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CARE-Emory Implementation Science Research
Delivery of high quality, at-scale, and sustained services is a major challenge in the water, sanitation, and hygiene (WASH) sector, made more challenging by a dearth of evidence-based models for adaption across contexts in low- and middle-income countries. Implementation science is commonly defined as the study of methods and strategies to promote the uptake of interventions that have proven effective into routine practice, with the aim of improving population health. Implementation research addresses the “know-do” gap: the gap between what we “know” to do and “how” we do in practice. We describe the value of expanding the application of implementation science to environmental health, specifically WASH interventions, as a way to respond to the complexity of sustainable service delivery here.

Emory and CARE have received funds from an anonymous donor over three years to enhance program impact and improve the state of the knowledge for implementation science and research in the fields of the highly interrelated areas of gender equity, economic empowerment, WASH, and nutrition. We will utilize the CARE-Emory Collaboration to provide an interdisciplinary implementation science research-practice community to improve gender equity, economic empowerment, WASH, and nutrition in development programs. This project will align with the vision of the CARE-Emory Collaboration to jointly produce high-impact, policy- and programmatically- relevant applied research and learning to address global challenges to human development for transformative impact at scale. Potential settings for collaboration will fall within CARE’s broader Water+ and water-adjacent portfolio and utilize the interdisciplinary research expertise of the Network for Evaluation and Implementation Sciences at Emory.

PROJECT STAFF (Emory) Jonny Crocker, Emily Ogutu Awino, Jedidiah Snyder, Lilly O’Brien

Publications

1. Haque, Sabrina S., and Matthew C. Freeman. The applications of implementation science in water, sanitation, and hygiene (WASH) research and practice. Environmental health perspectives 129.6 (2021): 065002.

Using Sewage Surveillance as an Early Warning Tool to Monitor the Circulation of SARS-CoV-2 in the Population
SARS-CoV-2 is primarily transmitted via the respiratory tract. However, there is recent evidence that SARS-CoV-2 is also shed in human feces and can be detected in fecal samples and wastewater. The purpose of this study is to collect and test weekly samples of wastewater immediately downstream of Emory University Hospital and wastewater influent from municipal wastewater treatment plants in metro Atlanta, in collaboration with colleagues at Georgia Institute of Technology, and compare trends in SARS-CoV-2 titer over time with number of reported COVID-19 cases in the wastewater catchment areas served by the treatment plants. The results from this study will provide valuable public health information on COVID-19 trends in metro Atlanta and may serve as an early warning system if COVID-19 infections rise as more public venues are opened or if COVID-19 infections re-emerge later in 2020/2021.  This study will enable us to adapt our wastewater analyses methods to detect SARS-CoV-2 in wastewater to determine how well we can use wastewater to monitor COVID-19 prevalence in hospital and community populations.

Development of a Quantitative Personal Hygiene Assessment Tool (qPHAT)                   Personal hygiene practices are believed to represent intermediate behavioral factors along the causal pathways that lead to diseases. Consequently, many public health programs promote the adoption of improved personal hygiene practices for disease prevention and control. In low and middle-income settings, interventions promoting personal hygiene are often undertaken within community-based water, sanitation, and hygiene (WASH) and neglected tropical disease (NTD) programming. Valid, reliable measurement of personal hygiene practices would be useful for monitoring, evaluation, and development of better interventions. However, within the trachoma community, there exists no universally endorsed operational definition of facial cleanliness (or, conversely poor facial hygiene, poor facial “cleanliness”, or “unclean” face) or recommendations for the standardized measurement of F in SAFE programming (e.g., facial and hand hygiene, specific indicators of established F-related risk factors and related measurement metrics).

Using color theory principles, Dr. Matt Freeman and his team of researchers developed and tested a novel metric that generates quantitative measures of facial and hand cleanliness, proxy indicators of personal hygiene practices. The quantitative personal hygiene assessment tool (qPHAT) uses an 11-point color scale to rate the color of a wipe taken from the skin along the face and hand of individuals, which indicates facial and hand cleanliness. We tested this new measurement method in the Amhara region of Ethiopia during our Andilaye Trial, and found that the new way of measuring facial and hand cleanliness is reliable, meaning different people rated the wipes similarly.

PAASIM Study (Freeman Research Group)

See the study’s progress on our Data Collection Dashboard!

Evidence shows that repeated exposures to diarrheal pathogens change the microbiome of a person’s gut. Water supply improvements limit exposure to pathogens via drinking water and improving water access for hand-washing and food hygiene. A five-year, $140 million World Bank-funded project is being implemented in Mozambique to improve piped water supply for over 800,000 people in urban areas.

