Leading and Learning in wash
Leading and Learning in wash
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
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.
September 2025
The association between women’s decision-making roles in sanitation and mental well-being in urban Bangladesh
Nicole Stephan, Sheela S. Sinharoy, Rachel Waford, Madeleine Patrick, Thea Mink, Tanushree Bhan, Tanvir Ahmed, Alauddin Ahmed, Bethany A. Caruso
Risk prediction of healthcare-associated neonatal sepsis in Amhara, Ethiopia: A prospective cohort study
Nadine Najjar, Abebe Gebremariam Gobezayehu, , Joseph Hopkins, Heran Biza , Habib Yakubu, Lindsay Denny, Mulusew Lijalem, Lamesgin Alamineh Endalamaw, Yakob S. Ahmed, Taye Zeru Tadege, Mekuanint Wasihun Endalew, Yichalal Endayehu Tafere, Gurmesa Tura Debelew, Erin Stone, Christine L. Moe, John N. Cranmer
August 2025
Faecal exposure in cholera hotspots: Sanipath exposure assessment in informal settlements of Nairobi, Kenya
Cecilia Mbae, Kelvin Kering, Michael Mugo, Habib Yakubu, Yuke Wang, Susan Kavai, RonaldNgetich, Sheillah Mundalo, Diana Imoli, Christine Kioko, Collins Kebenei, Zillah Wakio, Beatrice Ongadi, Evans Kibet, Darius OwegiIdeke, Aniruddha Deshpande, Sarah Durry, Pengbo Liu, Christine L. Moe, Samuel Kariuki
Variation in Severity of Symptoms Associated With Two Snow Mountain Virus Inocula
Hongyan Qu, Nadine Rouphael, Mark Mulligan, Yuke Wang, Orlando Sablon, Christine L. Moe, Pengbo Liu
Current international tools and guidance for the implementation of hand hygiene recommendations in community settings: a scoping review
Clara MacLeod, Joanna Esteves Mills, Bethany A. Caruso, Claire Chase, Kondwani Chidziwisano, Jenala Chipungu, Robert Dreibelbis, Regina Ejemot-Nwadiaro, Bruce Gordon, Ann Thomas, Oliver Cumming, Laura Braun
July 2025
Process Limit of Detection for Salmonella Typhi, Vibrio cholerae, Rotavirus, and SARS-CoV-2 in Surface Water and Wastewater
Pengbo Liu, Orlando Sablon, Anh Nguyen, Audrey Long, Christine Moe
Resilience measurement for environmental shocks and stressors: scale development and psychometric assessment for coastal urban informal settlements in Fiji and Indonesia
Hemali H. Oza, Allison P. Salinger, Ruzka Taruc, Autiko Tela , S. Fiona Barker , Karin Leder, Matthew C. Freeman, Thomas Clasen, and Sheela S. Sinharoy
The Impact of Urban Water Supply Improvements on Infant Enteric Pathogen Infection, Diarrhea, and Growth: Results from the PAASIM Matched Cohort Study
Matthew Freeman, Courtney Victor, Joshua Garn, Rebecca Kann, Christine Fagnant-Sperati, Erin Kowalsky, João Manuel, Magalhães Mangamela, Sandy McGunegill, Molly Miller-Petrie, Jedidiah Snyder, Thomas Clasen, Konstantinos Konstantinidis, Joe Brown, Rassul Nalá, Karen Levy
June 2025
Integrating wastewater surveillance and meteorological data to monitor seasonal variability of enteric and respiratory pathogens for infectious disease control in Dhaka city
Farjana Jahan, Mizanul Islam Nasim, Yuke Wang, Sk Md Kamrul Bashar, Rezaul Hasan, Afroza Jannat Suchana, Nuhu Amin, Rehnuma Haque, Md Abul Hares, Akash Saha, Mohammad Enayet Hossain, Mohammed Ziaur Rahman, Megan Diamond, Suraja Raj, Stephen Patrick Hilton, Pengbo Liu, Christine Moe, Mahbubur Rahman
Quantitative multi-pathway assessment of exposure to Escherichia coli for infants in Rural Ethiopia
Yuke Wang, Yang Yang, Crystal M. Slanzi, Xiaolong Li, Amanda Ojeda, Fevi Paro, Loïc Deblais, Habib Yakubu, Bahar Mummed Hassen, Halengo Game, Kedir Teji Roba, Elizabeth Schieber, Abdulmuen Mohammed Ibrahim, Jeylan Wolyie, Jemal Yusuf Hassen, Gireesh Rajashekara, Sarah L. McKune, Arie H. Havelaar, Christine L. Moe, Song Liang
Association between heavy menstrual bleeding and depression among women in South Asia: a cross-sectional study
Isabel Charles, Madeleine Patrick, Thea Mink, Tanvir Ahmed, Y. Malini Reddy, Marisa R. Young, Rachel Waford, Bethany A. Caruso, Sheela S. Sinharoy
Sanitation-related withholding and suppression among women in urban Uganda and India
Elaina Sinclair , Anke Hüls, Madeleine Patrick , Srishty Arun, Vinod Ramanarayanan, Sheela S. Sinharoy & Bethany A. Caruso
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
May 2025
Knowledge, attitudes, and support of women’s menstrual experiences: A cross-sectional survey of men in Kampala, Uganda
Madeleine Patrick, Nicole Stephan, Thea Mink, Tanushree Bhan, Barbera Mary Aine, Nabutuwa Viola Matanda, Amelia Conrad, Sheela S. Sinharoy, Bethany A. Caruso
If we have water, we have money”: A qualitative investigation of the role of water in women’s economic engagement in Guatemala, Honduras, Kenya, and Zimbabwe
