Household water use and greywater management in Khulna city, Bangladesh

While substantial progress has been made in improving water and sanitation services in low- and middle-income countries, aligned basic services such as greywater, stormwater, and solid waste management have progressed little in recent decades. Data was collected in Khulna city, Bangladesh via a household survey (n = 192) of low-income areas exploring domestic water use and greywater volumes, characteristics, and disposal practices. Most households (71%) use a piped water supply for domestic purposes, supplemented by seasonal rainwater harvesting (26%) and greywater use (13%). Of the total water used by households (mean: 594 L/household/day and equivalent to 116 L/person/day), approximately 58% becomes greywater through bathing, dishwashing, religious practices, handwashing, laundry, and mopping. Greywater produced ranges from 61-1274 L/household/day, with a mean of 345 L/household/day and equivalent to 78.4 L/person/day. Greywater characteristics vary depending on the activity, individual behaviours and any products used during cooking, bathing, or cleaning. After generation, households dispose greywater to open drains (67%), nearby waterbodies (17%) directly to the ground (9%), or decentralised wastewater treatment system (7%). Without services for greywater management, greywater disposal may have considerable public and environmental health implications, necessitating careful attention and oversight from service-providers and stakeholders beyond the household-level.

Implementing risk-based approaches to improve drinking water quality in small water supplies in the Nordic region - barriers and solutions

Small water supplies face similar problems worldwide, regardless of ownership or management type. Non-compliance with water quality regulations is more frequent in small supplies than in large ones, as are waterborne disease outbreaks. The new European Union Drinking Water Directive requires risk-based approach (RBA) to secure water safety as is recommended in the World Health Organization's Guidelines for drinking water quality through 'water safety plans'. This is already in regulation in the Nordic countries, although less used in small supplies. In this research, we explore the challenges, barriers and possible solutions to implementing RBA and improving compliance in small supplies. This was achieved by conducting and analysing interviews with 53 stakeholders from all eight Nordic countries to produce recommendations for action by the different implicated actors. Our findings suggest the centrality of governmental policy, including support for continuous training, provision of simple RBA guidelines and increasing cooperation in the water sector. The Nordic experience reflects global challenges with small water supplies and the trend towards systematic preventive management epitomized in the framework for drinking water safety advocated by the World Health Organization since 2004.

Urban Sanitation: New Terminology for Globally Relevant Solutions?

Progress toward Sustainable Development Goals for global access to safe sanitation is lagging significantly. In this Feature, we propose that misleading terminology leads to errors of categorization and hinders progress toward sanitation service provision in urban areas. Binary classifications such as "offsite/onsite" and "sewered/nonsewered" do not capture the need for "transport to treatment" or the complexity of urban sanitation and should be discarded. "Fecal sludge management" is used only in the development context of low- or middle-income countries, implying separate solutions for "poor" or "southern" contexts, which is unhelpful. Terminology alone does not solve problems, but rather than using outdated or "special" terminology, we argue that a robust terminology that is globally relevant across low-, middle-, and upper-income contexts is required to overcome increasingly unhelpful assumptions and stereotypes. The use of accurate, technically robust vocabulary and definitions can improve decisions about management and selection of treatment, promote a circular economy, provide a basis for evidence-based science and technology research, and lead to critical shifts and transformations to set policy goals around truly safely managed sanitation. In this Feature, the three current modes of sanitation are defined, examples of misconceptions based on existing terminology are presented, and a new terminology for collection and conveyance is proposed: (I) fully road transported, (II) source-separated mixed transport, (III) mixed transport, and (IV) fully pipe transported.

Public health performance of sanitation technologies in Tamil Nadu, India: Initial perspectives based on E. coli release

Sanitation is intended to reduce the spread and burden of diseases transmitted from excreta. Pathogen reduction from excreta before sludge or effluent discharge to the environment would seem a logical and useful performance indicator for sanitation systems. However, the relative magnitudes of pathogen release from common sanitation technologies are not well understood. We, therefore, investigated the feasibility of performance measurement of different sanitation technologies in Tamil Nadu, India in reducing the release of the pathogen indicator Escherichia coli (E. coli). After conducting users’ surveys and technical assessments of the locally prevalent sanitation systems, we classified them into 7 distinct categories (based on both observed physical characteristic and usage) within a widely-accepted physical typology. Faecal sludge and wastewater samples were collected and analysed for E. coli and total solids from 136 household systems, 24 community systems, and 23 sanitary sewer oveflows. We estimated the average volumetric release rates of wastewater and faecal sludge from the different sanitation technologies. Average daily per capita E. coli release was computed, and used as one indicator of the public health performance of technologies. We found that on-site installations described by owners as “septic systems” included diverse forms of tanks and pits of uncertain performance. We observed a statistically significant difference in the average daily per capita E. coli release from different sanitation technologies (p = 0.00001). Pathogen release from the studied on-site sanitation technologies varied by as much as 5 orders of magnitude from “lined pits” (5.4 Log10 E. coli per person per day) to “overflowing sanitary sewers” and “direct discharge pipes” (10.3–10.5 Log10 E. coli per person per day). Other technologies lay between these extremes, and their performances in E. coli removal also varied significantly, in both statistical and practical terms. Our results suggest that although faecal sludge management along the sanitation service chain is important, sanitation planners of the observed systems (and probably elsewhere) should direct higher priority to proper management of the liquid effluents from these systems to minimize public health hazards. We conclude that (i) the work demonstrates a new and promising approach for estimating the public health performance of differing sanitation technologies, (ii) if E.coli is accepted as an indicator of the public health hazard of releases from sanitation systems, our results strongly suggest that safe containment of excreta for an extended period substantially reduces pathogen numbers and the risk of pathogen release into the environment; and (iii) there are some simple but little-used technical improvements to design and construction of on-site sanitation systems which could significantly reduce the release of pathogens to the environment.

