Water, Sanitation And Hygiene Access Research Articles

Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria.

Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited. We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group. CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.

A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs.

Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages-such as homelessness or drug injection practices-often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel 'MH WASH Domain Scale-12' among people who menstruate and who inject drugs in the Tijuana-San Diego region and identified correlates of MH access using this scale. We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0-12 points and higher scores indicating better MH access. We assessed the scale's reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020-2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our 'MH WASH Domain Scale-12' was reliable (Cronbach's alpha = 0.81, McDonald's Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing 'WASH availability' and Factor-2 contained items related to 'WASH security'-encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region.

There is no place to go in “America's Finest City”: Basic sanitation deprivation is punishment in San Diego, California, USA

Safe and consistent access to water, sanitation, and hygiene (WaSH) resources is an internationally recognized human right. Yet in the U.S., access to public toilets, handwashing facilities, potable water, and menstrual supplies is grimly limited, especially for unhoused people. This article develops the concept of “sanitation justice” and argues for its urgent consideration alongside calls for racial, gender, social, and environmental justice. We advance this argument via a case study analyzing three novel data sources on WaSH access in San Diego, California's second-largest city, with a focus on public restrooms: geospatial data on facility locations, infrastructure assessments, and interviews with unhoused people on their restroom needs and challenges. We present a conceptual model, informed by the prior literature and our data, for visualizing how deliberate sanitation deprivation in the U.S. urban environment functions as a punishment regime inflicted on city residents, unhoused residents especially, to the detriment of public health and safety. As our data show, WaSH access is the most basic way governments can support not only public health but also social and economic mobility. We conclude with a vision of sanitation justice that centers the voices of those most affected by sanitation deprivation.

Recent and future exposure of water, sanitation, and hygiene systems to climate-related hazards in Zambia

Abstract Climate change-driven water scarcity will lead to inequitable water, sanitation, and hygiene (WASH) access. However, current research in Zambia has ignored linking climate science dimensions to WASH access programs, thus limiting WASH-related climate action across the country. Here, we combine analyses of in situ datasets, modeling techniques, and systematic literature reviews to provide a solid climate science basis for WASH–climate action in Zambia. We find that in a warm near future climate, the stretch along the Copperbelt–Livingstone railroad from the north to the south of the country is expected to record an increase in heavy rainfall single-day events ranging between 50 and ≥150 mm. As such, bacterial diseases, such as cholera outbreaks, are expected to increase, especially in the Copperbelt, Central, Lusaka, Southern, and the Eastern Provinces. Models further predict a drier Zambia in the near and far future of up to 12 days year−1, suggesting a higher risk of increased aridity which will compound challenges to the provision of safe drinking water. The projected rapid population growth in these regions will also heighten the challenges of accessing safe drinking water. Strategic investments in enhancing WASH access in these areas should be considered a matter of urgency.

Socioeconomic predictors of access to improved water sources, sanitation facilities, and household water treatment in Nigeria

Abstract In Nigeria, the widespread lack of access to water, sanitation, and hygiene (WASH) represents a critical public health challenge. Yet, the socioeconomic determinants of WASH access at the national level remain poorly understood. This study uses 2018 Nigeria Demographic and Health Surveys (NDHS) cross-sectional data to investigate the socioeconomic factors associated with WASH access. The majority of survey respondents lived in rural areas (57%); used an improved source of drinking water (73%) and an improved sanitation facility (55%); and did not treat their drinking water (92%). Binary logistic regression showed that Nigerians living in rural areas were less likely to have access to an improved water source (p < 0.001, OR = 0.42 [0.41, 0.44]) and less likely to have access to an improved sanitation facility (p < 0.001, OR = 0.79 [0.77, 0.81]). A sub-group regression analysis of respondents without access to improved WASH found that rural residence (OR = 0.84 [0.76, 0.93]), along with lower levels of education and wealth were associated with non-treatment of their unimproved drinking water. This study suggests that efforts are needed to increase WASH access in rural areas and to improve household water treatment in areas without access to improved water and sanitation.