Emory University and collaborators at the World Bank, University of Washington, University of Nevada-Reno, Georgia Institute of Technology and Mozambican water and health agencies are executing a four-year study to research the ways in which improvements to the water supply affect children’s gut function and impact general pathogen infection. In the PAASIM study (Pesquisa Sobre o Acesso à Água e a Saúde Infantil em Moçambique – Research on Access to Water and Children’s Health in Mozambique), we are testing if and how improvements in water supply in urban areas of Beira, Mozambique reduce or delay enteric pathogen infection, alter gut microbiome composition, and affect enteric dysfunction and other health outcomes in infants.

This study will evaluate the effects of community-level water system improvements on health outcomes in young children. We will test whether improvements in household piped water supplies are effective in controlling child:

• Acute enteric pathogen infections and diarrhea – organisms that cause infection of the gut or intestinal track

• Altered gut microbiome – distresses that can increase susceptibility to enteric infections

• Enteric dysfunction – inflammation and reduced absorptive capacity and function in the small intestines

• Chronic gut dysfunction – conditions preventing development of a healthy gut microbiome

• Growth faltering – slower rate of weight gain that may result from undernutrition from gut dysfunction

With the collection of these data, we will examine how access to household connections and improved water network impacts the gut health of young children, by comparing households with and without improved water access. The results of the project will contribute novel findings to inform Mozambican and global policies on how to optimize water infrastructure investments to improve child health in low-income, urban settings.

*Latest Publications

February 2025
Interventions to improve hand hygiene in community settings: A systematic review of theories, barriers and enablers, behavior change techniques, and hand hygiene station design features
Sridevi K. Prasad, Jedidiah S. Snyder, Erin LaFon, Lilly A. O’Brien, Hannah Rogers, Oliver Cumming, Joanna Esteves Mills, Bruce Gordon, Marlene Wolfe, Matthew C. Freeman, Bethany A. Caruso

Efficacy and effectiveness of hand hygiene-related practices used community settings for removal of organisms from hands: A systematic review
Stephen P Hilton, Nick H. An, Lilly A. O’Brien, Jedidiah S. Snyder, Hannah Rogers, Oliver Cumming, Joanna Esteves Mills, Bruce Gordon, Matthew C. Freeman, Bethany A. Caruso, Marlene K Wolfe

Behavioural factors influencing hand hygiene practices across domestic, institutional, and public community settings: A systematic review
Bethany A. Caruso, Jedidiah S. Snyder, Lilly A. O’Brien, Erin LaFon, Kennedy Files, Dewan Muhammad Shoaib, Sridevi K. Prasad, Hannah Rogers, Oliver Cumming, Joanna Esteves Mills, Bruce Gordon, Marlene K. Wolfe, Matthew C. Freeman

Minimum material requirements for hand hygiene in community settings: A systematic review
Lilly A. O’Brien, Kennedy Files, Jedidiah S. Snyder, Hannah Rogers, Oliver Cumming, Joanna Esteves Mills, Bruce Gordon, Matthew C. Freeman1
Bethany A. Caruso, Marlene K. Wolfe

January 2025
Impact of water, sanitation, and hygiene indicators on enteric viral pathogens among under-5 children in low resource settings
Rina Das, Md. Nasif Hossain, Myron M. Levine, Karen L. Kotloff, Dilruba Nasrin, M. Jahangir Hossain, Richard Omore, Dipika Sur, Tahmeed Ahmed, Robert F. Breiman, A.S.G. Faruque, Matthew C. Freeman

Water, sanitation, handwashing, and nutritional interventions can reduce child antibiotic use: evidence from Bangladesh and Kenya
Ayse Ercumen, Andrew N. Mertens, Zachary Butzin-Dozier, Da Kyung Jung, Shahjahan Ali, Beryl S. Achando, Gouthami Rao, Caitlin Hemlock, Amy J. Pickering, Christine P. Stewart, Sophia T. Tan, Jessica A. Grembi, Jade Benjamin-Chung, Marlene Wolfe, Gene G. Ho, Md. Ziaur Rahman, Charles D. Arnold, Holly N. Dentz, Sammy M. Njenga, Theodora Meerkerk, Belinda Chen, Maya Nadimpalli, et al

Sanitation-related empowerment resources are associated with women’s well-being, anxiety, and depression: findings from Bangladesh, India, Senegal, and Uganda
Thea Mink, Madeleine Patrick, Amelia Conrad, Tanvir Ahmed, Srishty Arun, Vinod Ramanarayanan, Niladri Chakraborti, Y. Malini Reddy, Abhilaasha Nagarajan, Tanushree Bhan, Sheela S. Sinharoy, Bethany A. Caruso