MRI Patterns in Pediatric CNS Hemophagocytic Lymphohistiocytosis

BACKGROUND AND PURPOSE

Neuroimaging has an important role in detecting CNS involvement in children with systemic or CNS isolated hemophagocytic lymphohistiocytosis. We characterized a cohort of pediatric patients with CNS hemophagocytic lymphohistiocytosis focusing on neuroradiologic features and assessed whether distinct MR imaging patterns and genotype correlations can be recognized.

MATERIALS AND METHODS

We retrospectively enrolled consecutive pediatric patients diagnosed with hemophagocytic lymphohistiocytosis with CNS involvement treated at 2 pediatric neurology centers between 2010 and 2018. Clinical and MR imaging data were analyzed.

RESULTS

Fifty-seven children (40 primary, 70%) with a median age of 36 months (interquartile range, 5.5-80.8 months) were included. One hundred twenty-three MR imaging studies were assessed, and 2 broad imaging patterns were identified. Pattern 1 (significant parenchymal disease, 32/57, 56%) was seen in older children (P = .004) with worse clinical profiles. It had 3 onset subpatterns: multifocal white matter lesions (21/32, 66%), brainstem predominant disease (5, 15%), and cerebellitis (6, 19%). All patients with the brainstem pattern failed to meet the radiologic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. An attenuated imaging phenotype (pattern 2) was seen in 25 patients (44%, 30 studies) and was associated with younger age.

CONCLUSIONS

Distinct MR imaging patterns correlating with clinical phenotypes and possible genetic underpinnings were recognized in this cohort of pediatric CNS hemophagocytic lymphohistiocytosis. Disruptive mutations and missense mutations with absent protein expression correlate with a younger onset age. Children with brainstem and cerebellitis patterns and a negative etiologic work-up require directed assessment for CNS hemophagocytic lymphohistiocytosis.

Evidence Map and Systematic Review of Disinfection Efficacy on Environmental Surfaces in Healthcare Facilities

Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28-34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, and subsequently HAIs, in critical care settings. This evidence map includes a systematic review on the efficacy of disinfecting environmental surfaces in healthcare facilities. We screened 17,064 abstracts, 635 full texts, and included 181 articles for data extraction and study quality assessment. We reviewed ten disinfectant types and compared disinfectants with respect to study design, outcome organism, and fourteen indictors of study quality. We found important areas for improvement and gaps in the research related to study design, implementation, and analysis. Implementation of disinfection, a determinant of disinfection outcomes, was not measured in most studies and few studies assessed fungi or viruses. Assessing and comparing disinfection efficacy was impeded by study heterogeneity; however, we catalogued the outcomes and results for each disinfection type. We concluded that guidelines for disinfectant use are primarily based on laboratory data rather than a systematic review of in situ disinfection efficacy. It is critically important for practitioners and researchers to consider system-level efficacy and not just the efficacy of the disinfectant.

Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda

Contaminated drinking water causes morbidity and mortality worldwide, especially in low- and middle-income countries. Drinking water quality has been studied extensively in household settings, but little research is available on drinking water quality in schools. School settings are of particular importance, because children are more susceptible than adults to a variety of diseases from contaminated drinking water. Many school water, sanitation and hygiene (WaSH) interventions have been studied for their efficacy to reduce diarrheal disease incidence, but few have evaluated drinking water quality, which reflects an important exposure pathway between WaSH services and health outcomes. Using school surveys developed from internationally established WaSH indicators and field microbiological water quality tests, we studied 374 rural schools in Mozambique and Uganda to understand the association between specific WaSH services and drinking water microbiological contamination, specifically testing most probable number (MPN) of Escherichia coli, an indicator of fecal contamination, per 100 mL. In Mozambique and Uganda, 71% and 83% respectively of rural schools had low risk drinking water quality (<1 E. coli/100 mL); thirteen percent and seven percent had very high-risk water quality (≥100 E. coli/100 mL). When accounting for all WaSH services studied, schools that used an improved-type water source had 0.22 times less E. coli in stored drinking water in Mozambique (95% CI: 0.07, 0.65) and 0.12 times less E. coli in Uganda (95% CI: 0.02, 0.80). In Mozambique, use of a water source within 30 minutes for travel and collection and the presence of water and soap/ash for handwashing were also significantly associated with less E. coli in drinking water. The findings of this study provide public health practitioners with implementable WaSH services to improve school drinking water quality, which has implications for the health, learning environment, and cognitive development of school children in rural Mozambique and Uganda.

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.

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.

Environmental health conditions in the transitional stage of forcible displacement: A systematic scoping review

In 2019, 30,000 people were forced to leave their homes due to conflict, persecution, and natural disaster each day. Eighty-five percent of refugees live in developing countries, and they often face underfunded and inadequate environmental health services. Many displaced persons live in camps and other temporary settlements long after the displacement event occurs. However, there is little evidence on environmental health conditions in the transitional phase-defined by the United Nations High Commissioner for Refugees as six months to two years after displacement. To address this gap in research, we conducted a systematic scoping review of environmental health conditions, exposures, and outcomes in transitional displacement settings, as well as reported obstacles and recommendations for improvement. Eighty-eight publications met the inclusion criteria. Water supply was the most frequently discussed environmental health topic. Overcrowding was the most common risk factor reported, Vibrio cholerae was the most common pathogen reported, and diarrhea was the most commonly reported health outcome. Obstacles and recommendations were categorized as institutional, political or implementation-based. Identified knowledge gaps included minimal information on setting logistics and on topics such as menstrual hygiene, oral hygiene and fomite contamination. In order to improve environmental health conditions in transitional displacement settings, all levels of government and non-governmental organizations should increase collaboration to improve resource provision. This study is the first to report on environmental health conditions in this important time of transition between the emergency and protracted stages of displacement.

