The Knowledge Base for Achieving the Sustainable Development Goal Targets on Water Supply, Sanitation and Hygiene

Water, sanitation, and hygiene (WASH) practices in Africa: exploring the effects on public health and sustainable development plans

BACKGROUND

Suboptimal water, sanitation, and hygiene (WASH) practices constitute a serious public health risk, affecting one-third of the world's population. Remarkable progress has been made to improve WASH; however, challenges remain, with rapid population growth adding pressure on WASH systems. This study explores the current state of WASH practices and diseases in Africa, identifies challenges, and proposes public health recommendations for sustainable implementation.

MAIN BODY

The staggering burden of WASH-related diseases in low- and middle-income countries (LMICs), particularly in Africa, threatens public health, with millions of deaths and disability-adjusted life years (DALYs) attributed to poor WASH practices annually. Notable challenges plaguing WASH practices in the region include poverty, malnutrition, poor data reporting, illiteracy, climate change, and poor healthcare financing. This results in adverse health consequences, including waterborne infections like cholera, typhoid, dysentery, and diarrheal diseases. Additionally, neglected tropical diseases (NTDs) such as intestinal worms, schistosomiasis, trachoma, lost productivity, and environmental pollution from soil and underground water contamination have been implicated. Geographical disparities, cultural norms, and inadequate funding further complicate efforts to improve WASH infrastructure and practices. Globally concerted efforts are required to address these issues and permit WASH practices to protect human health by preventing infectious diseases and contributing to economic growth. Strong financial frameworks, skills training, and tools like WASH Fit are recommended for a stronger WASH approach in Africa.

CONCLUSION

The consequences of poor WASH extend beyond public health, impacting economic growth, gender equality, and environmental sustainability. WaterAid's policy recommendations prioritizing government administration, institutional capacity enhancement, and more financial resources are expedient.

How does the citizens' choice of water use actions based on their empirical knowledge affect the water quality in a rural community of the Philippines?

This research assessed water quality, based on the purpose of water consumption, in households in the municipality of Barbaza, the Province of Antique, Philippines, according to the national water quality guidelines. The effects of the empirical/traditional water use actions taken by local people on the quality of the water they use were investigated through a descriptive study using water quality measurements. Most of the drinking water in the community did not meet the required standards of pH, total dissolved solids (TDS), or coliform. Tap water and well water samples generally met the pH and TDS standards. However, Escherichia coli (E. coli) and coliform were detected, and nitrogen pollution in well water was also confirmed. Local practices, such as using old clothes as filters for well pumps, increased the coliform concentration from 0-10 CFU/mL to too numerous to count (TNTC) levels of more than 100 CFU/mL. Storing well water in a bucket also affected both E. coli and coliform concentrations. Such empirical/traditional water use actions create a high risk of exposing local people to harmful microorganisms. This research integrated citizen science into the methodology for local water management, which could assist governors, practitioners, and citizens, particularly in Southeast Asia, where strong community relationships exist.

An assessment of latrine front-end characteristics and associated surface E. coli indicated faecal contamination in rural Fiji

In Fiji, 90% of the population has access to basic sanitation; however, there are still persistent health risks from endemic faecal-oral diseases such as typhoid fever. There is a need to assess the contribution of existing sanitation facilities in the faecal pathogen transmission pathway. This study was conducted as part of a larger planetary health study across 29 rural communities within five river catchments. This specific research aimed to characterise latrine front-ends, both infrastructure and usage behaviour, and to assess the faecal contamination levels on various frequently contacted latrine surfaces in rural Fiji. A sanitation survey, along with observation and latrine swab sampling, was conducted in households over three phases: baseline (n = 311) (Aug-Dec 2019), endline (n = 262) (Jun-Sep 2022) and an in-depth front-end study (n = 12) (Oct-Nov 2022). Of 311 households, almost all had pedestal-type latrines, predominately cistern-flush (83%), followed by pour-flush (13%), and then hole-type (pit) latrines (4%). Washable latrine floors had significantly higher E. coli densities (6.7 × 102 CFU/25 cm2) compared to non-washable floors (1.3 × 102 CFU/25 cm2) (p = 0.05), despite washable floors indicating improved latrines. The in-depth front-end analysis found that moist latrine surfaces had significantly elevated E. coli densities (1.2 × 103 CFU/25 cm2) compared to the dry ones (14.3 CFU/25 cm2) (p < 0.001), highlighting the importance of maintaining dry latrine surfaces. Latrine floors and mid-walls were the most frequently contaminated surfaces, emphasising the need to clean and disinfect these surfaces. Only 46% of the households reported always using soap for handwashing after defecation, exacerbating the risk of transmitting faecal pathogens. This study highlights that latrine cleanliness and hygiene are as crucial as latrine infrastructures for the effective disruption of faecal pathogens transmission during latrine use.

Impact of an educational intervention on water, sanitation and hygiene knowledge, attitudes, and practices in early childhood development centres in low-socio-economic areas in the Nelson Mandela Bay, South Africa

Good water, sanitation, and hygiene (WASH) enhance healthy living and safe environments for child development. The study aimed to evaluate the impact of an educational intervention on WASH status, knowledge, attitudes and practices in early child development (ECD) centres in low socio-economic areas in the Nelson Mandela Bay in 2021. This quasi-experimental, one group, pre-post-test study elicited responses from 51 ECD practitioners (1 per ECD centre). Telephonic structured knowledge, attitude and practices (KAP) questionnaires were used. KAP was good among participants. The educational intervention significantly improved mean knowledge (p<0.001, 95% CI: 0.58-1.11) attitudes (p<0.001, 95% CI: 0.39-0.67) and practices (p = 0.001, 95% CI: 0.20-0.74). WASH knowledge was significantly impacted by toilet facilities ventilation status (p = 0.083) while WASH attitudes scores were significantly impacted by ventilation where the potties are kept (p = 0.041). WASH practice scores were significantly impacted by across the bush/field (no facility) (p = 0.021) and plastic potties usage (p = 0.057). The educational intervention significantly improved WASH-related knowledge, attitudes, and practices among ECD practitioners. WASH conditions in the ECD centres in the study area require additional interventions targeted to sustainable strategies to enhance behavioural modifications for acceptability and sustainability of intervention strategies.

Reduction of Malnutrition Related to Unsafe Water Consumption in Developing Countries: Potabilization of Surface Water and Traditional Well Water, with Plant Extracts

The consumption of unsafe water in rural areas is a real public health problem in developing countries. This situation mainly affects children under five years of age and causes several deaths and many cases of malnutrition every year. The objective of this study was to evaluate and optimize the capacity of four local plant extracts in the potabilization of unsafe water. Thus, Moringa oleifera and Boscia senegalensis seeds, or Aloe vera and Opuntia ficus-indica mucilages were prepared in a solution and applied during a jar test as biocoagulants and bioflocculants on three raw water samples of 82.3 NTU, 549.8 NTU and 796.9 NTU. After treatment results showed that 0.9 g/L of Moringa biocoagulant or 1 g/L of Boscia biocoagulant applied with 0.4 mL of Aloe vera bioflocculant or 0.6 mL of Opuntia ficus-indica bioflocculant reduced the turbidity of each water sample to values less than 5 NTU after only 15 min of decanting. Moreover, the sanitary quality of the water treated by these different extracts showed a perfect conformity of the physicochemical and microbiological parameters with the standards of acceptability in drinking water decreed by the World Health Organization. Thus, the application of these local plant extracts has made it possible to considerably improve the quality of unsafe water in record time. Their popularization could be an alternative in the fight against malnutrition related to the consumption of unsafe water, especially in rural areas.

Drinking water, sanitation, hygiene, and health conditions in India: Findings from the national sample survey

Introduction

Uncertainty exists in the drinking water, sanitation, hygiene, and health conditions due to mosquitoes and flies across India. Therefore, this study aimed to assess the availability of drinking water, sanitation, hygiene, and health in India.

Methods

We used secondary analysis data on 95,548 household members from the National Sample Survey, which included 113,822 homes and 555,351 persons across India between June 2017 and 2018.

Results

About 36.4% of household members stated that tube wells or boreholes outside the property at a distance of less than 0.2 km were their main source of drinking water. More than 87% of respondents said that the water they drank was free of impurities, and 55.1% said that it had not been treated. About 45.7% of respondents stated that there were no bathrooms in the dwellings. More than 50% of the time, according to the respondents, garbage was not collected. A flea or mosquito problem was reported by about 97% of households. Around 97% of households reported fevers that were caused by a disease.

Conclusion

In India, poor access to drinking water, sanitary facilities, good hygiene, and healthcare existed. The results will support the next visionary programs to increase living standards in the country.