Inadequate WASH access and risk for non-partner sexual violence in low- and middle-income countries

Abstract Background Globally, 6% of women and girls have ever experienced non-partner sexual violence (NPSV) at least once in their lifetime. Prior literature suggests that inadequate access to water, sanitation and hygiene (WASH) facilities can exacerbate the vulnerability to NPSV against women and girls, especially in low- and middle-income countries (LMICs). Nevertheless, quantitative evidence on the association between NPSV and inadequate WASH access is still limited. Methods Demographic and Health Surveys from 27 LMICs were used for the analysis of 237,324 women aged 15-49 years. Experience of NPSV was defined as an event within 12 months preceding the survey. Explanatory variables included type of sources for drinking water (private, public, and open source) and toilet facilities (private, shared, and open type). Multivariable three-level random effects logistic regressions were conducted. Results Overall, 6.6% of women were getting water from open sources such as river and 19.9% were openly defecating. 0.5% of the study sample had recent experience of NPSV. After adjusting for demographic and socioeconomic covariates, having to use public or open source for drinking water was associated with 26% and 37% greater likelihood of experiencing NPSV, respectively (OR: 1.26, 95% CI: 1.04-1.51 for public; OR: 1.37, 95% CI: 1.01-1.84). Using shared toilets and practicing open defecation were also associated with 16% and 39% greater risk for NPSV (OR: 1.16, 95% CI: 1.00-1.34 for shared; OR: 1.39, 95% CI: 1.16-1.68 for open). Conclusions To prevent the victimization of women with disadvantaged WASH infrastructures and achieve Target 5 from the Sustainable Development Goals, which envisions to eliminate all forms of violence against all women and girls by 2030, it is essential to secure private water sources and toilet facilities via multinational official development assistance as well as country-level policies alongside with ensuring gender equality. Key messages • One out of 200 women in low- and middle-income countries has experienced non-partner sexual violence within a year. • Risk for such non-partner sexual violence was positively associated with inadequate access to water and sanitation facilities, particularly in low-resource settings.

Geographical Origin, WASH Access, and Clinical Descriptions for Patients Admitted to a Cholera Treatment Center in Northwest Syria between October and December 2022.

Background  On September 10, 2022, a cholera outbreak was declared in Syria for the first time in over a decade of protracted conflict. As of May 20, 2023, 132,782 suspected cases had been reported, primarily in northwest and northeast Syria. We aim to provide a detailed description of water sources and clinical status of a patient cohort seen at a cholera treatment center (CTC) in northwest Syria. Methods  We retrospectively identified patients with confirmed cholera who presented to the CTC in Idlib governorate between October 8 and December 18, 2022. Data were obtained from clinical case records and analyzed in R v4.0.4. Results  Ninety-four patients (55.3% men) were treated at the CTC. Thirty-five patients were severely dehydrated (Plan C treatment), 54 had some dehydration (Plan B), and 5 had no dehydration (Plan A). Most patients were between 11 and 20 years old ( n  = 25, 26.6%) or 31 and 40 years old ( n  = 19, 20.2%). Note that 70.2% ( n  = 66) of patients were seen in November 2022 and most were from Harim district ( n  = 44, 46.8%). Public wells ( n  = 46, 48.9%) and water trucking ( n  = 41, 43.6%) were the most commonly used water sources. Note that 76.6% ( n  = 72) did not have access to chlorine-treated water. Forty-seven patients (50%) had more than five water, sanitation, and hygiene (WASH)-related cholera risk factors. Following treatment, six patients were transferred to another treatment center, three died (case fatality rate: 3.2%), and the remainder were discharged. Conclusion  Most patients reported WASH-related risk factors for cholera, reflecting the poor state of WASH in northwest Syria after over a decade of conflict. This relates to the direct and indirect impacts of urban and periurban violence as well as the underfunded humanitarian response. Strengthening WASH and health promotion are important components to control the outbreak.

COVID-19 brought the water struggles in Ghana into our homes in Canada: Collective emotions and WASH struggles in distant locations during health emergencies.

The COVID-19 pandemic has heightened and made visible the embodied consequences of water, sanitation and hygiene (WASH) inequalities and the relationalities of health in place. This paper combines insights from relational geographies and embodied epidemiology to explore psychosocial concerns among Ghanaian migrants in Canada due to their multiple and simultaneous roles in the WASH space in Ghana, particularly during the COVID-19 pandemic. We explored this using narratives from in-depth interviews with 27 participants (16 women and 11 men) residing in Ontario, Canada. The case of Ghana offers insight into how social ties with home communities could provide a safety net during emergencies but could also affect the psychosocial wellbeing of migrants. Results revealed four interrelated psychosocial stressors, including social stressors, financial stressors, stressors related to perceived inequality and stressors related to the fear of infection during WASH access. The paper underscores the urgent need for research to move beyond local health implications of WASH inequalities and begin to prioritize how these social inequalities are embodied at distant locations.