Factors associated with water quality, sanitation, and hygiene in rural schools in 14 low- and middle-income countries

Improving access to water, sanitation, and hygiene (WaSH) and menstrual hygiene management (MHM) in schools is important to achieve Sustainable Development Goals (SDGs) 3 and 6. Inadequate WaSH and MHM in schools adversely affect student health and educational performance, as well as teacher satisfaction. However, there is little evidence describing factors associated with WaSH services and MHM in schools. We conducted 2690 surveys and collected 1946 water samples at randomly selected schools in rural areas of 14 low- and middle-income countries (LMICs). We developed multilevel mixed-effects logistic regression models to identify factors associated with basic water services, water quality, basic sanitation facilities, basic handwashing facilities, and availability of MHM materials. We found that 51% of schools had at least a basic, on-premises water service. Twenty-eight percent of schools had at least basic sanitation services, 12% had at least a basic handwashing facility, and 26% had MHM materials available. Four percent of schools had all basic WaSH services. Half (52%) of schools had drinking water compliant with the WHO guideline value for E. coli. In regression models, we found that schools that did not share their water point with a community, had a parent-teacher association that supported WaSH, or had support from an external WaSH program were more likely to have access to basic, continuous, on-premises water service versus worse access. Schools with an on-premises water point, water available on the day of survey, a health club, or handwashing stations near toilets were more likely to have a basic sanitation service versus a lower service. Schools with limited or basic sanitation, health clubs, an MHM curriculum, a designated MHM focal person, or school funds for WaSH were more likely to have MHM materials. We conclude that improved institutional management and external support, accountability mechanisms, and enhanced training and hygiene curriculum will support sustained WaSH service delivery in schools in LMICs.

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.

Environmental conditions in maternity wards: Evidence from rural healthcare facilities in 14 low- and middle-income countries

Adequate environmental conditions, comprising sufficient environmental hygiene items (e.g. gloves, soap, and disinfectant), adequate infrastructure (e.g. sanitation facilities, water supply), a clean environment, and hygienic behaviors in healthcare facilities (HCFs) are necessary for safe care in maternity wards. Few data are available describing environmental conditions in maternity wards in rural areas of low- and middle-income countries (LMICs). We collected data on these conditions from 1547 HCFs with maternity wards in 14 countries (Ethiopia, Ghana, Honduras, India, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe). We described patterns and availability of essential environmental conditions, and a regression model was developed to explore predictive factors. 73% of HCFs offering maternal and neonatal health (MNH) services did not meet the guidelines for the World Health Organization 'six cleans' (clean perineum, clean bed surface, clean hands, clean blade, clean cord tie, and clean towels to wrap the baby and mother). The items with the lowest availability were clean towels (40%). In a multivariable logistic regression model, HCFs that provided maternity services were more likely to have all 'six cleans' available if they: had at least an improved water source; had an infection prevention and control (IPC) protocol; had a budget considered sufficient that included funding for water, sanitation, hygiene, and IPC; and emphasized the importance of IPC within the nearby community. Our results demonstrate substantial differences between countries in the availability of environmental hygiene items, facility cleanliness, and quality of environmental health infrastructure in HCF maternity wards. There are several low-cost, high-impact, context-relevant opportunities to enhance essential environmental conditions that would improve the quality of neonatal and maternal care in maternity wards in HCFs in LMICs.

Cost effectiveness of community led total sanitation in Ethiopia and Ghana

We conducted cost effectiveness analyses of four different CLTS interventions implemented in Ethiopia and Ghana. In each country, a pilot approach in which additional local actors were trained in CLTS facilitation was compared to the conventional approach. Data were collected using bottom-up costing, household surveys, and observations. We assessed variability of cost effectiveness from a societal perspective for latrine ownership and latrine use outcomes in different contexts. Cost effectiveness ranged from $34–$1897 per household ($5.85–$563 per person) gaining access to a private latrine or stopping open defecation, depending on the intervention, context, and outcome considered. For three out of four interventions, CLTS appeared more cost effective at reducing open defecation than at increasing latrine ownership, although sensitivity analysis revealed considerable variation. The pilot approaches were more cost effective at reducing open defecation than conventional approaches in Ethiopia, but not in Ghana. CLTS has been promoted as a low-cost means of improving the ownership and use of sanitation facilities. In our study, the cost of CLTS per household gaining latrine access was slightly higher than in other studies, and the cost of CLTS per household stopping OD was slightly lower than in other studies. Our results show that aggregate measures mask considerable variability in costs and outcomes, and thus the importance of considering and reporting context and uncertainty in economic analysis of sanitation interventions.

Energy access in Malawian healthcare facilities: consequences for health service delivery and environmental health conditions

Many healthcare facilities (HCFs) in low-income countries experience unreliable connectivity to energy sources, which adversely impacts the quality of health service delivery and provision of adequate environmental health services. This assessment explores the status and consequences of energy access through interviews and surveys with administrators and healthcare workers from 44 HCFs (central hospitals, district hospitals, health centres and health posts) in Malawi. Most HCFs are connected to the electrical grid but experience weekly power interruptions averaging 10 h; less than one-third of facilities have a functional back-up source. Inadequate energy availability is associated with irregular water supply and poor medical equipment sterilization; it adversely affects provider safety and contributes to poor lighting and working conditions. Some challenges, such as poor availability and maintenance of back-up energy sources, disproportionately affect smaller HCFs. Policymakers, health system actors and third-party organizations seeking to improve energy access and quality of care in Malawi and similar settings should address these challenges in a way that prioritizes the specific needs of different facility types.

