are good.
I can show this [text] message to 10 more people.
If the phone [voice message] comes first and the message [text message] comes later this would be good. Then if you cannot remember the content of the call, you can read the message [text message].
I feel so happy when Chobi apa [sister] says-yes! You are right [IVR quiz message response].
CHoBI7 mHealth message delivery and content
Government stakeholders
During their hospital stay they will give 80% of their time to health related issues but in their house they may give 1% of their time …[give] a few messages … what you want to emphasize.
Sending messages out to everyone would be a wastage of money … [this] should be for times like during diarrhea outbreaks and should be areas-based [and] people-based not general.
Patient households
Everybody will see these messages and learn from them. They would then be free from cholera and other diseases.
These are not bad words, and people will be more careful after reading the text message. (Mobile Message 4 in Additional file 1: Table S2).
We always have to be clean to stay away from diseases. Like Dr. Chobi says, we should always wash our hands. We should wash our hands right after cleaning up children after toileting [defecating]. If we do this we would be free from all diseases.
Access to CHoBI7 mHealth messages
Patient households
Chobi apa [sister] taught us. We are Aklima, we will tell other people … They will gain a benefit from this.
The person who is in charge of maintaining the home--you should send [mobile messages] to her.
If you send this information by mobile phone, it would be good, but not everyone will come to know this [information]. Like, I don’t have a mobile phone. Then how would I know that you sent a message? Suppose my husband has a mobile phone and receives and reads those [text] messages but doesn’t tell me anything about them? Don’t we have to know about these [messages]? Of course, we have to know about these messages.
Timing and frequency for CHoBI7 mHealth message delivery
Government stakeholders
Patient households
At night the phone remains with us. We do not go anywhere then, do not remain busy, and the phone remains nearby. If a call comes we can receive it immediately. And if a [text] message comes we can see it. So if [the message] is sent at night it would be good.
We received [text] messages at 5 pm ... We all read those together in the night.
If you don’t send us text messages frequently, we will forget everything within 6 months. So, we will be able to keep them in our mind if you send them frequently.