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)
Authors: Thomas Elizabeth D. , Zohura Fatema , Hasan M. Tasdik , Rana Md. Sohel , Teman Alana , Parvin Tahmina , Masud Jahed , Bhuyian Md. Sazzadul Islam , Hossain Md. Khobair , Hasan Maynul , Tahmina Sanya , Munmun Farzana , Khan Md. Abul Hashem , Monira Shirajum , Sack David A. , Leontsini Elli , Winch Peter J. , Alam Munirul , George Christine Marie 
Published: June 2020

Abstract
Background
During the time a diarrhea patient presents at a health facility, the household members of the patient are at higher risk of developing diarrheal diseases (> 100 times for cholera) than the general population. The Cholera-Hospital-based-Intervention-for-7-Days (CHoBI7) is a health facility-initiated water treatment and handwashing with soap intervention designed to reduce transmission of diarrheal diseases between patients and their household members. The present research aimed to (1) develop a scalable approach to integrate the CHoBI7 intervention program into services provided at government and private health facilities in Bangladesh; and (2) tailor the intervention program for the household members of all diarrhea patients, irrespective of the etiology of disease.

Methods
We conducted 8 months of formative research, including 60 semi-structured interviews, 2 group discussions, and a pilot study. Thirty-two interviews were conducted with diarrhea patients and their family caregivers, government stakeholders, and health care providers both to explore existing WASH and diarrhea patient care practices in health facilities and to identify considerations for scaling the CHoBI7 program. Fifty-two diarrhea patient households participated in a pilot study of a modified version of the CHoBI7 intervention program for tailoring. Twenty-eight interviews and 2 group discussions were conducted with pilot households to explore experiences with and recommendations for intervention delivery.

Results
The intervention program was modified based on formative research findings. 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 1) providing additional pictorial modules, cues to action, enabling technologies, and supplies for safe drinking water and handwashing with soap behaviors in the health facility; 2) switching out technology prone to breaks and leaks as well as sourcing plastic technologies from a high-quality, local manufacturer; and 3) including instructions discouraging the non-use or misuse of technologies and supplies. Considerations for scalability 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.

Conclusions
Formative research identified important considerations for the content, delivery, and scalability of the CHoBI7 health facility-initiated WASH intervention program.