Mitigating drought impacts in remote island atolls with traditional water usage behaviors and modern technology

Adaptation to drought is particularly challenging on remote island atolls, such as those found in the Republic of the Marshall Islands (RMI), a nation of 58,000 populating 29 low-lying coral atolls spread over >2 million km². Exposure to consecutive atmospheric hazards, such as meteorological floods and droughts diminish scarce water resources and erode the resilience of island communities. Drought impact mitigation measures must supply emergency drinking water to stricken communities, while simultaneously conserving natural sources in order to reduce their vulnerability to subsequent events. Household surveys (n = 298) and focus group discussions (n = 16) in eight RMI communities revealed that 86% of households have experienced drought and 88% reported using multiple water sources to meet normal household needs. With no surface water and a thin freshwater lens (FWL), rainwater collected from rooftops is the most common household water source. The traditional use of carved hollows in the base of coconut trees to collect rainwater ("Mammaks") appears to have been displaced by large rainwater tanks. However, rationing of rainwater for consumption only during drought was widely reported, with private wells supporting non-consumptive uses. Reverse osmosis (RO) desalination units have provided relief during drought emergencies but concerns have been raised around dependency, maintenance challenges, and loss of traditional water practices. Most notably, RO use has the potential to change the anthroposhpere by adversely affecting the FWL; 86% of RO units were installed at island-centre where excessive pumping can cause upconing, making the FWL brackish. Balancing the introduction of desalination technology to mitigate water shortages with maintenance of traditional water conservation practices to preserve the quantity and quality of the FWL is a promising strategy on island atolls that requires further investigation.

COVID-19: urgent actions, critical reflections and future relevance of 'WaSH': lessons for the current and future pandemics

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

Sources of and Solutions to Toxic Metal and Metalloid Contamination in Small Rural Drinking Water Systems: A Rapid Review

Exposure to toxic metals and metalloids (TMs) such as arsenic and lead at levels of concern is associated with lifelong adverse health consequences. As exposure to TMs from paint, leaded gasoline, canned foods, and other consumer products has decreased in recent decades, the relative contribution of drinking water to environmental TM exposure and associated disease burdens has increased. We conducted a rapid review from June to September 2019 to synthesize information on the sources of TM contamination in small rural drinking water systems and solutions to TM contamination from these sources, with an emphasis on actionable evidence applicable to small rural drinking water systems worldwide. We reviewed publications from five databases (ProQuest, PubMed, Web of Science, Embase, and Global Health Library) as well as grey literature from expert groups including WHO, IWA, and others; findings from 61 eligible review publications were synthesized. Identified sources of TMs in included studies were natural occurrence (geogenic), catchment pollution, and corrosion of water distribution system materials. The review found general support for preventive over corrective actions. This review informs a useful planning and management framework for preventing and mitigating TM exposure from drinking water based on water supply characteristics, identified contamination sources, and other context-specific variables.

Status of risk-based approach and national framework for safe drinking water in small water supplies of the Nordic water sector

Reliable safe water supply is a pillar of society and a key to public health. The Nordic countries have an abundance of clean fresh water as a source for drinking water supplies. They have followed developments in safeguarding water, both the recommendations of the World Health Organization framework for safe drinking water and European legislation. Worldwide, including the Nordic countries, small water supplies are less compliant with water safety regulation. The forthcoming EU directive on drinking water require risk-based approaches and improved transparency on water quality. This research looks at the Nordic frameworks for safe water supply, with emphasis on risk-based approaches and smaller systems. We analyzed the legal frameworks for safe water, the structure of the water sector across the Nordic countries and explored how prepared these countries are to meet these requirements. Our findings show that, while legal requirements are mostly in place, delivery of information to the public needs to be improved. Most Nordic countries are in the process of implementing risk-based management in large and medium size water supplies, whereas small supplies are lagging. We conclude that a key to success is increased training and support for small supplies. We suggest wider adoption of the Nordic model of cooperation with benchmarking of safe water for all to transfer knowledge between the countries. This work provides insights into challenges and opportunities for the Nordic countries and provides insights relevant to countries worldwide in their effort towards realization of SDG Target 6.1.

Environmental health conditions in protracted displacement: A systematic scoping review

Adequate environmental health services are critical for human rights, health, and development, especially in the context of forced displacement. There are more than 70 million forcibly displaced persons worldwide, most in protracted situations, having been displaced for more than two years. Some live in camps or informal settlements, but most live in urban areas. Environmental health services are important in the transition from emergency response to sustainable development in these settings, but evidence on environmental health in displaced populations is disparate and of variable quality. We conducted a systematic scoping review of environmental conditions, exposures, and outcomes in protracted displacement settings; obstacles to improvement in environmental health services; and recommendations made for improvement. We included 213 publications from peer-reviewed and grey literature databases. Data were extracted on environmental health topics including water, sanitation, hygiene, overcrowding, waste management, energy supply, vector control, menstrual hygiene, air quality, and food safety. Most studies present data from low- and lower-middle income countries. Northern Africa and Western Asia and Sub-Saharan Africa are the most-represented regions. There is substantial evidence on water, sanitation, and crowding, but few studies report findings on other environmental health topics. Water-related disease, parasites, and respiratory infections are frequently cited and studies report that services often fail to meet international standards for humanitarian response. The most frequent obstacles and recommendations are institutional, political, or implementation-related, but few studies provide concrete recommendations for improvement. Our review compiles and characterizes the research on environmental health in protracted displacement. We recommend including displaced populations in international environmental health policy and monitoring initiatives, and bridging from humanitarian response to sustainable development by preparing for long-term displacement from the early stages of a crisis.

