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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


  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

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

January 2024
Pathways of Exposure to Vibrio Cholerae in an Urban Informal Settlement in Nairobi, Kenya.
Kevin Kering, Yuke Wang,  Cecila Mbae, MIchael Muba, Habib Yakubu, Pengbo Liu, Sarah Durry, Christine Moe, et al

December 2023
Women in research: A systematic re-review of WASH interventions to prevent diarrhea and acute respiratory infection in low and middle-income countries
Bethany Caruso, April Ballard, Julia Sobolik, Madeleine Patrick, Janice Dsouza, Sheela Sinharoy, Oliver Cumming, Jennyfer Wolf, Isha Ray

November 2023
Opportunities to Interrupt Transmission of Enteropathogens of Poultry Origin in Maputo, Mozambique: A Transmission Model Analysis
Kayoko Shioda, Andrew F. Brouwer, Frederica Lamar, Hermógenes N. Mucache, Karen Levy and Matthew C. Freeman

October 2023
Prevalence of heavy menstrual bleeding and associations with physical health and wellbeing in low-income and middle-income countries: a multinational cross-sectional study
Sheela S Sinharoy, Lyzberthe Chery, Madeleine Patrick, Amelia Conrad,
Anupama Ramaswamy, Aparna Stephen, Bethany A Caruso, et al

Assigning Pathogen Etiology for Childhood Diarrhea in High-Burden Settings: A Call for Innovative Approaches
James A. Platts-Mills and Elizabeth T. Rogawski McQuade

Critical success factors for high routine immunisation performance: a qualitative analysis of interviews and focus groups from Nepal, Senegal, and Zambia
Zoe Sakas, Kyra A Hester, Anna Ellis, Emily A Ogutu, Katie Rodriguez, Robert Bednarczyk, Sameer Dixit, William Kilembe, Moussa Sarr, Matthew C Freeman

Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis
Hannah K Smalley, Francisco Castillo-Zunino, Pinar Keskinocak, Dima Nazzal, Zoë M Sakas, Moussa Sarr, and Matthew C Freeman

Symptomatic and asymptomatic enteric protozoan parasitic infection and their association with subsequent growth parameters in under five children in South Asia and sub-Saharan Africa
Rina Das, Parag Palit, Md. Ahshanul Haque, Myron M. Levine, Karen L. Kotloff, Dilruba Nasrin, M. Jahangir Hossain, Dipika Sur, Tahmeed Ahmed, Robert F. Breiman, Matthew C. Freeman, and S. G. Faruque

September 2023
Blockade Antibody Responses in Human Subjects Challenged with a New Snow Mountain Virus Inoculum
Makoto Ibaraki, Lilin Lai, Christopher Huerta, Muktha S. Natrajan, Matthew H. Collins, Evan J. Anderson, Mark J. Mulligan, Nadine Rouphael, Christine L. Moe, Pengbo Liu

Facilitators and barriers to the utilisation of sanitation-related decision-making support tools among environmental health practitioners in Uganda
Richard K. Mugambe, Tonny Ssekamatte, John Bosco Isunju, Aisha Nalugya, Doreen Nakalembe, Patience Oputan, Habib Yakubu and Christine L. Moe

Plugging the leaks: antibiotic resistance at human– animal interfaces in low- resource settings
Maya L Nadimpalli,
Marc Stegger, Roberto Viau, Vuthy Yith, Agathe de Lauzanne, Nita Sem, Laurence Borand, Bich-tram Huynh, Sylvain Brisse, Virginie Passet, Søren Overballe- Petersen, Maliha Aziz, Malika Gouali, et al

Indicators for National and Global Monitoring of Girls’ Menstrual Health and Hygiene: Development of a Priority Shortlist
Julie Hennegan, Bethany A. Caruso, Garazi Zulaika, Belen Torondel, Jacquelyn Haver, Penelope A. Phillips, et al.