The status of water access, sanitation, and hygiene in schools: A cross sectional survey to identify capacities and assess coverage in Garoua, North Cameroon

There has been an increasing global interest in understanding, documenting, and monitoring water, sanitation, and hygiene (WASH) services in schools. This study is the first to identify existing WASH-in-school capacities and understand the magnitude of the gaps in WASH coverage in schools in the Northern Cameroon, a region of the country marked by recurrent sanitary emergencies, the highest prevalence of acute malnutrition, and representing the largest and heaviest focus of food and water insecurity. Using a cross-sectional design, relevant authorities of 176 schools in Garoua, were interviewed. The survey guide included core questions for monitoring WASH in schools from recommended guidelines. Eleven indicators-related variables were extracted from data to calculate the WASH-in-school indicators composite score, which could be used as a more reliable and useful tool for comparison across settings and can contribute to harmonize data with WASH in schools related indicators applied in national surveys. The results of this research showed suboptimal drinking water supply systems and sanitation facilities whereas most schools had hand washing points available. However, activities that aimed to promote and sustain a WASH positive environment among children still need to be put in place. The WASH-in-school indicators composite score predictive value corroborated the disparities related to WASH access in schools located in Garoua. This score hence provides an assessment of the spatial dimensions of reduced access to water in schools, improper hygiene practices, and inadequate sanitation facilities. Such a score could be used to identify hotspots lacking WASH infrastructural facilities and strategize optimal interventions to reduce the incidence of WASH related diseases in schools.

Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California

BackgroundAccess to water and sanitation is a basic human right; however, in many parts of the world, communities experience water, sanitation, and hygiene (WaSH) insecurity. While WaSH insecurity is prevalent in many low and middle-income countries, it is also a problem in high-income countries, like the United States, as is evident in vulnerable populations, including people experiencing homelessness. Limited knowledge exists about the coping strategies unhoused people use to access WaSH services. This study, therefore, examines WaSH access among unhoused communities in Los Angeles, California, a city with the second-highest count of unhoused people across the nation.MethodsWe conducted a cross-sectional study using a snowball sampling technique with 263 unhoused people living in Skid Row, Los Angeles. We calculated frequencies and used multivariable models to describe (1) how unhoused communities cope and gain access to WaSH services in different places, and (2) what individual-level factors contribute to unhoused people’s ability to access WaSH services.ResultsOur findings reveal that access to WaSH services for unhoused communities in Los Angeles is most difficult at night. Reduced access to overnight sanitation resulted in 19% of the sample population using buckets inside their tents and 28% openly defecating in public spaces. Bottled water and public taps are the primary drinking water source, but 6% of the sample reported obtaining water from fire hydrants, and 50% of the population stores water for night use. Unhoused people also had limited access to water and soap for hand hygiene throughout the day, with 17% of the sample relying on hand sanitizer to clean their hands. Shower and laundry access were among the most limited services available, and reduced people’s ability to maintain body hygiene practices and limited employment opportunities. Our regression models suggest that WaSH access is not homogenous among the unhoused. Community differences exist; the odds of having difficulty accessing sanitation services is two times greater for those living outside of Skid Row (Adj OR: 2.52; 95% CI: 1.08–6.37) and three times greater for people who have been unhoused for more than six years compared to people who have been unhoused for less than a year (Adj OR: 3.26; 95% CI: 1.36–8.07).ConclusionOverall, this study suggests a need for more permanent, 24-h access to WaSH services for unhoused communities living in Skid Row, including toilets, drinking water, water and soap for hand hygiene, showers, and laundry services.

Unequal access to improved water and sanitation in a post-conflict context of Liberia: Evidence from the Demographic and Health Survey

Public health and wellbeing in Liberia have been compromised by a lack of access to safe drinking water, sanitation, and hygiene (WASH), compounded by 14 years of civil unrest. After almost two decades of relative peace and stability, disparities in WASH access persist and diseases linked to WASH such as Ebola, cholera, and COVID-19 have posed major public health challenges. Yet, there is nascent research in the context of post-war Liberia examining the determinants of access to WASH. To contribute to WASH policy in Liberia, this study examined the predictors of improved water and sanitation using the 2019–20 Liberia Demographic and Health Survey. Using the complementary log-log link function, we found that some socioeconomic and geographical factors were associated with access to improved water and sanitation. For example, poorer and rural households were less likely to have access to improved water and sanitation compared to their wealthier and urban counterparts, respectively. Based on these findings, we discussed policy implications and potential directions for future research.