How we assess water safety: A critical review of sanitary inspection and water quality analysis

Sanitary inspection is used in low-, medium- and high-income settings to assess the risk of microbial contamination at water sources. However, the relationship between sanitary inspection and water quality is not well understood. We conducted a critical literature review and synthesized the findings of 25 studies comparing the results of sanitary inspection and microbial water quality analysis. Most studies used sub-standard sanitary inspection and water quality analysis methods, and applied simplistic comparisons that do not characterize the complexity of the relationship. Sanitary risk score was used to represent sanitary inspection results in 21 (84%) studies; of which 12 (57%) found a significant association between score and microbial water quality and nine (43%) did not. Participatory sanitary inspection (12%) and reporting results back to communities (24%) were uncommon. Most studies relied on laboratory-based water quality analysis as an independently sufficient measure of safety, but reported inadequate quality control (52%) and/or sub-standard sample processing methods (66%). We found that sanitary inspections could contribute to improving water safety through four mechanisms: guiding remedial action at individual water sources, allowing operators and external support programs to prioritize repairs, identifying programmatic issues, and contributing to research. The purpose of the sanitary inspection should be considered when planning sanitary inspection execution, data analysis, and reporting to ensure appropriate methods are employed and results are fit for purpose. Further exploration should recognize that sanitary risk factors represent sources of contamination, pathways for contaminants to enter water supplies, and breakdowns in barriers to contamination. These different sanitary risk factor types have different and inter-dependent effects on water quality.

Environmental health in forced displacement: A systematic scoping review of the emergency phase

There are 70.8 million forcibly displaced people worldwide, including internally displaced persons, refugees, and asylum seekers. Since mortality rates are highest in the first six months of displacement, the provision of adequate services and infrastructure by relief organizations is critical in this "emergency phase." Environmental health provisions such as adequate water supply, excreta management, solid waste management, and vector control measures are among those essential services. We conducted a systematic scoping review of environmental health in the emergency phase of displacement (the six months following first displacement). A total of 122 publications, comprising 104 peer-reviewed and 18 grey literature publications, met the inclusion criteria. We extracted data relating to environmental health conditions and services, associated outcomes, and information concerning obstacles and recommendations for improving these conditions and services. Despite the fact that most displaced people live outside of camps, publications largely report findings for camps (n = 73, 60%). Water supply (n = 57, 47%) and excreta management (n = 47, 39%) dominate the literature. Energy access (n = 7, 6%), exposure to harsh weather from inadequate shelter (n = 5, 4%), food hygiene and safety (n = 4, 3%), indoor air quality (n = 3, 3%), menstrual hygiene management (n = 2, 2%), dental hygiene (n = 2, 2%), and ambient air quality (n = 1, 1%) are relatively understudied. The most common health outcome attributed to inadequate environmental conditions in the included publications is diarrhea (n = 43, 35%). We found that organizations and governments often embrace their own standards, however we call for policymakers to adopt standards no less rigorous than Sphere for the emergency phase of displacement. Although other reviews examine water, sanitation, and hygiene interventions in emergencies, this is the first systematic review of environmental health more broadly in the first six months of displacement.

Geographical inequalities in drinking water in the Solomon Islands

Sustainable Development Goal 6.1 seeks to "by 2030, achieve universal and equitable access to safe and affordable drinking water", which is challenging particularly in Small Island Developing States (SIDS) and Pacific Island Countries (PIC). We report drinking water sources and services in the Solomon Islands and examine geographical inequalities. Based on two quantitative baseline datasets of n = 1,598 rural and n = 1,068 urban households, we analyzed different drinking water variables (source type, collection time, amount, use, perceived quality, storage, treatment) and a composite index, drinking water service level. We stratified data by urban and rural areas and by province, mapped, and contextualized them. There are substantive rural-urban drinking water inequalities in the Solomon Islands. Overall, urban households are more likely to: use improved drinking water sources, need less time to collect water, collect more water, store their water more safely, treat water prior to consumption, perceive their water quality as better and have an at least basic drinking water service than rural households. There are also provincial and center-periphery inequalities in drinking water access, with more centrally located provinces using piped water supplies and more distant and remote provinces using rainwater and surface water as their primary source. There are also inter-national inequalities. Out of all PICs, the Solomon Islands have among the lowest access to basic drinking water services: 92% of urban and 55% of rural households. Of all SIDS, PICs are least serviced. This study shows that drinking water inequality is a critical issue, and highlights that all identified dimensions of inequality - rural-urban, provincial, center-periphery and inter-national - need to be explicitly recognized and addressed and included in pro-equity monitoring, policy and programming efforts by the Solomon Islands Government and stakeholders to reduce inequalities as per the Agenda 2030.

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.

Application of tools to monitor environmental conditions, identify exposures, and inform decision-making to improve infection prevention and control practices in Malawian maternity wards

Healthcare-acquired infections (HAIs) contribute to maternal and neonatal morbidity and mortality, especially in low- and middle-income countries (LMICs). Deficient environmental health (EH) conditions and infection prevention and control (IPC) practices in healthcare facilities (HCFs) contribute to the spread of HAIs, but microbial sampling of sources of contamination is rarely conducted nor reported in low-resource settings. The purpose of this study was to assess EH conditions and IPC practices in Malawian HCFs and evaluate how EH deficiencies contribute to pathogen exposures and HAIs, and to provide recommendations to inform improvements in EH conditions using a mixed-methods approach. Thirty-one maternity wards in government-run HCFs were surveyed in the three regions of Malawi. Questionnaires were administered in parallel with structured observations of EH conditions and IPC practices and microbial testing of water sources and facility surfaces. Results indicated significant associations between IPC practices and microbial contamination. Facilities where separate wards were not available for mothers and newborns with infections and where linens were not used for patients during healthcare services were more likely to have delivery tables with surface contamination (relative risk = 2.23; 1.49, 3.34). E. coli was detected in water samples from seven (23%) HCFs. Our results suggest that Malawian maternity wards could reduce microbial contamination, and potentially reduce the occurrence of HAIs, by improving EH conditions and IPC practices. HCF staff can use the simple, low-cost EH monitoring methods used in this study to incorporate microbial monitoring of EH conditions and IPC practices in HCFs in low-resource settings.