June 2023
Wastewater monitoring can anchor global disease surveillance systems
Aparna Keshaviah, Megan B Diamond, Matthew J Wade, Samuel V Scarpino, on behalf of the Global Wastewater Action Group: Christine L Moe, Marlene Wolfe, Habib Yakubu et al

Comparison of Nanotrap® Microbiome A Particles, membrane filtration, and skim milk workflows for SARS-CoV-2 concentration in wastewater
Pengbo Liu, Lizheng Guo, Matthew Cavallo, Caleb Cantrell, Stephen Patrick Hilton, Anh Nguyen Audrey Long, Jillian Dunbar,
Robbie Barbero, Robert Barclay, Orlando Sablon III, Marlene Wolfe, Ben Lepene, Christine Moe

Burden of disease attributable to unsafe drinking water, sanitation and hygiene in domestic settings: a global analysis for selected adverse health outcomes
Jennyfer Wolf, Richard B Johnston, Argaw Ambelu, Benjamin F Arnold, Robert Bain, Michael Brauer, Joe Brown, Bethany A Caruso,  Thomas Clasen, John M Colford Jr, Joanna Esteves Mills, Barbara Evans,  Matthew C Freeman, Bruce Gordon, Gagandeep Kang, Claudio F Lanata, Kate O Medlicott, Annette Prüss-Ustün, Christopher Troeger, Sophie Boisson, Oliver Cumming,

May 2023
Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis
Ian Ross, Sarah Bick, Philip Ayieko, Robert Dreibelbis, Jennyfer Wolf, Matthew C Freeman, et al.

Variation in Severity of Symptoms Associated with Two Snow  Mountain Virus Inocula
Pengbo Liu, Hongyan Qu, Nadine Rouphael, Mark Mulligan, Yuke Wang, and Christine Moe

April 2023
Norovirus acute gastroenteritic amongst US and European travelers to areas of moderate to high risk of travelers diarrhoea: a prospective cohert study
Martin Alberer, Christine L Moe, Christoph Hatz, Kerstin Kling,  Amy E Kirby, Lisa Lindsay, Hans D Nothdurft, Margarita Riera-Montes, Robert Steffen, Thomas Verstraeten, Henry M Wu, Herbert L DuPont

Effectiveness of handwashing with soap for preventing acute respiratory infections in low-income and middle-income countries: a systematic review and meta-analysis
Ian Ross, PhD, Sarah Bick, MSc, Philip Ayieko, PhD, Robert Dreibelbis, PhD, Jennyfer Wolf, PhD, Prof Matthew C Freeman, PhD, Prof Elizabeth Allen, PhD, Prof Michael Brauer, ScD, Oliver Cumming, MSc

March 2023
Measurement in the study of human exposure to animal feces: A systematic review and audit
April M. Ballard, Nicholas Laramee, Regine Haardörfer, Matthew C. Freeman, Karen Levy, Bethany A. Caruso

Effects of water, sanitation, and hygiene interventions on detection of enteropathogens and host-specific faecal markers in the environment: a systematic review and individual participant data meta-analysis
Andrew Mertens, Benjamin F Arnold, Jade Benjamin-Chung, Alexandria B Boehm, Joe Brown, Drew Capone, Thomas Clasen, et al

Study design and retionale for the PAASIM project: a matched cohort study on urban water supply improvements and infant enteric pathogen infection, gut microbiome development and health in Mozambique
Karen Levy, Joshua V Garn, Zaida Adriano Cumbe, Bacelar Muneme, Christine S Fagnant Sperati, Sydney Hubbard, Antonio Júnior, João Luís Manuel, Magalhães Mangamela, Sandy McGunegill, Molly K Miller-Petrie, Jedidiah S Snyder, Courtney Victor, Lance A Waller, Konstantinos T Konstantinidis, Thomas F Clasen, Joe Brown, Rassul Nalá,  and Matthew C Freeman

Women, work and water
Bethany Caruso, Jenala Chipungu, Seema Kulkami and Isha Ray

Joint Food and Water Insecurity Had a Multiplicative Effect on Women’s Depression in Urban Informal Settlements in Makassar, Indonesia during the COVID-19 Pandemic Isabel Charles, Allison Salinger, Rohan Sweeney, Becky Batagol, S. Fiona Barke, Sudirman Nasir, Ruzka R. Taruc, Naomi Francis, Thomas Clasen, Sheela S. Sinharoyfor the RISE consortium




*Names in bold indicate CGSW Core Faculty and Fellows





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