WASH Levels and Associated Human Health Risks in War-Prone West African Countries: A Global Indicators Study (2015 to 2021)

Water, Sanitation and Hygiene (WASH) levels have been shown to have impacts on health. However, the knowledge of WASH levels in war-prone West African countries is limited. The study extracted data (2015-2021) from the Joint Monitoring Programme (WHO/UNICEF), World Bank and Demographic and Health Surveys (DHS) to estimate WASH levels in the study countries. Pearson correlation analysis was used to establish the association among the WASH levels. Results showed that women had better access to safe water (56.39%), good sanitation (59.36%) and good hygiene (60.23%) compared to men. The urban population had better access to safe water (57.60%), good sanitation (61.23%), and good hygiene (65.65%) than the rural population. Among the countries under study, Nigeria had the highest access to safe water (36.10%) and good sanitation (24.41%), while Mali had the highest access to good hygiene (27.93%). Pearson correlation analysis showed a strong positive association between safe water and good hygiene (r = .998), safe water and sanitation (r = .996) and hygiene and sanitation (r = .998) at .00 significant levels. Based on the findings, it is recommended that integrated WASH programmes with combined infrastructure development, behaviour change campaigns and community engagement should be encouraged to ensure peaceful and sustainable access to WASH levels.

Membrane-based technology in water and resources recovery from the perspective of water social circulation: A review

In this review, the application of membrane-based technology in water social circulation was summarized. Water social circulation encompassed the entire process from the acquirement to discharge of water from natural environment for human living and development. The focus of this review was primarily on the membrane-based technology in recovery of water and other valuable resources such as mineral ions, nitrogen and phosphorus. The main text was divided into four main sections according to water flow in the social circulation: drinking water treatment, agricultural utilization, industrial waste recycling, and urban wastewater reuse. In drinking water treatment, the acquirement of water resources was of the most importance. Pressure-driven membranes, such as ultrafiltration (UF), nanofiltration (NF) and reverse osmosis (RO) were considered suitable in natural surface water treatment. Additionally, electrodialysis (ED) and membrane capacitive deionization (MCDI) were also effective in brackish water desalination. Agriculture required abundant water with relative low quality for irrigation. Therefore, the recovery of water from other stages of the social circulation has become a reasonable solution. Membrane bioreactor (MBR) was a typical technique attributed to low-toxicity effluent. In industrial waste reuse, the osmosis membranes (FO and PRO) were utilized due to the complex physical and chemical properties of industrial wastewater. Especially, membrane distillation (MD) might be promising when the wastewater was preheated. Resources recovery in urban wastewater was mainly divided into recovery of bioenergy (via anaerobic membrane bioreactors, AnMBR), nitrogen (utilizing MD and gas-permeable membrane), and phosphorus (through MBR with chemical precipitation). Furthermore, hybrid/integrated systems with membranes as the core component enhanced their performance and long-term working ability in utilization. Generally, concentrate management and energy consumption control might be the key areas for future advancements of membrane-based technology.

Rural Sanitation Sustainability Dynamics: Gaining Insight through Participatory and Simulation Modeling

Improved sanitation provides many benefits to human health and well-being and is integral to achieving Sustainable Development Goal Six. However, many nations, including most of sub-Saharan Africa, are not on track to meeting sanitation targets. Recognizing the inherent complexity of environmental health, we used systems thinking to study sanitation sustainability in Uganda. Our study participants, 37 sanitation actors in three rural districts, were engaged in interviews, group model building workshops, and a survey. The resulting model was parametrized and calibrated using publicly available data and data collected through the Uganda Sanitation for Health Activity. Our simulations revealed slippage from improved sanitation in all study districts, a behavior reflected in real interventions. This implies that systemic changes-changes to the rules and relationships in the system-may be required to improve sanitation outcomes in this context. Adding reinforcing feedback targeting households' perceived value of sanitation yielded promising simulation results. We conclude with the following general recommendations for those designing sanitation policies or interventions: (1) conceptualize sanitation systems in terms of reinforcing and balancing feedback, (2) consider using participatory and simulation modeling to build confidence in these conceptual models, and (3) design many experiments (e.g., simulation scenarios) to test and improve understanding.

Water, sanitation, and hygiene global research: evolution, trends, and knowledge structure

Water, sanitation, and hygiene (WASH) services play a crucial role in promoting public and environmental health as well as social and economic development. At the global level, particularly in the developing world, WASH issues continue to present significant challenges. These challenges have been further intensified by factors such as the COVID-19 pandemic, escalating conflicts, climate change, water scarcity, and rising inequality. The scientific community has actively engaged in constructive discussions on these issues, as evidenced by the notable research findings. Therefore, the aim of this study was to comprehensively examine and evaluate global knowledge on WASH. To search for relevant publications, the Scopus database was utilized using specific terms associated with WASH. VOSviewer 1.6.18 software was employed to generate network visualization maps, which assessed collaborative patterns and research trends in the field of WASH. The research output of countries was adjusted considering their gross domestic product (GDP) and population size. The total number of WASH-related publications, including all types of documents, was 1805. By narrowing the search to articles and reviews, the overall global productivity yielded 1589 documents: 1367 (86.0%) original articles and 222 (14.0%) review articles. The USA had the highest number of WASH publications (n = 668; 42.0%), followed by the UK (n = 396; 24.9%), Switzerland (n = 151; 9.5%), and Australia (n = 141; 8.9%). Ethiopia emerged as the leading country in terms of GDP per capita and the number of publications, followed by Uganda, Malawi, India, and Bangladesh. The USA, the UK, and Switzerland exhibited the most extensive collaboration among countries. The main research areas encompassed the role of WASH in sustainable development, the impacts of inadequate access to WASH services on gender equality, children, infants, and the outbreak of COVID-19 and other diseases, as well as the significance of hygiene practices and community and school-based WASH interventions in reducing infections. This study provides a novel analysis of global WASH-related research and highlights the distribution of outcomes across nations. Continued and increased collaboration between developed and developing nations will facilitate the sharing of responsibility for WASH research outcomes and the implementation of effective policies.

COVID-19 unanticipated benefits to hand washing coverage and practices in health care facilities in central Uganda

Introduction

Hand hygiene in health care facilities (HCFs) remains a significant public health challenge. Global baseline estimates on water, Sanitation, and Hygiene (WASH) in HCFs indicate that 26% of HCFs lack access to an improved water source on the premises. In this study, we sought to assess the proportion of handwashing coverage and the associated factors among healthcare workers in public and private healthcare facilities in Ndejje division, Makindye Ssabagabo municipality, Wakiso district.

Methods

A descriptive cross-sectional study with both quantitative and qualitative methods of data collection was conducted. A total of 350 healthcare workers were interviewed using a self-administered structured open-ended paper questionnaire and Focus Group Discussions (FGD) guide. Data was analysed using STATA 14.2 and ATLAS. ti version 8 software.

Results

The majority of 350 (92.6%) of healthcare workers were from private health facilities. We found out that the proportion of handwashing facilities coverage was 97.7%. The proportion of handwashing was good coupled with a positive attitude towards handwashing. Being a nurse was highly associated with washing hands in both private and public health facilities.

Conclusion

High hand washing proportion was attributed to the COVID-19 guidelines and enforcement which sparked adherence to the standard operating procedures.

Hygienic Disposal of Children's Stools Practices Among Women of Children With Diarrhoea in Sub-Saharan Africa

Background

Diarrhoea stools contain infectious agents and pose a public health threat to children and members of the entire family when exposed to them. Therefore, their hygienic disposal is essential. Empirical data are needed to stir the needed public health interventions to encourage or enforce proper disposal practices to curb associated clinical issues. This study assessed the prevalence and correlates of hygienic stool disposal practices by mothers of children with diarrhoea in sub-Saharan Africa (SSA).

Methods

The Demographic and Health Surveys (DHS) data of 16 sub-Saharan African countries from 2015 to 2021 involving 22 590 mother-child pairs were analysed. Multilevel binary logistic analysis was conducted to assess the individual- and household-level factors associated with the hygienic disposal of stool practices by mothers of children with diarrhoea. The results were presented using adjusted odds ratios (AOR) and 95% confidence intervals (CI) at a statistical significance of P < .05.