Global Water, Sanitation and Hygiene Research Priorities and Learning Challenges under Sustainable Development Goal 6

MOTIVATION

Sanitation and Water for All (SWA) is a global partnership addressing challenges to universal water, sanitation, and hygiene (WaSH) access. Shortly following adoption of the United Nations' Sustainable Development Goals, the Research and Learning (R&L) constituency of SWA undertook a systematic study to determine global research priorities and learning needs.

PURPOSE

We aimed to identify priority topics where improved knowledge would aid achievement of Goal 6, by developing a global WaSH research agenda, and to describe evidence-use challenges among WaSH professionals.

APPROACH AND METHODS

We delivered a tailored, semi-structured electronic questionnaire to representatives from countries, R&L institutions, and other SWA partners (external support agencies, civil society, and private sector). The survey gathered views from 76 respondents working in an estimated 36 countries across all world regions. Data were analyzed quantitatively and qualitatively to identify patterns and themes.

FINDINGS

Most responses indicated lowered confidence on at least one Goal 6 target area, especially managing untreated wastewater and faecal sludge. Both brief and lengthy information formats were valued. WaSH information was perceived as conflicting or unreliable among non-R&L constituencies, suggesting differences in perceptions and information-seeking approaches. While the R&L constituency appeared saturated with learning and training opportunities, others perceived barriers to participating (e.g. not receiving notice or invitation). Research and other WaSH activities were frequently constrained by upward accountability to funders, while stakeholders were inconsistently included in research processes.

POLICY IMPLICATIONS

This study offers insight into perceived research and decision challenges related to Goal 6 targets. It develops a unified research agenda focused on high priority topics, and recommends renewed attention to evidence synthesis, learning and implementation support, research engagement, and multisectoral coordination.

Adapting Translational Research Methods to Water, Sanitation, and Hygiene

Translational research applies scientific techniques to achieve practical outcomes, connecting pure research and pure practice. Many translational research types have arisen since the mid-1900s, reflecting the need to better integrate scientific advancement with policy and practice. Water, sanitation, and hygiene (WaSH) development efforts have aimed to reduce morbidity and mortality and improve service delivery; thus, associated research has a strong orientation toward applied studies that use diverse methods to support decision-making. Drawing from knowledge that emerged to support other professional fields, such as manufacturing and clinical healthcare, we characterize different types of translational research and clarify nomenclature and principles. We describe study approaches relevant to translational research questions, and offer overarching recommendations, specific examples, and resources for further study as practical advice to professionals who seek to apply translational methods to WaSH problems. To enhance collective outcomes, professionals should mindfully align projects within the translational spectrum. We further recommend overarching good practices such as documenting intervention adaptations, overtly considering contextual factors, and better distinguishing efficacy from effectiveness research by replicating studies in different contexts. By consciously improving the compatibility and linkages between WaSH science and practice, this guide can accelerate urgently needed progress toward global development goals.

Water safety plans for water supply utilities in China, Cuba, France, Morocco and Spain: costs, benefits, and enabling environment elements

Water Safety Plans (WSPs) are a management tool to identify and prioritize risks and implement appropriate control measures throughout the water supply chain, from catchment to consumer. WSPs have been implemented in over 90 countries; yet, costs, benefits and the enabling environment elements necessary for WSP implementation are under-studied. To better understand these factors, we conducted interviews with WSP implementation management teams from 20 private urban water utilities in China, Cuba, France, Morocco and Spain in 2014. Collectively, these utilities serve 10.6 million consumers and supply over 2.2 million m3/day of water to consumers. Time for WSP implementation to achieve certification averaged 13 months. The main startup cost was staff time, averaging 16.2 full-time equivalent person-months. Additional costs, averaging €16,777, were for training staff, hiring consultants, purchasing equipment, and certifying WSPs. Benefits commonly reported included improved hazard control, treatment practices, record keeping, and client and health agency confidence.

Urban and rural sanitation in the Solomon Islands: How resilient are these to extreme weather events?

The Solomon Islands, like other small island developing states in the Pacific, face significant challenges from a changing climate, and from increasing extreme weather events, while also lagging behind the rest of the world in terms of drinking water, sanitation and hygiene (WaSH) services. In order to support planning for the implementation of national WaSH strategies and policies, this study contextualizes representative urban and rural baselines for Sustainable Development Goal (SDG) 6 ("by 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation"). We highlight specific threats to the current sanitation services under extreme weather events such as flooding and drought, both of which are commonly observed in the country, and provide suggestions for structural improvements to sanitation facilities to increase resiliency. As the first detailed nationally representative cross-sectional sanitation study in urban and rural areas in the Solomon Islands, the results of this paper inform national WaSH policy, strategic planning and programming by the Solomon Islands Government and stakeholders.

External support programs to improve rural drinking water service sustainability: A systematic review

Achieving sufficient, safe, continuously-available drinking water services in rural areas is a challenge, in high- and especially low-and middle-income countries. External support programs (ESPs) - which may include administrative, financial, and technical assistance - have been hypothesized to contribute to sustainable rural water services. While there are many descriptions of ESPs, a standard terminology and typology of ESP activities does not exist and the effect of ESP activities on system sustainability remains inadequately characterized. We conducted a systematic review of ESPs for rural drinking water systems to identify ESP terminology and describe ESP activities. Findings from 218 publications from low-, middle-, and high-income countries were analyzed. ESP terms were used inconsistently between regions and income classifications. There were few studies describing ESP activities related to mechanized piped water systems. Few studies quantitatively assess the effect of ESPs. Those that did found positive associations with functionality, household satisfaction, household participation, and financial stability. This review is the first comprehensive evaluation of the ESP literature and we derive a definition of external support programs and typology of ESP activities from the descriptions of ESPs. A common understanding of ESPs facilitates discussion and knowledge transfer between stakeholders. Consistent terminology creates a foundation for adapting ESPs to water services in community institutions and for mechanized piped water systems.

