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Kihagi GW, Hansen LS, Agure E, Muok EMO, Mank I, Danquah I, Sorgho R. 'Counselling is not just providing information': perceptions of caregivers and stakeholders on the design of nutrition and health counselling interventions for families with young children in rural Kenya. BMC Health Serv Res 2024; 24:597. [PMID: 38715044 PMCID: PMC11077832 DOI: 10.1186/s12913-024-10872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 03/14/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Globally, a fifth of the children continue to face chronic undernutrition with a majority of them situated in the Low- and Middle-Income Countries (LMIC). The rising numbers are attributed to aggravating factors like limited nutrition knowledge, poor feeding practices, seasonal food insecurity, and diseases. Interventions targeting behaviour change may reduce the devastating nutrition situation of children in the LMICs. OBJECTIVE For the co-design of a Behaviour Change Communication (BCC) intervention for young children in rural Kenya, we aimed to identify the experiences, barriers, facilitators, and preferences of caregivers and stakeholders regarding nutrition and health counselling. DESIGN We employed a qualitative study design and used a semi-structured interview guide. The in-depth interviews were recorded, transcribed, and analysed using content analysis, facilitated by the software NVivo. SETTING Health and Demographic Surveillance System (HDSS) area in Siaya County, rural Kenya. PARTICIPANTS We interviewed 30 caregivers of children between 6 and 23 months of age and 29 local stakeholders with experience in implementing nutrition projects in Kenya. RESULTS Nutrition and health counselling (NHC) was usually conducted in hospital settings with groups of mothers. Barriers to counselling were long queues and delays, long distances and high travel costs, the inapplicability of the counselling content, lack of spousal support, and a high domestic workload. Facilitators included the trust of caregivers in Community Health Volunteers (CHVs) and counselling services offered free of charge. Preferences comprised (1) delivering of counselling by CHVs, (2) offering individual and group counselling, (3) targeting male and female caregivers. CONCLUSION There is a disconnect between the caregivers' preferences and the services currently offered. Among these families, a successful BCC strategy that employs nutrition and health counselling should apply a community-based communication channel through trusted CHVs, addressing male and female caregivers, and comprising group and individual sessions.
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Affiliation(s)
- Grace Wothaya Kihagi
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.
| | - Lea-Sophie Hansen
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Erick Agure
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | | | - Isabel Mank
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- German Institute for Development Evaluation (DEval), Bonn, Germany
| | - Ina Danquah
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Hertz-Chair Innovation for Planetary Health and Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Raissa Sorgho
- Heidelberg Institute for Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Centre for Wellness and Nutrition, Public Health Institute, Sacramento, CA, USA
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Sensoy Bahar O, Nabunya P, Namuwonge F, Samtani S, Ssentumbwe V, Namuli F, Magorokosho N, Ssewamala FM. "It gives you a road map of what to do to solve your problems": acceptability of a combination HIV prevention intervention among adolescent girls in Uganda. BMC Public Health 2023; 23:249. [PMID: 36747149 PMCID: PMC9901100 DOI: 10.1186/s12889-023-15083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The HIV burden remains a critical public health concern and adolescent girls are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high HIV prevalence among adolescent girls and young women. Yet, both evidence-based HIV prevention interventions and their acceptability among adolescent girls have not been widely studied. In this study, we examined the acceptability of the Suubi4Her intervention, an evidence-based combination intervention aimed at reducing HIV risk among adolescent girls in Uganda. METHODS We conducted semi-structured in-depth interviews with 25 adolescent girls upon intervention completion to explore their experiences with the Suubi4Her intervention that was tested in a clinical trial in Uganda (2017-2023). Specifically, we explored their decision-making process for participating in the intervention, experiences with program attendance, and their feedback on specific intervention characteristics. Informed by the Theoretical Framework of Acceptability, the data were analyzed using thematic analysis. RESULTS The main motivation for participation was access to health-related information, including information on STIs, HIV, and pregnancy as well as information on banking, saving, and income-generating activities. Though many participants did not have any initial concerns, mistrust of programs, initial paperwork, caregiver's ability to commit time, concerns about ability to save, and HIV/STI and pregnancy testing were raised by some participants. Facilitators to session attendance included motivation to learn information, caregiver commitment, reminder calls, and incentives received for participation. The main challenges included household responsibilities and obligations, difficulty raising transport money, and weather challenges. Adolescent girls appreciated the group format and found the location and times of the sessions convenient. They also found the content relevant to their needs and noted positive changes in their families. CONCLUSIONS The results showed high intervention acceptability among adolescent girls. These findings have important programmatic and policy implications in Uganda, especially given the higher HIV prevalence among adolescent girls in the country. TRIAL REGISTRATION NCT03307226 (Registered: 10/11/17).
