27 Feb
2023

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Cell Phone App Helps Battle Cholera: Research shows hope for reducing infection

By Hugh Markey

Even as the world seems to be recovering from several years of battling COVID, there is another disease that has been quietly killing people for decades. Like COVID, cholera treatment relies on medicines and an educational campaign. But for people in rural parts of the world, receiving vital information about cholera hot spots can be nearly impossible.

Prof. Ali Akanda and his team have just completed a one-year trial of a cell phone app that is designed to provide non-technical, actionable information about potential spikes in infection rates to people living in remote areas in Bangladesh. Thus far, Akanda is pleased with the results.

Cholera is a serious illness caused by consumption of food or water containing Vibrio cholera bacteria. The current pandemic has been around since 1963 when it came from Indonesia, and it has spread throughout many different countries in Africa and Asia. According to the Center for Disease Control, an estimated 1.3 to 4 million people around the world get cholera each year and 21,000 to 143,000 people die from it.

Akanda has spent over a decade researching the origins of infection and methods to prevent it. “When I started looking at the outbreaks, my first observation was that cholera comes in two waves: one in spring when there is little water, and one in fall after the monsoon season when there is a lot of water. And as a hydrologist by training, I started thinking, how was it related with the water situation on the ground?” He began to see that drought conditions produced more sharing of the limited water supply:  people bathing in the water, watering their livestock, and eating and drinking. Later, heavy rains of monsoon season meant that concentrated areas of infection became more widespread, as the rains washed the contaminated waters into new locations.

Addressing the source of the infection

He began to assemble data to determine the correlation between these two water events and infection rates. Hospitals in Bangladesh were already in the habit of keeping records of infection, and eventually Akanda was able to obtain vital, up to date information about water levels using NASA satellites. The satellite database models assembled information covering large landscape areas daily, and his team was able to generate weekly risk maps that were updated every month, giving users the chance to prepare for likely infection rates that were developing.

The process continued until 2020, but Akanda felt there was more that could be done with the information his team was assembling. Until then, his main audiences were the government public health offices, his partners in Bangladesh, and some research institutions in that part of the world. It was a group well versed in interpreting data, but Akanda felt the information was not reaching the people who were might benefit from it: those living in rural communities.

“The grassroots people who are actually contracting cholera are living through the water scarcity or flooding day to day were not really getting our information directly. They were getting it through these other institutions, which are trying to help but were not really conveying information the way we thought it should. We wanted to change this information chain from top down,” Akanda said. At that point, he and his team began to create a more direct method of reaching the far-flung villages of Bangladesh: a cell phone app.

Choleramap

With the help of his partners, Akanda found that, while many locations were too isolated to have access to land lines, villagers often had smart phones.  “They are not very tech savvy users, but they can use their phone, they can look at the maps, they can look at the apps. So if the information can be delivered through an app in an intelligent way, perhaps it will work. And that’s what we tried to do in this project.”

Akanda knew that just having the information available would not be enough to make the app useful. It would need interesting graphics that would appeal to users and encourage them to look for the specially colored maps that told them which areas were at high risk for cholera infection.

Outbreaks and Culture Clashes

Just as the group began creating the app, COVID stepped in to shut the operation down. Yet in July 2020, while much of the world was still shut down, Akanda managed to get a flight to see his mother in Bangladesh. He already knew that using smart phones purchased in the US would not allow him to test the app the way he needed. It would take purchasing a product common to Bangladeshis. “I visited my mother and later bought a bunch of cheap Chinese smartphones that I knew that people in the villages would use. They cost less than $70, really the bare bones models. I came back after seeing my mother and we started building the app.”

Akanda had the help of colleagues in Bangladesh who conducted extensive research as much on the culture as the science. He used the information to develop things such as which map colors were most likely to spark interaction. The local researchers conducted multiple interviews with over a thousand village women as app components were created and refined. “They would show graphics to this village women asked them what they understood from the graphics. Does it really make sense to you? Can you read this? Can you understand what this map means? We kept doing these iterations with these village women every week.”

The interview process revealed that the team was dealing with more than a simple question of how comprehensible the graphics were. To make the app most likely to be used, they would have to understand the culture of their potential users. “We found that it is mostly the women who came forward and agreed to install the app. We don’t really have an explanation for that, but I think our  understanding is that the women are in charge of household: the safety of the kids, safety of the water and food. And that’s why they were more convinced by the information that we were willing to provide. In the end, we found out that about 70% of our users were women. That was a very eye opening and pleasant finding for us.” That knowledge guided them to do such things as have artists create an animation of a woman on the main page of the app. They would adjust the character’s facial expression to reflect the level of concern “she” had for various villages.

Whose phone is it, anyway?

The team found that a majority of households had inexpensive cell phones. The only problem was that in many cases the phone belonged to “…the man of the house. In some cases the man didn’t really want anyone to install the app because they were skeptical about what the app would really do, and whether it would consume too much data; things like that. In many houses, we were turned back because the man basically made the decision on the app and he did not want to install it. We had many experiences that were eye opening for us.

“But at the end, we were very happy that we were able to enroll 1500 households: 750 for a control app and 750 with an app with the very interactive maps.”

The Test

Akanda decided to conduct a one-year trial of the app. Villagers received updates on whether they should boil their water before using it, along with tips on proper sanitation and hygiene.  “The more people are exposed to the environmental water, meaning ponds and rivers and streams, the more they are likely exposed to the bacteria because it is naturally present in the ecosystem.” His URI students maintained daily data collections to keep the outbreak predictions as accurate as possible. The trial period just recently ended, and Akanda is happy with the results.

“We found that our app was able to reduce that environmental water usage by 37%. What that means is that at times of high risk, we found that fewer people were using natural water sources like the ponds, rivers, and streams. Users were more likely to safeguard themselves from exposure to the bacteria. That was one of the main goals of the app, and we found that it was definitely working.”

Akanda recognizes the many contributions that helped the project become a success. “Without the help of my collaborators on this project and on the ground in Bangladesh, none of this would have been possible, especially in getting this rolling in within the pandemic.” He credits funding to a consortium from NASA, along with a Washington, D.C. group called Resources for Future Foundation (RFF). The consortium aided in funding through a new program called G.A.B.S., Grants for Assessing the Benefits of Satellites.

The next phase of testing will include introducing the app to more villages. Akanda says that more information will need to be collected, since more villages have different hydrologic regions. He also wants to see whether the technology can be deployed on a much larger scale. “Similar water problems exist in many South Asian countries and more so in Sub Saharan Africa. There are so many countries that have water scarcity and water contamination problems.

“There is a tremendous opportunity where this could be expanded: big population growth and climate change will happen. We feel that we need to reach those affected populations where there will be some usage for this kind of app.”