The implementation of environmental health policies in health care facilities: The case of Malawi

Establishing and maintaining safe and sufficient environmental health (EH) conditions in health care facilities (HCFs) is important to prevent and control infections. In 2018, the Government of Malawi finalized an environmental health policy that defines specific targets and programs for EH in healthcare settings. This and other related policies have been used since 2010 as a guide for EH practice in HCFs, but the implementation of these policies has been incomplete to-date. This study qualitatively examines the successes and shortcomings of implementing these policies in Malawi's public HCFs. Thematic analysis of interviews with 53 respondents from all levels of government was used to identify the successes of the policies and the barriers to effective implementation using Contextual Interaction Theory. The greatest identified strength lies in the design of the EH department and its ability to connect individual HCFs and EH actors directly to the policy-making level of government. Identified barriers to implementation include: insufficient financial support; lack of human resources; incomplete reporting; poor stakeholder coordination; and insufficient training of EH actors. We recommend refresher trainings for all EH actors, the establishment of a directorate level EH position, and strengthened coordination to improve the collection, analysis, and reporting of monitoring data to enable EH actors to advocate for the additional funding needed to develop programs for EH personnel and to apply effective EH interventions.

Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries

Background

To develop updated estimates in response to new exposure and exposure-response data of the burden of diarrhoea, respiratory infections, malnutrition, schistosomiasis, malaria, soil-transmitted helminth infections and trachoma from exposure to inadequate drinking-water, sanitation and hygiene behaviours (WASH) with a focus on low- and middle-income countries.

Methods

For each of the analysed diseases, exposure levels with both sufficient global exposure data for 2016 and a matching exposure-response relationship were combined into population-attributable fractions. Attributable deaths and disability-adjusted life years (DALYs) were estimated for each disease and, for most of the diseases, by country, age and sex group separately for inadequate water, sanitation and hygiene behaviours and for the cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.

Findings

An estimated 829,000 WASH-attributable deaths and 49.8 million DALYs occurred from diarrhoeal diseases in 2016, equivalent to 60% of all diarrhoeal deaths. In children under 5 years, 297,000 WASH-attributable diarrhoea deaths occurred, representing 5.3% of all deaths in this age group. If the global disease burden from different diseases and several counterfactual exposure distributions was combined it would amount to 1.6 million deaths, representing 2.8% of all deaths, and 104.6 million DALYs in 2016.

Conclusions

Despite recent declines in attributable mortality, inadequate WASH remains an important determinant of global disease burden, especially among young children. These estimates contribute to global monitoring such as for the Sustainable Development Goal indicator on mortality from inadequate WASH.

A systematic scoping review of environmental health conditions in penal institutions

Adequate environmental health conditions in penal institutions are necessary to protect and promote the health of prisoners and prison workers. We conducted a scoping systematic review to: describe the environmental health conditions in penal institutions and the associated exposures and health outcomes; identify effective approaches to prevent environmental health concerns; and identify evidence gaps on environmental health in penal institution populations. PubMed, Web of Science, EBSCOhost, Scopus, and ProQuest were searched. Peer-reviewed studies that reported original data and on environmental health conditions and/or exposures in penal institutions were included. Seventy-three studies met these criteria. The most common risk factor identified was contaminated food and/or beverages prepared or handled in the institution's kitchen. Overcrowding, inadequate ventilation, and a lack of, or sharing of, soap and other hygiene products increased the risk of adverse health outcomes. Common responses included isolating infectious patients, educating prisoners and prison staff on improved sanitation and hygiene practices, improving ventilation, and disinfecting contaminated surfaces and/or water sources. Inadequate environmental health conditions in penal institutions are common, and adversely impact the health of prisoners and prison staff, yet are preventable. Few studies have been conducted in low- and middle-income countries, biasing our results. The development and implementation of national guidelines for essential environmental health in prisons, monitoring of conditions, and greater accountability of facility managers are needed to secure the health, rights, and well-being of prisoners.

Faster and safer: Research priorities in water and health

The United Nations' Sustainable Development Goals initiated in 2016 reiterated the need for safe water and healthy lives across the globe. The tenth anniversary meeting of the International Water and Health Seminar in 2018 brought together experts, students, and practitioners, setting the stage for development of an inclusive and evidence-based research agenda on water and health. Data collection relied on a nominal group technique gathering perceived research priorities as well as underlying drivers and adaptation needs. Under a common driver of public health protection, primary research priorities included the socioeconomy of water, risk assessment and management, and improved monitoring methods and intelligence. Adaptations stemming from these drivers included translating existing knowledge to providing safe and timely services to support the diversity of human water needs. Our findings present a comprehensive agenda of topics at the forefront of water and health research. This information can frame and inform collective efforts of water and health researchers over the coming decades, contributing to improved water services, public health, and socioeconomic outcomes.

A systematic scoping review of hygiene behaviors and environmental health conditions in institutional care settings for orphaned and abandoned children

BACKGROUND

Adequate hygiene behaviors and environmental health conditions are fundamental to children's health, development, and well-being. They are especially important in institutional care settings for orphaned and abandoned children, a particularly vulnerable population whose basic needs are often not met.

OBJECTIVES

We systematically reviewed the evidence about hygiene behaviors and environmental health conditions in institutional care settings for children and associated health outcomes; interventions to improve these behaviors, conditions, and outcomes; and obstacles to improvement.

