Dialing in Prevention of Childhood Stunting and Diarrhea in Low-Income Countries Free

(See the Major Article by George et al on pages e2560–8.)

“My son was very sick; he almost died. Dr Chobi told me about washing my hands at 4 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!”

- scripted message from Akima, a mother character in the CHoBI7 mHealth program

In this issue of Clinical Infectious Diseases, Dr Christine Marie George, Dr Munirul Alam, and colleagues present intriguing findings on the impact of a mobile health program—the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7, an acronym derived from the Bangla word for picture, chobi)—on rates of childhood diarrhea and stunting in urban slums in Dhaka, Bangladesh [1]. Using a randomized control trial study design, they recruited households of young children where: (1) a family member was recently hospitalized for diarrhea, (2) no basin for running water was present, and (3) a working mobile phone and electricity were readily available. Households were randomized to 1 of 3 groups: standard counseling prior to discharge from the healthcare facility on the use of oral rehydration therapy (ORT), CHoBI7 plus mHealth (with no home visits), or CHoBI7 plus mHealth with 2 home visits. CHoBI7 targeted behaviors surrounding preparation and use of hand soap, chlorination, and safe storage of home drinking water during the high-risk period following discharge home from the hospital, and boiling of drinking water thereafter. Two mHealth characters, Dr Chobi, a local doctor, and Akima, a mother who brought her child to the hospital for diarrhea, sent weekly voice and text reminders to participants to reinforce CHOBI7 messaging. In the primary outcome, children <5 years of age whose households received the CHoB17 interventions had lower diarrhea burdens, regardless of whether home visits were performed. Second, children <2 years of age in CHoB17 households were less likely to be stunted. Improvements in diarrhea and nutritional status were accompanied by higher water quality in CHoBI7 households.

These important findings offer a number of timely lessons for clinicians and public health practitioners across low-, middle-, and high-income settings. First, by investing in the development and validation of culturally competent behavioral interventions, patients can be empowered to care for themselves and their households. Second, behavioral interventions delivered in healthcare settings can scale to the community level using mHealth to produce sustained change in behaviors cost-effectively. Given the typical guidance provided by clinicians to caregivers of children recovering from infectious diarrhea, and the authors’ prior successes in applying CHoBI7 to reduce cholera and increase handwashing behaviors [2, 3], we were surprised to see that control households received messaging only addressing ORT and not diarrhea prevention. Now that these investigators have demonstrated the benefits of CHoBI7 plus mHealth in combination, the next informative step might be to test CHoBI7 messaging at discharge, with or without the addition of mHealth and home visit components, to untangle the additional benefits of each.

As acknowledged by the authors, establishing the generalizability of their findings to other settings will be critical. Mobile technologies are revolutionizing the reach of medicine and public health, however persistent inequities across rural/urban, income, literacy, and stigma divides may further exacerbate disparities [4]. In Bangladesh, mobile phone owners are predominantly men between the ages of 19 and 26 years [5], raising potential concerns for rural settings, where women’s access to mHealth may be more limited. In this trial, enrollment was understandably limited to households with reliable mobile phones and charging. Households without these lifelines are likely at greater risk of diarrhea and undernutrition. Shades of this dynamic are currently on display in high- and middle-income countries where social distancing efforts surrounding coronavirus disease 2019 (COVID-19) control have thrust patients and physicians headfirst into telemedicine. Unacceptably, rural and/or poor patients with limited access to mobile phones, computers, and broadband internet service have been unable to connect with their providers to receive telemedicine care for acute and chronic conditions [6].

mHealth, like all communication, is more powerful when it is bidirectional. Increased access to low cost smart phones, with camera, wireless, and global positioning system (GPS) capabilities, and universal wireless internet is coming to low- and middle-income countries. With proper attention to profoundly important ethical and privacy issues, data science could transform mHealth into a dynamic dialogue between households and hospitals in ways that accelerate progress toward the Sustainable Development Goals.

Imagine the possibilities. Prior to a child’s discharge home following hospitalization for diarrhea or pneumonia, a household’s smartphone is linked to the electronic medical record to allow home monitoring of vital signs and symptoms. In high-income settings, smart devices now allow for babies with complex congenital heart disease and prematurity to return home sooner, with remote monitoring and quick communication with nurses and physicians should the need arise [7]. In settings with high burdens of childhood diarrhea and stunting, a household’s smartphone could provide digital images of handwashing stations, water storage units, and latrines, providing data on water, sanitation, and hygiene (WASH) infrastructure and enhancing messages to reinforce WASH behaviors. Counterintuitive results from the WASH benefits and sanitation, hygiene, infant nutritional efficacy project (SHINE) trials showed household-level elementary WASH interventions in rural low-income settings are unlikely to reduce stunting or anemia and might not reduce diarrhea [8]. This has led to calls for transformative WASH, tailored to address the local exposure landscape and enteric disease burden [9]. Herein lies the opportunity for integrating existing technologies to transform outcomes.

Digital images of household meals could be analyzed by computer vision and artificial intelligence to remotely estimate household food security and shape complementary feeding behaviors during weaning and episodes of diarrhea. The smartphone’s GPS could empower earlier detection of diarrhea outbreaks leading to quicker control. Incorporating technologies with input from creative, local, out-of-the-box input from disciplines such as marketing will be essential to realizing mHealth’s full potential. Use of social media or phone-enabled virtual communities can be further leveraged to engineer behavioral changes [10, 11]. Any of these future scenarios would simultaneously be triumphs for mHealth and an indictment of our continued collective failure to provide clean water and basic nutrition to the poorest of the poor around the world [12]. Nonetheless, the advances of George, Alam, and colleagues are commendable steps forward in the right direction of mHealth-empowered health promotion and disease prevention for a brighter future for children in high-risk settings.

Note

Potential conflicts of interest. The authors: No reported conflicts of interest. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

References