Results

The overall prevalence of hygienic disposal of children's stools among women of children with diarrhoea was 49.01% (95% CI: 48.40-49.62) and ranged from 15.70% in Liberia to 86.6% in Rwanda. The practice of hygienic disposal of stools of children with diarrhoea was likely to increase among mothers who are working (AOR: 1.19; 95% CI: 1.09-1.30), those with partners with primary level of education (AOR: 1.18; 95% CI: 1.06-1.31), Muslims (AOR: 1.69; 95% CI: 1.49-1.91) and widowed/divorced (AOR: 8.94, 95% CI: 3.55-22.53). Again, mothers in the richer (AOR: 1.23; 95% CI: 1.08-1.39) wealth index had increased odds of disposing of stools hygienically compared to those in the poorest wealth index. Women who were 20 years and above, to who belonged to Traditional Religions (AOR: 0.57; 95% CI: 0.43-0.74), and those with unimproved sources of water (AOR: 0.89; 95% CI: 0.82-0.98) and toilet facilities (AOR: 0.63; 95% CI: 0.58-0.69) were less likely to dispose of child's diarrhoea stool hygienically than their counterparts.

Conclusion

The study reveals that the unhygienic disposal of the stool of children with diarrhoea is prevalent in SSA and requires a concerted effort to curb it. Sanitation practices such as educating mothers about hygienic disposal of children's stool and improving water and sanitation facilities are crucial in lowering the high prevalence of unhygienic disposal of the diarrhoeic stool of children. Additional country-level research is needed to assess children's defecation behaviours and the disposal of diarrhoeic stools using different methodologies.

Quantifying Factors Associated with Personal Hygiene as Measured by the qPHAT Methodology: Andilaye Trial, Ethiopia

Many water, sanitation, and hygiene (WASH) interventions target improvements in personal hygiene behaviors. Yet measuring personal hygiene behaviors is a challenge due to a lack of reliable, valid, objective, and simple-to-use approaches. The purpose of this study was to examine differences between two types of hygiene outcome measures and their ability to detect relationships between WASH-related behavioral factors and behaviors. We compared hygiene outcomes generated by the Quantitative Personal Hygiene Assessment Tool (qPHAT), which yields objective measures of cleanliness on an 11-point scale, and those generated by conventional, dichotomous indicators of cleanliness. We used cross-sectional data on hygiene outcomes related to facial and hand cleanliness collected during the Andilaye Trial, an impact evaluation of a community-based WASH intervention implemented in Amhara, Ethiopia. We fit multivariable models to examine associations between measures of children's facial and hand cleanliness, via both qPHAT and dichotomous indicators, and 1) household WASH conditions, 2) psychosocial factors, and 3) reported personal hygiene practices. The qPHAT-generated outcomes were able to detect relationships between intermediate behavioral factors and hygiene outcomes that dichotomous indicators were not, including associations with water insecurity and various psychosocial factors. qPHAT-generated outcomes were negatively associated with reported face washing practices, suggesting a bias in reported behaviors. Our study highlights the limitations of reported practices and dichotomous hygiene indicators and indicates that using more quantitative hygiene outcome measures, such as those generated by qPHAT, may reveal important intermediate factors that influence hygiene behavior and support improved monitoring and evaluation of interventions.

A bibliometric analysis of global research on drinking water and health in low- and lower-middle-income countries

Heightened interest in drinking water research in recent decades has been aimed at narrowing the knowledge gaps surrounding water and health in a global pursuit to provide safely managed drinking water services to populations who continue to lack access. This study used bibliometrics and network analysis to produce a global overview of publications and groups that have contributed to research on drinking water and health in low- and lower-middle-income countries (LLMICs). The United States and the United Kingdom, which have historically dominated the field based on the production and impact of scientific literature, remain at the center of international collaborative research partnerships with emerging countries. However, in recent years, the volume of publications produced by India has surpassed that of the United States while Bangladesh is ranked third for the strongest international collaborations. Iran and Pakistan are also emerging as major producers of research, yet publications out of these countries and India remain disproportionately restricted behind paywalls. Contamination, diarrheal disease, and water resources are the themes that characterize the majority of research on water and health. These findings may be used to accelerate equitable, inclusive research in the realm of water and health, thereby enabling gaps in global drinking water inequalities to be filled.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

Using water-adjusted person years to quantify the value of being water secure for an individual's quality of life

Domestic water insecurity harms quality of life outcomes beyond health, for example in worry about water availability or anger at disrupted plans. However, these outcomes are excluded from cost-benefit analyses of water supply interventions, which typically measure and value only prevented disease and time savings. In this paper, I propose a means of quantifying the value of being water secure for an individual's quality of life, the water-adjusted person year (WAPY). One WAPY represents a year lived in complete water security. It is inspired by the quality-adjusted life year in health economics, which combines time with a health-related quality of life index. The WAPY combines time using water services with a water-related quality of life (WaterQoL) index, where 0 = completely water insecure and 1 = completely water secure. The index could be derived from an existing four-attribute Water Insecurity Experiences scale, which includes questions such as "how often did you worry that you would not have enough water for all of your needs?". Other questions concern drinking water, disrupted plans, and handwashing. Responses can be combined in a weighted index based on the relative importance of the four attributes to people. If someone has a WaterQoL index of 0.6, over a 10 year period they would have 6 WAPYs. If a water supply intervention raised WaterQoL to 0.8, they would gain 2 WAPYs over 10 years. The monetary value of WAPYs gained (e.g. in US$) could be estimated by willingness to pay and included in a cost-benefit analysis. Some interventions might result in greater WaterQoL gains than others, or longer-lasting services. Incorporating WAPYs in cost-benefit analyses, alongside prevented disease and time savings, could help identify interventions which provide better water services to more people within a given budget.

Impact of a sanitation intervention on quality of life and mental well-being in low-income urban neighbourhoods of Maputo, Mozambique: an observational study

OBJECTIVES

Toilet users often report valuing outcomes such as privacy and safety more highly than reduced disease, but effects of urban sanitation interventions on such outcomes have never been assessed quantitatively. In this study, we evaluate the impact of a shared sanitation intervention on quality of life (QoL) and mental well-being.

DESIGN

We surveyed individuals living in intervention and control clusters of a recent non-randomised controlled trial, and used generalised linear mixed regression models to make an observational comparison of outcomes between arms.

SETTING

Low-income unsewered areas of Maputo City, Mozambique.

PARTICIPANTS

We interviewed 424 participants, 222 from the prior trial's intervention group and 202 from the control group.

INTERVENTIONS

The control group used low-quality pit latrines. The intervention group received high-quality shared toilets, with users contributing 10%-15% of capital cost.

OUTCOMES

Our primary outcome was the Sanitation-related QoL (SanQoL) index, which applies respondent-derived weights to combine perceptions of sanitation-related disgust, privacy, safety, health and shame. Secondary outcomes were the WHO-5 mental well-being index and a sanitation Visual Analogue Scale.

RESULTS

The intervention group experienced a 1.6 SD gain in SanQoL compared with the control group. This adjusted SanQoL gain was 0.34 (95% CI 0.29 to 0.38) on a 0-1 scale with control mean 0.49. Effect sizes were largest for safety and privacy attributes. Intervention respondents also experienced a 0.2 SD gain in mental well-being. The adjusted gain was 6.2 (95% CI 0.3 to 12.2) on a 0-100 scale with control mean 54.4.

CONCLUSIONS

QoL outcomes are highly valued by toilet users and can be improved by sanitation interventions. Such outcomes should be measured in future sanitation trials, to help identify interventions which most improve people's lives. Since SanQoL weights are derived from respondent valuation, our primary result can be used in economic evaluation.

Assessment of Water, Sanitation and Hygiene Practices Among Households, 2019 - Sierra Leone: A Community-based Cluster Survey

INTRODUCTION

In Sierra Leone, diseases related to water, sanitation, and hygiene remain among the leading cause of morbidity and account for 20% of all death. This study assessed the water, sanitation, and hygiene services and practices at household level in Sierra Leone.

METHODS

A cluster survey was conducted among 1002 households in 4 districts of Sierra Leone. Data was collected on water, sanitation, and hygiene indicators, occurrence of diarrhoeal diseases at household level within 14-day prior to the survey. Chi-square test at 95% significant level was computed to compare the difference in accessing improved water sources, sanitation, and hygiene in urban and rural areas.

RESULT

Of the 1002 households surveyed, 650 (65%) had access to improved drinking water sources. In the urban areas, 432 (88%) out of 486 households had improved drinking water source, which is higher as compared to rural areas. Only 218 (42%) out of 516 households had improved drinking water (P < .001). Of the total households surveyed, 167 (17%) had improved sanitation with 45 (5%) having a handwashing facility. There were 173 households reporting diarrhoeal disease within 2 weeks prior to the survey, with prevalence of 17%.

CONCLUSION

Majority of households in rural areas do not have access to improved water sources, sanitation, and handwashing facilities. This study found a high prevalence of diarrhoeal disease at the household level. It is recommended that The Ministry of Health and Sanitation work with relevant sectors to increase access to improved drinking water, sanitation, and handwashing facilities in rural areas.