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Affiliation(s)
- Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Flavia Namuwonge
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Satabdi Samtani
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Vicent Ssentumbwe
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Florence Namuli
- International Center for Child Health and Development Field Office, Masaka, Uganda
| | - Natasja Magorokosho
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
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Sensoy Bahar O, Boateng A, Nartey PB, Ibrahim A, Kumbelim K, Nabunya P, Ssewamala FM, McKay MM. " ANZANSI Program Taught Me Many Things in Life": Families' Experiences with a Combination Intervention to Prevent Adolescent Girls' Unaccompanied Migration for Labor. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13168. [PMID: 36293748 PMCID: PMC9603225 DOI: 10.3390/ijerph192013168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
Approximately 160 million children work as child laborers globally, 39% of whom are female. Ghana is one of the countries with the highest rates of child labor. Child labor has serious health, mental health, and educational consequences, and those who migrate independently for child labor are even at higher risk. Yet, evidence-based efforts to prevent unaccompanied child migration are limited. In this study, we examined the acceptability of a family-level intervention, called ANZANSI (resilience in local language) combining two evidence-based interventions, a family economic empowerment intervention and a multiple family group family strengthening intervention, to reduce the risk factors associated with the independent migration of adolescent girls from the Northern region to big cities in Ghana. We conducted semi-structured interviews separately with 20 adolescent girls and their caregivers who participated in ANZANSI. Interviews were conducted in the local language and transcribed and translated verbatim. Informed by the theoretical framework of acceptability, the data were analyzed using thematic analysis. The results showed high intervention acceptability among both adolescent girls and their caregivers, including low burden, positive affective attitude, high perceived effectiveness, low opportunity costs, and high self-efficacy. The study findings underline the high need for such interventions in low-resource contexts in Ghana and provide the foundation for testing this intervention in a larger randomized trial.
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Affiliation(s)
- Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130, USA; (P.B.N.); (P.N.); (F.M.S.)
| | - Alice Boateng
- Department of Social Work, University of Ghana, Accra P.O. Box LG419, Ghana;
| | - Portia B. Nartey
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130, USA; (P.B.N.); (P.N.); (F.M.S.)
| | - Abdallah Ibrahim
- School of Public Health, University of Ghana, Accra P.O. Box LG419, Ghana;
| | | | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130, USA; (P.B.N.); (P.N.); (F.M.S.)
| | - Fred M. Ssewamala
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130, USA; (P.B.N.); (P.N.); (F.M.S.)
| | - Mary M. McKay
- Vice Provost Office, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130, USA;
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Jahir T, Winch PJ, Leontsini E, Hwang ST, Yeasmin F, Hossain K, Das JB, Amin R, Nurul Huda TM, Sultana J, Khan R, Akter F, Shoab AKM, Hasan R, Pitchik HO, Tofail F, Fernald LCH, Luby SP, Rahman M. Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157891. [PMID: 34360185 PMCID: PMC8345337 DOI: 10.3390/ijerph18157891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022]
Abstract
Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.
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Affiliation(s)
- Tania Jahir
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
- Correspondence: ; Tel.: +880-1819140900
| | - Peter J. Winch
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Elli Leontsini
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Sharon T. Hwang
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Farzana Yeasmin
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Khobair Hossain
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Jyoti Bhushan Das
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Ruhul Amin
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Tarique Md. Nurul Huda
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Jesmin Sultana
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Rizwana Khan
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Fahmida Akter
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - AKM Shoab
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Rezaul Hasan
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Helen O. Pitchik
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh;
| | - Lia C. H. Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
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Pitchik HO, Tofail F, Rahman M, Akter F, Sultana J, Shoab AK, Huda TMN, Jahir T, Amin MR, Hossain MK, Das JB, Chung EO, Byrd KA, Yeasmin F, Kwong LH, Forsyth JE, Mridha MK, Winch PJ, Luby SP, Fernald LC. A holistic approach to promoting early child development: a cluster randomised trial of a group-based, multicomponent intervention in rural Bangladesh. BMJ Glob Health 2021; 6:bmjgh-2020-004307. [PMID: 33727278 PMCID: PMC7970287 DOI: 10.1136/bmjgh-2020-004307] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/13/2021] [Accepted: 02/10/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction In low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention. Methods We conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions (‘group’); alternating groups and home visits (‘combined’); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers. Results In July–August 2017, 621 pregnant women and primary caregivers of children<15 months were enrolled (group n=160, combined n=160, control n=301). At endline, immediately following intervention completion (July–August 2018), 574 participants were assessed (group n=144, combined n=149, control n=281). Primary caregivers in both intervention arms participated in more play activities than control caregivers (age-adjusted means: group 4.22, 95% CI 3.97 to 4.47; combined 4.77, 4.60 to 4.96; control 3.24, 3.05 to 3.39), and provided a larger variety of play materials (age-adjusted means: group 3.63, 3.31 to 3.96; combined 3.81, 3.62 to 3.99; control 2.48, 2.34 to 2.59). Compared with the control arm, children in the group arm had higher total ASQi scores (adjusted mean difference in standardised scores: 0.39, 0.15 to 0.64), while in the combined arm scores were not significantly different from the control (0.25, –0.07 to 0.54). Conclusion Our findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale. Trial registration number The trial is registered in ISRCTN (ISRCTN16001234).
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Affiliation(s)
- Helen O Pitchik
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Mahbubur Rahman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Fahmida Akter
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Jesmin Sultana
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Abul Kasham Shoab
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Tarique Md Nurul Huda
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Tania Jahir
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Md Ruhul Amin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Md Khobair Hossain
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Jyoti Bhushan Das
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Esther O Chung
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Farzana Yeasmin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Laura H Kwong
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
| | - Jenna E Forsyth
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
| | - Malay K Mridha
- Center for Non-communicable Diseases and Nutrition, BRAC James P Grant School of Public Health, BRAC University, Dhaka, Dhaka District, Bangladesh
| | - Peter J Winch
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
| | - Lia Ch Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA
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