Emily Ogutu, Sheela S. Sinharoy, Madeleine Patrick, Thea Mink, Alicia Macler, Loice Mbogo, Olivia Bendit, Ingrid Lustig, Jazmina Nohemí Irías, Sandra Antonio, Gladys Ramos, Alma Juarez, Carlos Daniel Sic, Erick Calderón, Héctor Salvador Peña Ramírez, Jorge Lemus, Everlyne Atandi, Peter Mwangi, Paul Ruto, Rohin Otieno Onyango, Gilbert Mushangari, Jammaine Jimu, Morris Chidavaenzi, Makaita Maworera, Nobuhle Dungeni Mlotshwa, Sithandekile Maphosa, Munyaradzi Damson, Bethany A.Caruso
Women’s Health and Empowerment for Sustainable Development: Linking Sanitation Burden and Agency in Asia and Africa
Tanushree Bhan, Bethany A. Caruso, Sheela S. Sinharoy
April 2025
Correlation of SARS-CoV-2 in Wastewater and Individual Testing Results in a Jail, Atlanta, Georgia, USA
Lindsay B Saber, Shanika S Kennedy, Yixin Yang, Kyler N Moore, Yuke Wang, Stephen P Hilton, Tylis Y Chang, Pengbo Liu, Victoria L Phillips, Matthew J Akiyama, Christine L Moe, Anne C Spaulding 1,
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 and Matthew J. Akiyama
Pre Print: Urban water network upgrades improve quality and access to drinking water in the PAASIM matched cohort study in Beira, Mozambique
Courtney Victor ,Joshua Garn, Rassul Nalá, João Manuel, Magalhães Mangamela, Sandra McGunegill, Jedidiah Snyder, Sydney Hubbard, Christine Fagnant-Sperati, Joe Brown, Thomas Clasen, Konstantinos Konstantinidis, Elizabeth Rogawski McQuade, Lance Waller, Karen Levy, Matthew Freeman
Systems thinking for hygiene in settings with high risk of infectious disease transmission
Matthew C. Freeman, Jonny Crocker, Jenala Chipungu, Jay Bagwan, Michel Dione, Robert Dreibelbis, Maria Corazon Dumlao, ASG Faruque, Meriel Flint-O’Kane, Om Prasad Gautam, Ndeye Aissatou Lakhe, Richard Muga, Arundati Muralidharan, Idrissa Ndiaye & Moussa Sarr
March 2025
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 N. S. Eisenberg, Matthew C. Freeman
February 2025
Effectiveness of measures taken by governments to support hand hygiene in community settings: A systematic review
Jedidiah S. Snyder, Erika Canda, Jordan C. Honeycutt, Lilly A. O’Brien, Hannah K. Rogers, Oliver Cumming, Joanna Esteves Mills, Bruce Gordon, Marlene K. Wolfe, Bethany A. Caruso, Matthew C. Freeman
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
Differential Effectiveness of Water, Sanitation, and Handwashing Interventions to Reduce Child Diarrhea in Dry and Rainy Seasons: A Systematic Review and Meta-Analysis of Intervention Trials
Sydney Hubbard, Jennyfer Wolf, Hemali H. Oza, Benjamin F. Arnold, Matthew C. Freeman, and Karen Levy
A critical review on measurement tools of urban household and community resilience to disasters and environmental shocks and stressors among low- and middle-income countries: Theory, application, and guidance
Hemali H. Oza, Anuj Nanavati, Thomas Clasen, Allison P. Salinger, Matthew C. Freeman, Sheela S. Sinharoy
Leveraging seasonal dynamics to identify the strength of disease transmission along multiple environmental pathways
Kayoko Shioda, Miwa Watanabe, Matthew Freeman, Karen Levy, Andrew Brouwer
Variation in exposure in neighborhoods of Dhaka, Bangladesh across different environmental pathways: The influence of human behavior on fecal exposure in urban environments
Nuhu Amin, Suraja Raj, Jamie Green, Shahjahan Ali, Sabrina Haque, Yuke Wang, Wolfgang Mairinger, Tanvir Ahmed, George Joseph, Mahbubur Rahman, Christine L. Moe
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
Gender equality and quality of life must be central to the design and delivery of sanitation
Emory/CGSW authors: Kelly T Alexander, Bethany A Caruso, Sheela S. Sinharoy, et al
Accumulation of microbial hazards and assessment of food hygiene associated with broiler chicken processing at open air food markets in Maputo, Mozambique
Frederica Lamar, Amélia Mondlane-Milisse, Denise R.A. Brito, Hermógenes N. Mucache, Kelsey J. Jesser, Christine S. Fagnant-Sperati, Courtney Victor, Kayoko Shioda , José M. Fafetinec, Joaquim Ângelo Osvaldo Saíde, Eric M. Fèvre, Mia Catharine Mattioli , Karen Levy , Matthew C. Freeman
Wastewater for public health: timely, sensitive, and reliable SARS-CoV-2 omicron variant monitoring in California
Burnor , A. T. Yu , M. K. Wolfe , R. S. Kantor†, T. M. León, S. Ravuri, M. S. Rane, M. V. Panditrao, C. Naughton, A. Rabe S. Harris-Lovett ,,et al
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, Marlene Wolfe, Maya Nadimpalli, et al
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
*Names in bold indicate CGSW Core Faculty and Fellows