Assessing Water, Sanitation and Hygiene Access and Use in Nabilatuk District, Uganda: A Cross-Sectional Study of Different Data Collection Methods

Good access and appropriate use of Water, Sanitation and Hygiene (WASH) is important in the control, elimination and eradication of a number of neglected tropical diseases (NTDs). Poor WASH access and use may explain continued high trachoma prevalence in Nabilatuk district, Uganda. This study aimed to investigate the level of WASH access and use through different WASH data collection methods and the triangulation of their results. A mixed-methods cross-sectional study was conducted in 30 households in Nabilatuk district, from 10 households in each of three nomadic villages. The data collection methods used were: (1) direct observations of routine WASH behaviours; (2) structured quantitative household questionnaires; (3) demonstrations of specific WASH behaviours. With regards to access, observations indicated less WASH access and use compared with questionnaire responses: the questionnaire indicated all households had access to an improved water source, but 70% had a >30-min round-trip, and no households had access to an improved latrine, whereas some observations indicated longer water collection times. In terms of behaviour, there were also differences between the data collection methods, with demonstrations revealing knowledge of good practice, such as thorough handwashing, but this was not routinely observed in the observations. Further systematic investigation of barriers to appropriate WASH access and use in the local context is needed, as is the development of feasible, valid and reliable WASH access and use assessment methods for use in national NTD programmes.

Water, Sanitation, and Hygiene of Nepal: Status, Challenges, and Opportunities

Access to water, sanitation, and hygiene (WASH) has been a challenge to south Asia’s rapidly growing and climate change-sensitive region. Nepal, a water-abundant country, faces obstacles to fulfilling the highly prioritized WASH Sustainable Development Goal 6 (SDG 6). This review offers details about Nepal’s WASH status from 2000 to 2020 with regard to the challenges Nepal had in delivering reliable WASH services to the people, as well as opportunities for a sustainable way forward, and provides insights that can be applied to other developing countries. From analysis of national-level assessments, estimates point toward healthy progress in extending WASH access to the population. However, large inequalities persist at the subnational level between urban and rural residents, between poor and rich residents, and between genders. Many local constraints such as a lack of long-term infrastructural capacity to provide and maintain WASH services, financial issues, and institutional and policy incompatibilities are some of the key factors that technical considerations and private sector involvement could address. We also propose roles for Nepal’s central, provincial, and local governments for identification and adaptation to the undeniable risks of climate change. Furthermore, there is a need to capitalize on the potential opportunities for developing a much-needed robust and climate-resilient WASH sector in Nepal, safeguarding the rights of future generations to safe and clean water.

School Water, Sanitation, and Hygiene: A Systematic Review of an Effect on Health, Attendance, Regularity, and Educational Achievements

The review was started aiming to assess the effect of school-based Water, Sanitation, and Hygiene (WASH) facilities on students’ health status, school regularity, and educational achievement. Two major academic and scientific research journals as Springer and PubMed have been selected, where WASH is the search engines, separately. There were 8,443 relevant publications found, with Springer having6, 888 and PubMed having 1,555. Among these publications, author synthesized 17 with abstracts and full articles, including references for this study. The findings of this study indicates that intervention of school WASH facilities have an effect on students’ health status, regularity in school attendance, and educational achievement. It protects students from various infectious diseases caused by poor WASH access; however, ways of handling it is equally important. The intervention in WASH facilities at school improves students’ health, school regularity, and educational achievements. Thus, the study strongly suggests interventions in school-based WASH facilities to make students healthier, more regular, and better academic performer.