Infection prevention and control and water, sanitation, and hygiene status of healthcare facilities in the Greater Kampala Metropolitan region during the COVID-19 pandemic in Uganda
Richard K. Mugambe ,Rhoda K. Wanyenze, Tonny Ssekamatte, John Bosco Isunju, Aisha Nalugya, Solomon T. Wafula, David Musoke, Hajra Comfort Mukasa, Julie Balen, Habib Yakubu, Christine L. Moe

Strengthening Policy Relevance of Wastewater-Based Surveillance for Antimicrobial Resistance
Sheena Conforti, Amy Pruden, Nicole Acosta, Christopher Anderson, Helmut Buergmann, Juliana Calabria De Araujo, Judith R. Cristobal, Barbara Drigo, Claire Ellison, Zanah Francis, Dominic Frigon, Markus Gaenzle, Julia Vierheilig, Timothy R. Julian, Uli Klümper, Liping MaChand Mangat, Maya Nadimpalli et al

December 2024
Resilience Measurement for Environmental Shocks and Stressors: Scale Development and Validation for Urban Areas in Low- and Middle-Income
Countries
Hemali H. Oza, Allison P. Salinger, Ruzka Taruc, Autiko Tela, Fiona S. Barker, Karin Leder. Matthew C. Freeman, Thomas Clasen, Sheela Sinharoy

Unsafe containment: Public health risks of septic tanks discharging to drains in Dhaka Bangladesh
Freya Mills ,Tim Foster, Christine Moe, Nuhu Amin, Pengbo Liu, Mahbubur Rahman, Barbara Evans, Juliet Willetts

Farm-to-fork changes in poultry microbiomes and resistomes in Maputo City, Mozambique
Natalie Olson, Frederica Lamar, Hermógenes Mucache, José Fafetine, Joaquim Saíde, Amélia Milisse, Denise R. A. Brito, Kelsey J. Jesser, Karen Levy, Matthew C. Freeman, Maya L. Nadimpalli1

November 2024
Anopheles gambiae Re-Emergence and Resurgent Malaria Transmission in Eastern Rwanda, 2010-2020
Ian Hennessee, Alphonse Mutabazi, Dunia Munyakanage, Michee Kabera, Aimable Mbituyumuremyi, Naomi Lucchi, Miles A Kirby, Lance A Waller, Thomas F Clasen, Uriel Kitron, Emmanuel Hakizimana

October 2024
Water, sanitation and hygiene (WASH): the evolution of a global health and development sector
Sara de Wit, Euphrasia Luseka, David Bradley ,Joe Brown, Jayant Bhagwan, Barbara Evans, Matthew C Freeman, Guy Howard, Isha Ray, Ian Ross, Sheillah Simiyu, Oliver Cumming et al

Towards integrated cross-sectoral surveillance of pathogens and antimicrobial resistance: Needs, approaches, and considerations for linking surveillance to action
Rachael Lappan,Steven L. Chown, Matthew French,Laura Perlaza-Jiménez, Thomas Clasen, et al

September 2024
Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area
Tonny Ssekamatte, Richard K. Mugambe, John Bosco Isunju,, Rhoda K. Wanyenze,, Aisha Nalugya, Christine Adyedo,, Solomon T. Wafula,, Esther Buregyeya,, Rebecca Nuwematsiko,, Joann Bateman,, Julie Balen, Lynnette Lusenaka, Habib Yakubu and Christine L. Moe

Research priorities to strengthen environmental cleaning in healthcare facilities: the CLEAN Group Consensus
…Lindsay Denny, Nicholas Feasey, Lisa Hall, Joost Hopman, Laxman Kharal Chettry, Martin Kiernan, Claire Kilpatrick, Shaheen Mehtar, Christine Moe, Stephen Nurse-Findlay, Folasade Ogunsola, Tochi Okwor, Bruno Pascual, Molly Patrick, Oliver Pearse, Alexandra Peters, Didier Pittet, Julie Storr, Sara Tomczyk, Thomas G. Weiser, Habib Yakubu and others

Multilevel factors drive child exposure to enteric pathogens in animal feces: A qualitative study in northwestern coastal Ecuador
April M. Ballard, Betty Corozo Angulo, Nicholas Laramee, Jayden Pace Gallagher, Regine Haardörfer, Matthew C. Freeman, James Trostle, Joseph N. S. Eisenberg, Gwenyth O. Lee, Karen Levy, Bethany A. Caruso

Systemic re-review of WASH trials to assess women’s engagement in intervention delivery and research activities
BA Caruso, AM Ballard, J Sobolik, M Patrick, J Dsouza, SS Sinharoy, O Cummins, J Wolf and I Ray