Assessing the Sustainability of an Integrated Rural Sanitation and Hygiene Approach: A Repeated Cross-Sectional Evaluation in 10 Countries

An evaluation of area-wide sanitation interventions in 10 countries found that 6 of the 12 program areas had sustained similar levels of basic sanitation 1–2 years post-implementation, with varying levels of slippage in the other program areas.

Introduction:

While many studies have implemented programs to increase sanitation coverage throughout the world, there are limited rigorous studies on the sustainability of these sanitation programs.

Methods:

Between 2014 and 2018, the rural Sustainable Sanitation and Hygiene for All (SSH4A) approach was implemented by SNV in sub-Saharan Africa and Asia. Repeated cross-sectional household surveys were administered annually throughout program implementation and 1 to 2 years following completion of program activities. We characterize to what extent sanitation coverage was sustained 1 to 2 years after implementation of this SSH4A intervention.

Results:

Surveys were conducted in 12 program areas in 10 countries, with 22,666 households receiving a post-implementation survey. Six of 12 program areas (Bhutan, Ghana, Kenya, both Nepal sites, Tanzania) had similar coverage levels of basic sanitation 1–2 years post-implementation, whereas there were varying levels of slippage in the other program areas (both Ethiopia sites, Indonesia, Mozambique, Uganda, Zambia), ranging from a drop of 63 percentage points in coverage in Ethiopia to a drop of only 4 percentage points in Indonesia. In countries that experienced losses in the coverage of household sanitation, sanitation sharing among neighbors generally did not increase, whereas open defecation did increase. In each of the areas where slippage occurred, the sanitation coverage levels at the final time point were all still higher than the initial time point before SNV started working in these areas. We found several factors to be associated with the sustainability of sanitation coverage, including household socioeconomic status, having household members with disabilities, baseline sanitation coverage levels of the program areas, and rate of change of coverage during program activities.

Conclusions:

Data revealed sustained gains in sanitation coverage in some program areas, yet slippage in other areas. This work may serve to benchmark the sustainability of sanitation interventions in sub-Saharan Africa and Asia.

Tap Water Consumption Is Associated with Schoolchildren’s Cognitive Deficits in Afghanistan

Environmental influence on intelligence quotient (IQ) is poorly understood in developing countries. We conducted the first cross-sectional investigation to assess the role of socio-economic and environmental factors on schoolchildren’s IQ in Jalalabad, Afghanistan. A representative sample of 245 schoolchildren aged 7–15 was randomly selected in five schools. Children’s records included: non-verbal IQ TONI-1 scale, body mass index, socio-economic status, and further environmental indicators (water supply, proximity to a heavy-traffic road, use of surma traditional cosmetics). The mean age of the children was 11.7 years old (±2.0 years), and 70.2% and 29.8% were male and female, respectively. The children’s mean IQ was 83.8 (±12.6). In total, 37 (14.9%) of the children were overweight, 78 (31.5%) were living below the USD 1.25 poverty line, 133 (53.6%) used tap water supply, 76 (30.6%) used surma, and 166 (66.9%) were exposed to heavy road traffic. The children’s IQ was significantly and independently lowered by tap water use (−3.9; 95% CI [−7.1; −0.6]) and by aging (−1.4; 95% CI [−2.2; −0.6]), as revealed in multivariate analysis, independently of gender, socio-economic status, exposure to heavy road traffic, overweight status, and surma use. Lower IQ among older children is possibly attributed to chronic stress experienced by adolescents due to living conditions in Afghanistan. While using tap water prevents fecal peril, it may expose children to toxic elements such as lead which is known to lower their intellectual development.

Estimating global water, sanitation, and hygiene levels and related risks on human health, using global indicators data from 1990 to 2020

Water quality improvement, sanitation, and hygiene have been demonstrated to have positive impacts on health, social, and economic development. However, global understanding of water quality, sanitation, and hygiene is limited. The study extracted data from the Joint Monitoring Programme (WHO/UNICEF) and the Demographic and Health Surveys (DHS) to estimate global water, sanitation, and hygiene (WASH) levels. Statistical tools of univariate and multivariate analyses were used to process global access to WASH. Results show that men (53%) had access to safe water compared to women. Women (67%), on the other hand, demonstrated better hygiene practices than men (33%). In addition, adults had access to safe water compared to children, the elderly, and strangers. Globally, there is low water quality in landlock developing countries compared to small island developing states. The categorisation of countries into economic states of low, upper-middle, and high-income countries directly affects water quality, sanitation, and hygiene. Continentally, Africa recorded the least water quality, sanitation, and hygiene levels. Thus, African countries must learn from the best practice in governmental policies and management systems from other continents regarding water improvement, sanitation, and hygiene.

Socio-Economic Aspects of Centralized Wastewater System for Rural Settlement under Conditions of Eastern Poland

This paper presents a case study concerning multivariate analysis, including social and financial aspects, as well as environmental impacts, of the organized sanitation development under conditions of the selected rural settlement in Poland. Three technologically up-to-date variants of sanitary sewerage network concepts with the different assumed sewage transport, i.e., pressure, pressure-gravity and gravity, were proposed together with the investment and operation and maintenance costs estimation. The willingness-to-accept (WTA) and willingness-to-pay (WTP) survey was used to analyze the level of social acceptance and involvement. The financial analysis covered two economic and cost-efficiency dynamic indicators, benefits–costs ratio (BCR) and dynamic generation cost (DGC), commonly used to support the decision-making process. The environmental aspects were assessed by the possible anthropopressure caused by sewerage leakage and odor emissions. Results of the WTA and WTP survey presented a significant level of acceptance and involvement of the local population to sustain the improved sanitation. The determined values of DGC indicated low cost-efficiency of the gravity system, while obtained values of BCR for all variants and the actual regional sewage fees showed the low profitability of improved sanitation, i.e., BCR < 1.0. All studied sanitation systems were assessed positively due to their environmental impacts. The performed studies showed that, despite the declared willingness to accept the organized sanitation and to pay the sewage fees, the economical sustainability of the proposed designs is doubtful over the longer time duration due to the significant capital and operation costs affecting the sewerage payment value.

Prevalence and Correlates of Water, Sanitation, and Hygiene (WASH) and Spatial Distribution of Unimproved WASH in Nepal

This study aims to estimate the prevalence and correlation of household levels of water, sanitation, and hygiene (WASH), including the identification of areas where WASH facilities are unimproved in Nepal. The study population was 11,040 household heads, using the data collected in the Nepal Demographic and Health Survey 2016. Logistic regression analysis was performed and crude odds ratios (OR) with 95% confidence intervals (CI) using a 0.05 significance level are presented. Getis–Ord Gi* statistics were used to identify the hot and cold spot areas of unimproved WASH. GPS locations of WASH points were used for spatial analysis. Approximately 95% of households had an improved water source, 84% had improved sanitation facilities, 81% had a fixed place for handwashing, and 47% had soap and water. Education, wealth, and ecology were significantly associated with WASH. The people from the hills were less likely to have an improved water source (OR = 0.32; 95% CI: 0.16–0.64) than those from the plain. Households with a poor wealth index had 78% lower odds of having an improved water source compared to households with a rich wealth index. Respondents from Madhes Province had lower odds (OR = 0.15; 95% CI: 0.08–0.28) and Gandaki Pradesh had the highest odds (OR = 2.92; 95% CI: 1.52–5.61) of having improved sanitation facilities compared to Province 1. Respondents aged 35–44 years had higher odds (OR = 1.16; 95% CI: 1.04–1.29) of having soap and water available compared to those aged 45 years and older. Education and geographical disparities were the factors associated with having reduced access to WASH. These findings suggest the need to focus on advocacy, services, and policy approaches.

The effect of household practices on the deterioration of microbial quality of drinking water between source and point of use in Murewa district, Zimbabwe

Access to safe drinking water is a key determinant of public health and is considered a basic human right essential to avert waterborne diseases. Understanding the association between household drinking water handling practices and the bacteriological quality of water at the point of use is critical since water quality may deteriorate between source and point of use. This study aimed at determining this association in Murewa district in Zimbabwe. Interviews were conducted with 381 household heads and hygiene practices were observed at selected households. Logistic regression analysis was used to examine the association between household drinking water handling practices and independent variables. The variables that were significantly associated with safe water at the point of use were tertiary education (p = 0.006), monthly income (p = 0.005), cleanliness of water collection containers (p = 0.011) and the method of drawing water from containers (p = 0.001). There is a need to intensify health and hygiene education, emphasising the importance of hygienic water handling practices, cleaning of collection containers and hygienic drawing of water from storage containers. The integration of income-generating activities into WASH projects should be strengthened to enable the acquisition of water collection and storage containers that can safeguard the quality of water between collection and consumption.

Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique

Two billion people globally lack access to a basic toilet. While improving sanitation reduces infectious disease, toilet users often identify privacy, safety and dignity as more important. However, these outcomes have not been incorporated in sanitation-related economic evaluations. This illustrates the general challenge of outcome measurement and valuation in the economic evaluation of public health interventions, and risks misallocating the US$ 20 billion invested in sanitation in low- and middle-income countries every year. In this study in urban Mozambique, we develop an instrument to measure sanitation-related quality of life (SanQoL). Applying methods from health economics and the capability approach, we develop a descriptive system to measure five attributes identified in prior qualitative research: disgust, health, shame, safety and privacy. Sampling individuals from the intervention and control groups of a sanitation intervention trial, we elicit attribute ranks to value a SanQoL index and assess its validity and reliability. In combination with a measure of time using a sanitation service, SanQoL can quantify incremental benefits in a sanitation-focused cost-effectiveness analysis. After monetary valuation based on willingness to pay, QoL benefits could be summed with health gains in cost-benefit analysis, the most common method in sanitation economic evaluations.

An Application of the Integrated Behavioral Model for Water, Sanitation and Hygiene to Assess Perceived Community Acceptability and Feasibility of the Biosand Filter among Maasai Pastoralists in Rural Tanzania

In addition to diarrheal disease risk, lack of access to safe water may have other indirect effects throughout one's life, such as school and workplace absenteeism, leading to less economic productivity. In contexts with scarce resources and unsafe drinking water, household water treatment and safe storage options such as the Biosand filter (BSF) allows households to directly reduce contamination and increase the quality of their drinking water. This study aimed to develop an understanding of perceived community acceptability and feasibility related to pre- and post-implementation of a BSF pilot project in rural Maasai households in the Ngorongoro Conservation Area (NCA), Tanzania. The study was guided by the Integrated Behavioral Model for Water Sanitation and Hygiene interventions (IBM-WASH) to understand the various factors influencing end-user perceptions of the BSF. In-depth interviews, group discussions and think tanks were conducted among a cross-section of community members, stakeholders, and other actors from May 2016 to September 2017. The data were analyzed using a thematic content analysis approach. A range of perceived contextual, technological, and psychosocial factors were found to potentially affect the acceptability and feasibility of BSF adoption in the NCA, highlighting the complex layers of influences in the setting. Whilst the BSF is seemingly an accepted option to treat water within the NCA, the community identified key barriers that may lower BSF adoption. The application of the IBM-WASH model served as a useful framework for evaluating the introduction of the BSF, identifying insights into contextual, technological, and psychosocial community factors.

Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries

INTRODUCTION

Domestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs.

METHODS

Our model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation.

RESULTS

An estimated US$12.2-US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for 'top-up' promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%).

CONCLUSION

The annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Socio-Economic Inequalities in Access to Drinking Water among Inhabitants of Informal Settlements in South Africa

While evidence from several developing countries suggests the existence of socio-economic inequalities in the access to safe drinking water, a limited number of studies have been conducted on this topic in informal settlements. This study assessed socio-economic inequalities in the use of drinking water among inhabitants of informal settlements in South Africa. The study used data from “The baseline study for future impact evaluation for informal settlements targeted for upgrading in South Africa.” Households eligible for participation were living in informal settlements targeted for upgrading in all nine provinces of South Africa. Socio-economic inequalities were assessed by means of multinomial logistic regression analyses, concentration indices, and concentration curves. The results showed that the use of a piped tap on the property was disproportionately concentrated among households with higher socio-economic status (concentration index: +0.17), while households with lower socio-economic status were often limited to the use of other inferior (less safe or distant) sources of drinking water (concentration index for nearby public tap: −0.21; distant public tap: −0.17; no-tap water: −0.33). The use of inferior types of drinking water was significantly associated with the age, the marital status, the education status, and the employment status of the household head. Our results demonstrate that reducing these inequalities requires installing new tap water points in informal settlements to assure a more equitable distribution of water points among households. Besides, it is recommended to invest in educational interventions aimed at creating awareness about the potential health risks associated with using unsafe drinking water.

A multilevel analysis of individual and contextual factors associated with the practice of safe disposal of children's faeces in sub-Saharan Africa

Background

Over the years, sanitation programs over the world have focused more on household sanitation, with limited attention towards the disposal of children’s stools. This lack of attention could be due to the misconception that children’s stools are harmless. The current study examined the individual and contextual predictors of safe disposal of children’s faeces among women in sub-Saharan Africa (SSA).

Methods

The study used secondary data involving 128,096 mother-child pairs of under-five children from the current Demographic and Health Surveys (DHS) in 15 sub-Saharan African countries from 2015 to 2018. Multilevel logistic analysis was used to assess the individual and contextual factors associated with the practice of safe disposal of children’s faeces. We presented the results as adjusted odds ratios (aOR) at a statistical significance of p< 0.05.

Results

The results show that 58.73% (57.79–59.68) of childbearing women in the 15 countries in SSA included in our study safely disposed off their children’s stools. This varied from as high as 85.90% (84.57–87.14) in Rwanda to as low as 26.38% (24.01–28.91) in Chad. At the individual level, the practice of safe disposal of children’s stools was more likely to occur among children aged 1, compared to those aged 0 [aOR = 1.74; 95% CI: 1.68–1.80] and those with diarrhoea compared to those without diarrhoea [aOR = 1.17, 95% CI: 1.13–1.21]. Mothers with primary level of education [aOR = 1.42, 95% CI: 1.30–1.5], those aged 35–39 [aOR = 1.20, 95% CI: 1.12–1.28], and those exposed to radio [aOR = 1.23, 95% CI: 1.20–1.27] were more likely to practice safe disposal of children’s stools. Conversely, the odds of safe disposal of children’s stool were lower among mothers who were married [aOR = 0.74, 95% CI: 0.69–0.80] and those who belonged to the Traditional African Religion [aOR = 0.64, 95% CI: 0.51–0.80]. With the contextual factors, women with improved water [aOR = 1.13, 95% CI: 1.10–1.16] and improved toilet facility [aOR = 5.75 95% CI: 5.55–5.95] had higher odds of safe disposal of children’s stool. On the other hand, mothers who lived in households with 5 or more children [aOR = 0.89, 95% CI: 0.86–0.93], those in rural areas [aOR = 0.86, 95% CI: 0.82–0.89], and those who lived in Central Africa [aOR = 0.19, 95% CI: 0.18–0.21] were less likely to practice safe disposal of children’s stools.

Conclusion

The findings indicate that between- and within-country contextual variations and commonalities need to be acknowledged in designing interventions to enhance safe disposal of children’s faeces. Audio-visual education on safe faecal disposal among rural women and large households can help enhance safe disposal. In light of the strong association between safe stool disposal and improved latrine use in SSA, governments need to develop feasible and cost-effective strategies to increase the number of households with access to improved toilet facilities.

Bacteriological Quality of Drinking Water and Associated Factors at the Internally Displaced People Sites, Gedeo Zone, Southern Ethiopia: A Cross-sectional Study

BACKGROUND

Providing safe and adequate Water, Sanitation and Hygiene (WASH) services in response to emergencies is a major problem. Globally, few studies have investigated the bacteriological quality of drinking water at the IDP sites. Therefore, the objective of this study was to evaluate the bacteriological quality of drinking water and associated factors at the IDP sites of Gedeo zone.

METHODS

A cross-sectional study was conducted on 213 water samples collected from November to December 2018. The membrane filter technique was used to retain bacteria and lauryl sulphate broth media was used to detect faecal coliforms. After incubation of 14 hours at 44°C, faecal coliforms with yellow colonies were counted and expressed in terms of CFU/100 ml of water. The data were entered into Epi data version 3.1 and exported to STATA version 14 for analysis. Binary logistic regression analysis with 95%CI and P ⩽ .05 was used to identify factors associated with an outcome variable.

RESULTS

Out of 213 water samples collected, 107 (50.2%) samples were tested positive for faecal coliforms. The presence of latrines in uphill (AOR: 6.7, 95%CI: 1.0-42.9), other sources of pollution (AOR: 5.0, 95%CI: 1.1-22.3), inadequate fencing (AOR: 7.1, 95%CI: 1.3-40.2) and lack of diversion ditch (AOR: 6.3, 95%CI: 1.0-37.6) were factors significantly associated with faecal contamination of springs. Dug wells that had a latrine within 10 m (AOR: 11.4, 95%CI: 1.8-72.1), other pollution sources within 10 m (AOR: 7.9, 95%CI: 1.9-32.4), inadequate fencing (AOR: 2.8, 95%CI: 1.0-7.9), drawing water using a bucket with rope (AOR: 7.3, 95%CI: 1.6-33.4) and unsanitary well cover (AOR: 3.4, 95%CI: 1.1-10.4) were factors significantly associated with faecal contamination of wells.