I feel the pains of our past water struggles anytime I turn on the tap: Diaspora perceptions and experiences of water, sanitation, and hygiene (WaSH) gendered violence in Ghana

Gender-based violence resulting from water, sanitation and hygiene (WASH) insecurity is a major public health problem. WaSH gender-based (WaSH-GBV) is a spatio-temporal experience and has disproportionate health and wellbeing impacts on women and girls. However, the global community of WaSH practitioners and policymakers is yet to adequately address women's vulnerability to violence in relation to WaSH access. Informed by the feminist political ecology of health framework, we conducted in-depth interviews (n = 27, 16 women and 11 men) with Ghanaian immigrants to Canada to explore perceptions of WaSH experiences over lifecourse. Results revealed that participants' perceptions and experiences of GBV are both socially and context dependent, organized around four dimensions: structural, physical, psychological, and sexual. These muti-scalar dimensions of diasporans' WaSH experiences and perceptions in Ghana are discussed along with their implications for policy and practice, specifically in enhancing health equity and water security.

Prevalence of Trachoma after Implementation of Trachoma Elimination Interventions in Oromia Regional State, Ethiopia: Results of Impact Surveys in 131 Evaluation Units Covering 139 Districts

ABSTRACT Purpose To determine the prevalence of trachomatous inflammation—follicular (TF), trachomatous trichiasis (TT), water, sanitation, and hygiene (WASH) access in 131 evaluation units (EUs) after implementation of trachoma elimination interventions in Oromia Region, Ethiopia. Methodology A population-based cross-sectional survey was conducted in each EU using the World Health Organization-recommended two-stage cluster-sampling methodology. Twenty-six clusters, each with a mean of 30 households were enumerated in each EU. All residents aged ≥1 year in selected households were examined for TF and TT. Information on WASH access in surveyed households was also collected through questioning the household head and direct observation. Results A total of 419,858 individuals were enumerated in 131 EUs, of whom 396,134 (94%) were examined, 54% being female. Age-adjusted EU-level prevalence of TF in children aged 1–9 years ranged from 0.15% (95% confidence interval [CI]: 0.0–0.4) to 37.5% (95% CI: 31.1–43.7). The TF prevalence was <5% in 73/131 (56%) EUs. The EU-level age- and gender-adjusted prevalence of TT unknown to the health system among people aged ≥15 years ranged from 0.001% (95% CI: 0.00–0.02) to 2.2% (95% CI: 1.1–3.1) with 37/131 (28%) EUs having a prevalence <0.2%. Only 48% of all households surveyed had access to improved water sources for drinking. Approximately 96% of households did not have an improved latrine. Conclusion Oromia is on the path towards elimination of trachoma as a public health problem.

Water, sanitation, and hygiene access in Senegal and its impact on the occurrence of diarrhea in children under 5 years old.

Diarrheal diseases are the second leading cause of child mortality worldwide, occurring in about one in every nine child deaths, and were associated with water, sanitation, and hygiene (WASH) access. In this study, we provided an overview of WASH indicators' evolution from 2000 to 2017 and their impact on the occurrence of diarrhea in children under 5 years old in Senegal. It was a retrospective cross-sectional study, in which we did a secondary analysis of data from the Joint Monitoring Program (JMP) for water supply and sanitation and from the Senegal Demographic and Health Survey 2018. Our results showed that access to safely managed services increased by 18.1 and 19.1%, respectively, for water and sanitation. The prevalence of diarrhea estimated at 18.16% was associated with straining water through a cloth (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 1.21 [1.00-1.45]) and getting water supplies from a source not located in a dwelling (AOR [95% CI]: 1.59 [1.21-2.09]). The prevalence of diarrhea among children under 5 years old was still relatively high in Senegal and was significantly associated with a lack of WASH access. Although the latter continues to increase, additional efforts to make water safer to drink will significantly reduce the occurrence of diarrheal diseases among children under 5 years old in Senegal.

A qualitative cross-sectional study exploring the implementation of disability-inclusive WASH policy commitments in Svay Reing and Kampong Chhnang Provinces, Cambodia