August 2024
Shared sanitation facilities and risk of respiratory virus transmission in resource-poor settings: A COVID-19 modeling case study
Michael A L Hayashi, Sophia M Simon, Kaiyue Zou, Hannah Van Wyk, Mondal Hasan Zahid, Joseph NS Eisenburg, Matthew C Freeman

Effect of a behavior change and hardware intervention on safe child feces management practices in rural Odisha, India: a cluster-randomized controlled trial
Gloria D. Sclar, Valerie Bauza, Alokananda Bisoyi, Fiona Majorin, Hans-Joachim Mosler & Thomas F. Clasen

July 2024
Assessing the sustained effects of a water filter intervention: a 30-month longitudinal study in Rwamagana, Rwanda
Sabrina S. Haque, Miles A Kirby, Laurien Iyakaremye, Alemayehu Gebremariam, Matthew C Freeman, Howard H Chang and Thomas Clasen 

Municipal Solid Waste Management and Health Risks: Application of Solid Waste Safety Plan in Novi Sad, Serbia
Giovanni Vinti, Bojan Batinić, Valeria Bauza, Thomas Clasen, Terry Tudor, Christian Zurbrügg and Mentore Vaccari

June 2024
Enteric viral pathogens and child growth among under-five children: findings from South Asia and sub-Saharan Africa
R Das, Md A Haque, KL Kotloff, D Nasrin, MJ Hossain, DST Ahmed, MM Levine, RF Breiman, ASG Faruque and MC Freeman

Water, food, and mental well-being: Associations between drinking water course, household water and food insecurity, and mental well-being of low-income, pregnant women in urban Mozambique
Lilly O’Brien, Jedidiah Snyder, Joshua V Garn, Rebecca Kann, Antonio Júnior, Sandy McGunegill, Bacelar Muneme, João Luís Manuel, Rassul Nalá, Karen Levy and Matthew C Freeman

Farm-to-Fork Changes in Poultry Microbiomes and Resistomes in Maputo, Mozambique
N Olson, F Lamar, H Mucache, J Fafetine, J Saide, A Milisse, D Brito, K Levy, MC Freeman, M Nadimpalli

Rainfall and Temperature Influences on Childhood Diarrhea and the Effect Modification Role of Water and Sanitation Conditions: A Systemic Review and Meta Analysis
G Geremew, O Cumming, A Haddis, MC Freeman and A Ambelu

May 2024
Addressing Fecal Contamination in Rural Kenyan Households: the Roles of Environmental Interventions and Animal Ownership
JM Swarthout, M Mureithi, J Mboya, BF Arnold, MK Wolfe, HN Dentz, A Lin, CD Arnold, G Rao, CP Stewart, T Clasen, JM Colfold, C Null, AJ Pickering

A narrative review of norovirus epidemiology, biology and challenges to vaccine development
KB Carlson, A Dilley, T O’Grady, JA Johnson, B Lopman and E Viscidi

April 2024
Correlation of SARS-CoV-2 in Wastewater and Individual Testing Results in a Jail, Atlanta, Georgia, USA
ALB Saber, SS Kennedy, Y Yang, KN Moore, Y Wang, S Hilton, TY Chang, P Liu, VL Phillips, MJ Akiyama, CL Moe and A Spaulding

The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation and hygiene interventions: a scoping review
Jonny Crocker, Emily Ogutu, Jedidiah Snyder and Matthew Freeman

March 2024
A mechanistic modeling approach to assessing the sensitivity of outcomes of water, sanitation, and hygiene interventions to local contexts and intervention factors
Andrew F. Brouwer, Alicia N.M. Kraay, Mondal H. Zahid, Marisa C. Eisenberg, Matthew C. Freeman, Joseph N.S. Eisenberg

February 2024
Is detection of enteropathogens and human or animal faecal markers in the environment associated with subsequent child enteric infections and growth: an individual participant data meta-analysis
Andrew Mertens, Benjamin F Arnold, Jade Benjamin-Chung, Alexandria B Boehm, Joe Brown, Drew Capone, Thomas Clasen, Erica R Fuhrmeister, Jessica A Grembi, David Holcomb,et al

Surveillance via wastewater monitoring and nasal self-collection of specimens (The SWANSS Study): A CFIR-informed qualitative study with key carceral and healthcare stakeholders
Kyler N Moore, Patrick M Bircher, Emily A Ogutu, Shanika S Kennedy, Victoria M Brown, Matthew C. Freeman, Victoria L Phillips, Anne C. Spaulding

*Names in bold indicate CGSW Core Faculty and Fellows