CONCLUSIONS

The majority of the water sources in internally displaced people sites were tested positive for faecal coliforms. The presence of latrine in uphill, other sources of pollution, inadequate fencing, lack of diversion ditch, drawing water using a bucket with rope and unsanitary well cover were factors associated with the presence of faecal coliforms. Therefore, adequate fencing, proper diversion ditch construction and hygiene promotion should be done to protect water sources from faecal contamination. Furthermore, latrines and other point sources of contamination should be located at least 10 m away or at a lower elevation from water sources.

A toolkit for costing environmental health services in healthcare facilities

Environmental health services (EHS) are critical for safe and functional healthcare facilities (HCFs). Understanding costs is important for improving and sustaining access to EHS in HCFs, yet the understanding of costs is poor and no tools exist to specifically support costing EHS in HCFs in low- and middle-income countries. We developed a toolkit to guide the following steps of costing EHS in HCFs: defining costing goals, developing and executing a data collection plan, calculating costs, and disseminating findings. The costing toolkit is divided into eight step-by-step modules with instructions, fillable worksheets, and guidance for effective data collection. It is designed for use by diverse stakeholders involved in funding, implementation, and management of EHS in HCFs and can be used by stakeholders with no prior costing experience. This paper describes the development, structure, and functionality of the toolkit; provides guidance for its application; and identifies good practices for costing, including pilot testing data collection tools and iterating the data collection process, involving diverse stakeholders, considering long-term costs, and disaggregating environmental costs in records to facilitate future costing. The toolkit itself is provided in the Supplementary Material.

Climate change and health in urban informal settlements in low- and middle-income countries - a scoping review of health impacts and adaptation strategies

Background: Climate change affects human health with those with the least resources being most vulnerable. However, little is known about the impact of climate change on human health and effective adaptation methods in informal settlements in low- and middle-income countries.

Objective: The objective of this scoping review was to identify, characterize, and summarize research evidence on the impact of climate change on human health in informal settlements and the available adaptation methods and interventions.

Method: A scoping review was conducted using the Arksey and O’Malley framework. The four bibliographic databases PubMed, Web of Science, Embase, and the Cochrane library were searched. Eligibility criteria were all types of peer-reviewed publications reporting on climate change or related extreme weather events (as defined by the United Nations Framework Convention on Climate Change), informal settlements (as defined by UN-Habitat), low- and middle-income countries (as defined by the World Bank) and immediate human health impacts. Review selection and characterization were performed by two independent reviewers using a predefined form.

Results: Out of 1197 studies initially identified, 15 articles were retained. We found nine original research articles, and six reviews, commentaries, and editorials. The articles were reporting on the exposures flooding, temperature changes and perceptions of climate change with health outcomes broadly categorized as mental health, communicable diseases, and non-communicable diseases. Six studies had a geographical focus on Asia, four on Africa, and one on South America, the remaining four articles had no geographical focus. One article investigated an adaptation method for heat exposure. Serval other adaptation methods were proposed, though they were not investigated by the articles in this review.

Conclusion: There is a paucity of original research and solid study designs. Further studies are needed to improve the understanding of the impact, the most effective adaptation methods and to inform policy making.

Development and application of tools to cost the delivery of environmental health services in healthcare facilities: a financial analysis in urban Malawi

BACKGROUND

Environmental health services (EHS) in healthcare facilities (HCFs) are critical for providing a safe, functional healthcare environment, but little is known about their costs. Poor understanding of costs impedes progress towards universal access of EHS in HCFs. We developed frameworks of essential expenses required to provide EHS and conducted an ex-post financial analysis of EHS in a network of medical research and training facilities in Lilongwe, Malawi, serving an estimated 42,000 patients annually through seven outpatient buildings.

METHODS

We estimated the cost of providing the following EHS: water, sanitation, hygiene, personal protective equipment use at the point of care, waste management, cleaning, laundry, and vector control. We developed frameworks of essential outputs and inputs for each EHS through review of international guidelines and standards, which we used to identify expenses required for EHS delivery and evaluate the completeness of costs data in our case study. For costing, we use a mixed-methods approach, applying qualitative interviews to understand facility context and review of electronic records to determine costs. We calculated initial costs to establish EHS and annual operations and maintenance.

RESULTS

Available records contained little information on the upfront, capital costs associated with establishing EHS. Annual operations and maintenance totaled USD 220,427 for all EHS across all facilities (USD 5.21 per patient encounter), although costs of many essential inputs were missing from records. Annual operations and maintenance costs were highest for cleaning (USD 69,372) and waste management (USD 46,752).

DISCUSSION

Missing expenses suggests that documented costs are substantial underestimates. Costs to establish services were missing predominantly because purchases pre-dated electronic records. Annual operations and maintenance costs were incomplete primarily because administrative records did not record sufficient detail to disaggregate and attribute expenses.

CONCLUSIONS

Electronic health information systems have potential to support efficient data collection. However, we found that existing records systems were decentralized and poorly suited to identify EHS costs. Our research suggests a need to better code and disaggregate EHS expenses to properly leverage records for costing. Frameworks developed in this study are a potential tool to develop more accurate estimates of the cost of providing EHS in HCFs.

Promoting Water Conservation Based on the Matching Effect of Regulatory Focus and Emotion

This study aimed to examine the effects of regulatory focus and emotions on water-saving information dissemination. The findings revealed that when water-saving information is framed with a prevention focus, sad emotion fosters more active willingness to engage with the information dissemination than cheerful emotion. However, a promotion focus coupled with cheerfulness is slightly more persuasive than a promotion focus coupled with sadness. Furthermore, compared to the individuals in the nonfit group of emotions who had a regulatory focus, the individuals in the fit group formed a more favorable water-saving attitude and demonstrated a slightly higher willingness to disseminate water-saving information. This article is the first to contribute to exploring the dissemination of water-saving information from the perspective of the interactive effect of individual cognitive motivation and emotion.

Safe Healthcare Facilities: A Systematic Review on the Costs of Establishing and Maintaining Environmental Health in Facilities in Low- and Middle-Income Countries

A hygienic environment is essential to provide quality patient care and prevent healthcare-acquired infections. Understanding costs is important to budget for service delivery, but costs evidence for environmental health services (EHS) in healthcare facilities (HCFs) is lacking. We present the first systematic review to evaluate the costs of establishing, operating, and maintaining EHS in HCFs in low- and middle-income countries (LMICs). We systematically searched for studies costing water, sanitation, hygiene, cleaning, waste management, personal protective equipment, vector control, laundry, and lighting in LMICs. Our search yielded 36 studies that reported costs for 51 EHS. There were 3 studies that reported costs for water, 3 for sanitation, 4 for hygiene, 13 for waste management, 16 for cleaning, 2 for personal protective equipment, 10 for laundry, and none for lighting or vector control. Quality of evidence was low. Reported costs were rarely representative of the total costs of EHS provision. Unit costs were infrequently reported. This review identifies opportunities to improve costing research through efforts to categorize and disaggregate EHS costs, greater dissemination of existing unpublished data, improvements to indicators to monitor EHS demand and quality necessary to contextualize costs, and development of frameworks to define EHS needs and essential inputs to guide future costing.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh

Background

Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.

Methods

The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.

Results

For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (− 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, − 25% (− 35, − 15) Q2: − 34% (− 44, − 23%)] than the wealthiest household [Q5 DID: − 1% (− 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1–4 DID: 50–54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).

Conclusion

By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.

Trial registration

WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01353-7.

Motion but no speed: Colonial to post-colonial status of water and sanitation service provision in Mombasa city

Amidst climate change, coastal cities in Africa will face serious water and sanitation problems owing to the predicted flooding of coastal land and saltwater intrusion into freshwater aquifers. For cities such as Mombasa, the problems will be further compounded by high prevalence of informal economies and settlements superimposed on western style governance systems. Yet, right from colonisation to the present day, the water supply and sewage systems have been characterised by a series of inequalities in access. This review paper, discusses the water and sanitation backlogs in the coastal city of Mombasa, tracing them from the colonial times to the post-colonial period. Against this background, we overview the current situation of the water and sanitation sector in the city and discuss possible sustainable interventions. We argue that any analysis of the water and sanitation challenges must consider the motive of the development of the infrastructure during the colonial times. We conclude that sustainable water and sanitation services are likely to remain a mirage unless the issues of funding, cost recovery, data availability and overall governance are fully addressed. A good understanding of both historical inadequacies and current investments would help in designing sustainable interventions going forward.