BackgroundThe Government of Cambodia references core concepts of human rights of people with disabilities in their water, sanitation and hygiene (WASH) policies and guidance. However, few references clearly articulate activities to achieve these.MethodsThis cross-sectional study in Cambodia explores the implementation of core concepts of human rights referenced in Cambodia's WASH policies in Kampong Chhnang and Svay Reing Provinces: Individualized services, Entitlement/affordability, Participation, Family resource, Access. Seven government officials and 10 service providers working in Phnom Penh and the two provinces, 16 women and men with disabilities (aged 18–65+), and four caregivers living in the study sites were included. Purposive sampling was applied to select participants. In-depth interviews were conducted via Zoom and over the telephone and analyzed data thematically using Nvivo 12.ResultsThe Three Star Approach for WASH in Schools was noted as a promising approach for implementing policy commitments to make school WASH services accessible. However, policy commitments to disability-inclusive WASH were not always enacted systematically at all levels. Organizations of Persons with Disabilities faced challenges when advocating for disability rights at WASH sector meetings and people with disabilities were inconsistently supported to participate in commune WASH meetings. Poor access to assistive devices (e.g., wheelchair) and inaccessible terrain meant few people with disabilities could leave home and many had inadequate WASH services at home. Few could afford accessible WASH services and most lacked information and knowledge about how to improve WASH access for people with disabilities. Caregivers had no guidance about how to carry out the role and few had assistive devices (e.g., commodes, bedpans) or products (i.e., lifting devices), so supporting WASH for people with disabilities was physically demanding and time-consuming.ConclusionThis study has noted several areas where Cambodia's WASH systems are focusing efforts to ensure people with disabilities gain access to WASH, but it has also highlighted aspects where implementation of policy commitments could be strengthened. A more comprehensive and cross-sectoral approach to progressively realizing the rights to water and sanitation for people with disabilities and challenging disability discrimination more broadly could significantly disrupt the vicious cycle of poverty and disability.

Acceptability measures of water, sanitation and hygiene interventions in low- and middle-income countries, a systematic review

BackgroundInadequate access to water, sanitation, and hygiene (WASH) is an environmental risk factor for poor health outcomes globally, particularly for children in low- and middle-income countries (LMIC). Despite technological advancements, many interventions aimed at improving WASH access return less than optimal results on long term impact, efficacy and sustainability. Research focus in the ‘WASH sector’ has recently expanded from investigating ‘which interventions work’ to ‘how they are best implemented’. The ‘acceptability’ of an intervention is a key component of implementation that can influence initial uptake and sustained use. Acceptability assessments are increasingly common for health interventions in clinical settings. A broad scale assessment of how acceptability has been measured in the WASH sector, however, has not yet been conducted.Methods/Principal findingsWe conducted a systematic literature review of intervention studies published between 1990 and 2021 that evaluated the acceptability of WASH interventions in LMIC settings. Using an implementation science approach, focused outcomes included how acceptability was measured and defined, and the timing of acceptability assessment. We conducted quality assessment for all included studies using the Cochrane Risk of Bias tool for randomised studies, and the Newcastle-Ottawa Scale for non-randomised studies.Of the 1238 records; 36 studies were included for the analysis, 22 of which were non-randomized interventions and 16 randomized or cluster-randomized trials. We found that among the 36 studies, four explicitly defined their acceptability measure, and six used a behavioural framework to inform their acceptability study design. There were few acceptability evaluations in schools and healthcare facilities. While all studies reported measuring WASH acceptability, the measures were often not comparable or described.ConclusionsAs focus in WASH research shifts towards implementation, a consistent approach to including, defining, and measuring acceptability is needed.

Interventions to improve water, sanitation, and hygiene for preventing soil-transmitted helminth infection.

BackgroundIt is estimated that 1.5 billion people are infected with soil‐transmitted helminths (STHs) worldwide. Re‐infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours.ObjectivesTo assess the effectiveness of WASH interventions to prevent STH infection.Search methodsWe used standard, extensive Cochrane search methods. The latest search date was 19 October 2021.Selection criteriaWe included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non‐random method (non‐RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome.Data collection and analysisTwo review authors independently reviewed titles and abstracts and full‐text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non‐RCTs. We used a random‐effects meta‐analysis to pool study estimates. We used Moran’s I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach.Main resultsWe included 32 studies (16 RCTs and 16 non‐RCTs) involving a total of 52,944 participants in the review. Twenty‐two studies (14 RCTs (16 estimates) and eight non‐RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty‐one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non‐RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non‐RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non‐RCTs); and one on the prevalence of S stercoralis (1 non‐RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non‐RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non‐RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non‐RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis.The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate‐certainty evidence) and an OR of 0.71 amongst non‐RCTs (95% CI 0.54 to 0.94; low‐certainty evidence). All six of the meta‐analyses assessing individual worm infection amongst both RCTs and non‐RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome.We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA).Authors' conclusionsWhilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.