Transdisciplinary Research Priorities for Human and Planetary Health in the Context of the 2030 Agenda for Sustainable Development

Human health and wellbeing and the health of the biosphere are inextricably linked. The state of Earth's life-support systems, including freshwater, oceans, land, biodiversity, atmosphere, and climate, affect human health. At the same time, human activities are adversely affecting natural systems. This review paper is the outcome of an interdisciplinary workshop under the auspices of the Future Earth Health Knowledge Action Network (Health KAN). It outlines a research agenda to address cross-cutting knowledge gaps to further understanding and management of the health risks of these global environmental changes through an expert consultation and review process. The research agenda has four main themes: (1) risk identification and management (including related to water, hygiene, sanitation, and waste management); food production and consumption; oceans; and extreme weather events and climate change. (2) Strengthening climate-resilient health systems; (3) Monitoring, surveillance, and evaluation; and (4) risk communication. Research approaches need to be transdisciplinary, multi-scalar, inclusive, equitable, and broadly communicated. Promoting resilient and sustainable development are critical for achieving human and planetary health.

Individual and contextual factors associated with disposal of children's stools in Papua New Guinea: evidence from the 2016-2018 demographic and health survey

BACKGROUND

Proper sanitation has been one of the topmost priorities on the global public health agenda. In the past few decades, sanitation programs targeting households have often paid little attention to the disposal of children's stools. We assessed the individual and contextual factors associated with disposal of children's faeces in Papua New Guinea.

METHODS

The data used for this study forms part of the 2016-2018 Papua New Guinea Demographic and Health Survey (PDHS). For this study, we focused on women with children less than five years (n = 2095). Both descriptive and inferential analyses were carried out. Descriptive statistics were used to summarize the data, using frequency counts and percentages. The inferential analysis used multilevel logistic regression models to investigate the individual and contextual factors associated with disposal of children's stools. These models were presented as adjusted odds ratio (AORs), together with their corresponding 95% confidence intervals. Statistical significance was set at p < 0.05.

RESULTS

More than half (56%) of the women had disposed of their children's stools unsafely. With the individual level factors, the results showed that women with children < 12 months [AOR =1.71; CI = 1.28-2.29] and women aged 20-24 [AOR =2.58; CI = 1.24-5.37], 35-39 [AOR =2.34; CI = 1.09-5.04], and 40 years and above [AOR =2.51; CI = 1.09-5.79] were more likely to practice unsafe disposal of children's stool. The odds of unsafe disposal of faeces was also higher among women who visited the health facility for child diarrhea [AOR =1.69; CI = 1.25-2.28]. With the contextual factors, the odds of unsafe disposal of children's stool was higher among women who lived in the Southern region [AOR =4.82; CI = 2.08-11.18], those who lived in male-headed households [AOR =1.79; CI = 1.19-2.70], and those who had unimproved toilet facilities [AOR =1.96; CI = 1.39-2.76]. On the contrary, women with unimproved source of drinking water were less likely to dispose of their children's stool unsafely [AOR =0.54; CI = 0.35-0.83].

CONCLUSION

Both individual and contextual factors predict unsafe disposal of children's faeces in Papua New Guinea. It is recommended that sanitation programs should focus on behavioral change and not only on the extension of water and improved toilet facilities. Such programs should also focus on both individual and contextual factors of women.

Lack of Safe Drinking Water for Lake Chapala Basin Communities in Mexico Inhibits Progress toward Sustainable Development Goals 3 and 6

BACKGROUND

Access to safe, affordable and accessible drinking water is a human right and foundational to the third and sixth World Health Organization's Sustainable Development Goals (SDGs). Unsafe drinking water is a risk factor for chronic and enteric diseases. Both chronic kidney disease (CKD) and diarrheal disease are highly prevalent in the Lake Chapala basin, Jalisco, Mexico, suggesting disparities in factors leading to successful achievement of these two SDGs.

METHODS

This study aimed to assess progress towards SDG three and six in the Lake Chapala basin. Qualitative, quantitative, and geospatial data were collected between May and August of 2019 from three towns within the municipalities of Poncitlán and Chapala.

RESULTS

Ninety-nine households participated in this study. Water sampling analyses determined 81.18% of samples from water jugs (garrafones) and 70.05% of samples from tap water were contaminated with total coliform bacteria, often including E. coli. Additionally, 32% of garrafón samples and 61.9% of tap water samples had detectable levels of arsenic. Approximately 97.94% of respondents stated that they believe clean water is a human right, but 78.57% feel the Mexican government does not do enough to make this a reality.

CONCLUSIONS

This mixed methods approach highlights water quality as a serious issue in communities around Lake Chapala, and demonstrates inadequate drinking water as a key hazard, potentially perpetuating the high disease burden of both CKD and enteric disease in the region.

Open defecation-free slippage and its associated factors in Ethiopia: a systematic review

BACKGROUND

Recent studies have shown an increase in open defecation and slippage of open defecation-free certified villages in Ethiopia, despite significant progress the country made on sanitation programs. Hence, realizing of existing facts, this study was conducted aiming at a critical review of available literature and to provide consolidated data showing the level of slippage and its associated factors in Ethiopia.

METHODS

Systematic literature searches were performed from four international databases. The search involved articles published from December 1, 2013, up to June 4, 2019. The Cochran's Q and I2 test statistics were used to check heterogeneity among the studies. To negotiate heterogeneity from qualitative data, we used a mixed-method approach. The researchers also conducted a publication bias assessment and sensitivity analysis. A random effect meta-analysis was employed to determine the pooled estimates of open defecation free slippage rate with a 95% confidence interval (CI). The data analysis was performed using the CMA V.3 software program.

RESULT

After screening 1382 studies, 12 studies were finally included in this systematic review. The estimated pooled rate of open defecation-free slippage in Ethiopia was 15.9% (95% CI 12.9-19.4%). The main contributing factors for open defecation-free slippage were lack of technical support, financial constraints, low-quality building materials, improper program implementation, and lack of sanitation marketing.

CONCLUSION

It was estimated that 1 out of 6 Ethiopian households engaged in open defecation after they have certified open defecation-free status, implying the low possibility of achieving sustainable development goals of 2030, which aims to ensure sanitation for all. Therefore, the government of Ethiopia and donors should better give special attention to the following options: (1) awareness for open defecation-free slippage, (2) launch a post-open defecation-free program, and (3) encourage research on pro-poor sustainable sanitation technologies.

In pursuit of 'safe' water: the burden of personal injury from water fetching in 21 low-income and middle-income countries

INTRODUCTION

Water fetching for household needs can cause injury, but documentation of the burden of harm globally has been limited. We described the frequency, characteristics and correlates of water-fetching injuries in 24 sites in 21 low-income and middle-income countries in Asia, Africa and Latin America and the Caribbean.

METHODS

In a survey of 6291 randomly selected households, respondents reported whether and how they had experienced water-fetching injuries. Responses were coded for injury type, mechanism, bodily location and physical context. We then identified correlates of injury using a multilevel, mixed-effects logistic regression model.

RESULTS

Thirteen per cent of respondents reported at least one water-fetching injury. Of 879 injuries, fractures and dislocations were the most commonly specified type (29.2%), and falls were the most commonly specified mechanism (76.4%). Where specified, 61.1% of injuries occurred to the lower limbs, and dangerous terrain (69.4%) was the most frequently reported context. Significant correlates included being female (aOR=1.50, 95% CI 1.15 to 1.96); rural (aOR=4.80, 95% CI 2.83 to 8.15) or periurban residence (aOR=2.75, 95% CI 1.64 to 4.60); higher household water insecurity scores (aOR=1.09, 95% CI 1.07 to 1.10) and reliance on surface water (aOR=1.97, 95% CI 1.21 to 3.22) or off-premise water sources that required queueing (aOR=1.72, 95% CI 1.19 to 2.49).

CONCLUSION

These data suggest that water-fetching injuries are an underappreciated and largely unmeasured public health challenge. We offer guidelines for comprehensive data collection on injuries to better capture the true burden of inadequate water access. Such data can guide the design of interventions to reduce injury risk and promote equitable water access solutions.

Informing water distribution line rehabilitation through quantitative microbial risk assessment

Poor urban water quality has been linked to diminished source water quality, poorly functioning water treatment systems and infiltration into distribution lines after treatment resulting in microbiological contamination. With limited funding to rehabilitate distribution lines, developing nations need tools to identify the areas of greatest concern to human health so as to target cost effective remediation approaches. Herein, a case study of Hyderabad, Pakistan was used to demonstrate the efficacy of combining quantitative microbial risk assessment (QMRA) for multiple pathogens with spatial distribution system modeling to identify areas for pipe rehabilitation. Abundance of Escherichia coli, Enterococcus (enterococci), Salmonella spp., Shigella spp., Giardia intestinalis, Vibrio cholera, norovirus GI and adenovirus 40/41, were determined in 85 locations including the source water, treatment plant effluent and the city distribution lines. Bayesian statistics and Monte Carlo simulations were used in the QMRA to account for left-censored microbial abundance distributions. Bacterial and viral abundances in the distribution system samples decreased as follows: 9400 ± 19,800 norovirus gene copies/100 mL (average ± standard deviation, 100% of samples positive); 340 ± 2200 enterococci CFU/100 mL (94%), 71 ± 97 Shigella sp. CFU/100 mL (97%), 60 ± 360 E. coli CFU/100 mL (89%), 35 ± 79 adenovirus gene copies/100 mL (100%), and 21 ± 46 Salmonella sp. CFU/100 mL (76%). The QMRA revealed unacceptable probabilities of illness (>1 in 10,000 illness level) from the four exposure routes considered (drinking water, or only showering, tooth brushing, and rinsing vegetables consumed raw). Disease severity indices based on the QMRA combined with mapping the distribution system revealed areas for targeted rehabilitation. The combined intensive sampling, risk assessment and mapping can be used in low- and middle-income countries to target distribution system rehabilitation efforts and improve health outcomes.

Fecal Contamination of Drinking Water Was Associated with Diarrheal Pathogen Carriage among Children Younger than 5 Years in Three Peruvian Rural Communities

Drinking water contamination is a frequent problem in developing countries and could be associated with bacterial pathogen carriage in feces. We evaluated the association between the risk of drinking water and bacterial carrier status in children younger than 5 years in a cross-sectional study conducted in 199 households from three Peruvian rural communities. Fecal samples from children were screened for pathogenic Aeromonas, Campylobacter, and Vibrio species, as well as for Enterobacteriaceae, including pathogenic Escherichia coli. The drinking water risk was determined using E. coli as an indicator of contamination. Nineteen (9.5%) children were colonized with pathogens and classified as carriers, all without diarrhea symptoms. Of 199 drinking water samples, 38 (19.1%) were classified as very high risk because of high fecal contamination (> 100 E. coli/100 mL). Shared-use water sources, daily washing of containers, and washing using only water were associated with higher prevalence of bacterial carriage, whereas there was no association between households reporting boiling and chlorination of water and carrier status. The prevalence of carriage in children exposed to very high-risk water was 2.82 (95% CI: 1.21-6.59) times the prevalence of those who consumed less contaminated water, adjusted by the water source and daily washing. Our results suggest that household drinking water plays an important role in the generation of carriers with diarrheal pathogens. Our findings also highlight the importance of interventions to ensure the safety of drinking water. Further studies are needed to validate the observed association and determine its significance with respect to diarrhea in the community.

Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation

Background

Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs).

Methods

This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data.

Results and conclusions

Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.

Benefits and Costs of a Community-Led Total Sanitation Intervention in Rural Ethiopia-A Trial-Based ex post Economic Evaluation

We estimated the costs and benefits of a community-led total sanitation (CLTS) intervention using the empirical results from a cluster-randomized controlled trial in rural Ethiopia. We modelled benefits and costs of the intervention over 10 years, as compared to an existing local government program. Health benefits were estimated as the value of averted mortality due to diarrheal disease and the cost of illness arising from averted diarrheal morbidity. We also estimated the value of time savings from avoided open defecation and use of neighbours' latrines. Intervention delivery costs were estimated top-down based on financial records, while recurrent costs were estimated bottom-up from trial data. We explored methodological and parameter uncertainty using one-way and probabilistic sensitivity analyses. Avoided mortality accounted for 58% of total benefits, followed by time savings from increased access to household latrines. The base case benefit-cost ratio was 3.7 (95% CI: 1.9-5.4) and the net present value was Int'l $1,193,786 (95% CI: 406,017-1,977,960). The sources of the largest uncertainty in one-way sensitivity analyses were the effect of the CLTS intervention and the assumed lifespan of an improved latrine. Our results suggest that CLTS interventions can yield favourable economic returns, particularly if follow-up after the triggering is implemented intensively and uptake of improved latrines is achieved (as opposed to unimproved).

Water, sanitation and hygiene risk factors for the transmission of cholera in a changing climate: using a systematic review to develop a causal process diagram

Cholera is a severe diarrhoeal disease affecting vulnerable communities. A long-term solution to cholera transmission is improved access to and uptake of water, sanitation and hygiene (WASH). Climate change threatens WASH. A systematic review and meta-analysis determined five overarching WASH factors incorporating 17 specific WASH factors associated with cholera transmission, focussing upon community cases. Eight WASH factors showed lower odds and six showed higher odds for cholera transmission. These results were combined with findings in the climate change and WASH literature, to propose a health impact pathway illustrating potential routes through which climate change dynamics (e.g. drought, flooding) impact on WASH and cholera transmission. A causal process diagram visualising links between climate change dynamics, WASH factors, and cholera transmission was developed. Climate change dynamics can potentially affect multiple WASH factors (e.g. drought-induced reductions in handwashing and rainwater use). Multiple climate change dynamics can influence WASH factors (e.g. flooding and sea-level rise affect piped water usage). The influence of climate change dynamics on WASH factors can be negative or positive for cholera transmission (e.g. drought could increase pathogen desiccation but reduce rainwater harvesting). Identifying risk pathways helps policymakers focus on cholera risk mitigation, now and in the future.

Multidimensional Benefits of Improved Sanitation: Evaluating 'PEE POWER®' in Kisoro, Uganda

With 2.3 billion people around the world lacking adequate sanitation services, attention has turned to alternative service provision models. This study suggests an approach for meeting the sanitation challenge, especially as expressed in Sustainable Development Goal 6.2, using a toilet technology system, such as Pee Power® that generates electricity using diverted urine as a fuel. A field trial was carried out in a girls' school in Kisoro, Uganda, where the generated electricity was used to light the existing toilet block. The trial was evaluated in terms of social acceptability and user experience using a multidimensional assessment protocol. The results of our assessment show that users felt safer when visiting the toilets at night. Lights provided from the technology also helped with the perceived cleanliness of the toilets. The technology was well accepted, with 97% of the respondents saying that they liked the idea of the Pee Power® technology and 94% preferring it over other facilities on site. This shows how the technology helps meet SDG target 6.2, with its particular focus on vulnerable populations.

Budgeting for Environmental Health Services in Healthcare Facilities: A Ten-Step Model for Planning and Costing

Environmental health services (EHS) in healthcare facilities (HCFs) are critical for safe care provision, yet their availability in low- and middle-income countries is low. A poor understanding of costs hinders progress towards adequate provision. Methods are inconsistent and poorly documented in costing literature, suggesting opportunities to improve evidence. The goal of this research was to develop a model to guide budgeting for EHS in HCFs. Based on 47 studies selected through a systematic review, we identified discrete budgeting steps, developed codes to define each step, and ordered steps into a model. We identified good practices based on a review of additional selected guidelines for costing EHS and HCFs. Our model comprises ten steps in three phases: planning, data collection, and synthesis. Costing-stakeholders define the costing purpose, relevant EHS, and cost scope; assess the EHS delivery context; develop a costing plan; and identify data sources (planning). Stakeholders then execute their costing plan and evaluate the data quality (data collection). Finally, stakeholders calculate costs and disseminate findings (synthesis). We present three hypothetical costing examples and discuss good practices, including using costing frameworks, selecting appropriate indicators to measure the quantity and quality of EHS, and iterating planning and data collection to select appropriate costing approaches and identify data gaps.

Inequality in access to improved drinking water sources and childhood diarrhoea in low- and middle-income countries

In addition to the conventional wisdom of categorizing countries based on nationally-averaged coverage in access to improved drinking water sources (IDWS), this study incorporated sub-national inequality into a novel categorisation framework. The association between access to IDWS and the incidence of childhood diarrhoea (ICD) was also quantified. Information from 1.63 million households obtained through nationally representative and cross-sectional demographic and health survey (DHS) and multiple indicator cluster survey (MICS) from 81 countries were analysed. Sub-national inequalities in the access to IDWS were measured using proportional variability (PV). Most studied countries with low coverage and high inequalities in accessing IDWS were from Sub-Saharan Africa (SSA). Wealth status of households showed a higher variability in the IDWS than the variability across locations. Significant negative associations between accessing IDWS and ICD were observed for regional models, except for SSA. This study adds knowledge towards understanding the state of sustainable development goal achievements in terms of accessing IDWS. The knowledge may be helpful in designing country-specific, achievable, short- and long-term strategies. The non-decisive relation between access to IDWS and ICD indicates the adoption of additional measures in the modelling mechanism.