METHODS

PubMed, Web of Science, Scopus, and EBSCOhost were searched for studies in the peer-reviewed and grey literature. Studies were included if they reported primary data on one or more environmental health condition or hygiene behavior in an institutional care setting for orphaned and abandoned children.

RESULTS

Forty-five publications reporting on over 500 institutions in 29 countries were included. The most documented concern was poor personal hygiene behaviors followed by inadequate water and sanitation infrastructure and overcrowding. Protozoan, helminthic, viral infections, and diarrheal illness among institutionalized children were the most commonly documented associated health outcomes.

DISCUSSION

More studies documented the status of hygiene and environmental health in children's institutions than interventions to improve behaviors and conditions. Insufficient finances and expertise or involvement of caregivers are reported barriers to implementing improvements in children's institutions. The development of guidelines for essential environmental health standards in orphanages, monitoring of facility conditions, accountability for facility deficiencies, and implementation research to identify improvement opportunities would contribute to and promote the health and development of orphaned and abandoned children worldwide.

Capacity building and training approaches for water safety plans: A comprehensive literature review

The World Health Organization has recommended Water Safety Plans (WSPs), a holistic risk assessment and risk management approach, for drinking-water suppliers across low-, middle- and high-income countries, since publishing its 2004 Guidelines for Drinking-Water Quality. While rapid WSP adoption has occurred, capacity is still catching up to implementation needs. Many countries and regions lack case examples, legal requirements, and training resources for WSPs, corresponding to widespread capacity shortfall in the water supply sector. We undertook a comprehensive review of the literature on capacity building and training for WSPs, with the goal of providing recommendations for multiple stakeholder groups at the scales of individual utilities, national governments, and intermediate units of governance. We propose a WSP training taxonomy and discuss it in relation to the stages of learning (introduction, practice, and reinforcement); describe the importance of customizing training to the target group, local language and circumstances; highlight the relevance of auditing for evaluating change over time; and call for robust methods to monitor WSP capacity development.

Consumer perceptions and purchasing of packaged water products in Sierra Leone

Introduction

Access to improved sources of drinking water remains a complex challenge in Sierra Leone and other low and middle income countries. We aimed to qualitatively examine consumer perceptions and purchasing behaviors of packaged water products in Sierra Leone.

Methods

We conducted 25 focus groups with 178 consumers and petty traders of packaged water across the four geographic regions of Sierra Leone. Discussions were recorded, transcribed, and coded into themes. The Health Belief Model guided the thematic data analysis.

Results

Packaged water was broadly perceived as safe, accessible, and convenient. Participants who lived outside of the capital city, Freetown, were more likely to report cost as a barrier. Personal experiences with a brand moderated trust levels. Self-reported handling behaviors of PW products were generally unhygienic. There was widespread belief that packaged water keeps newborn babies healthy. Consumers desired a simple mechanism to better identify government approved PW products.

Conclusion

Perceived risks, benefits, barriers, self-efficacy, and reinforcing cues to action qualitatively influenced consumers’ purchasing behavior of packaged water. Government regulators should provide consumers with reliable means to identify approved packaged water products. Consumer education efforts should include hygienic handling of packaged water products in order to minimize post-production contamination.

Comparative evaluation of risk management frameworks for U.S. source waters

The U.S. Safe Drinking Water Act required states to develop source water assessment programs identifying existing and potential contamination sources; however, comprehensive risk prioritization and management approaches for surface water supplies have seen limited application. This participatory study assessed which permutation(s) of risk management frameworks and tools might benefit U.S. utilities by combining a literature review with external utility interviews. Qualitative data provided a basis for categorical assignments of goodness of fit with each of 24 framework evaluation criteria across five categories. Weighted integration using stakeholder input provided a relative ranking of applicability, later validated at a decision-making workshop. Hybridization of the American National Standards Institute/American Water Works Association (ANSI/AWWA G300) source water protection standard and World Health Organization Water Safety Plan guidance was recommended to develop a comprehensive risk management approach for U.S. source waters. Cost-benefit components of other guidance materials were recommended to incorporate financial considerations into risk ranking and mitigation decisions.

Health Risk Perceptions Are Associated with Domestic Use of Basic Water and Sanitation Services-Evidence from Rural Ethiopia

We examine factors associated with the use of basic water supply and sanitation services as part of an integrated community-based nutrition programme which included a drinking water, sanitation and hygiene (WaSH) intervention and emphasise findings related to health risk perceptions. Data were collected from 2658 households in four regions in Ethiopia with a cross-sectional survey in WaSH intervention areas, as well as in control areas, where the intervention was not implemented. The data were analysed using bivariate and multivariable regression analysis. Awareness of health risk factors related to inadequate WaSH was high in the programme area. The use of basic water and sanitation services was associated with several health risk perceptions: Perceiving water quality as good increased the odds of using basic water services as opposed to believing the water quality was poor (OR 3.94; CI 3.06–5.08; p ≤ 0.001). Believing that drinking unsafe water was the main cause for diarrhoea increased the odds of using basic water services (OR 1.48; CI 1.20–1.81; p ≤ 0.001). In the WaSH intervention group, the use of basic sanitation was more likely than in the control group. The use of basic sanitation was associated with households who had previously received sanitation training, as opposed to such who had not (OR 1.55; CI 1.22–1.97; p ≤ 0.001). Perceiving dirty space as the main cause of diarrhoea (OR 1.81; CI 1.50–2.19; p ≤ 0.001), and privacy when using a latrine (OR 2.00; CI 1.67–2.40; p ≤ 0.001), were associated with higher odds of using basic sanitation. Households that indicated a disadvantage of owning a latrine was maintenance costs were less likely to use basic sanitation (OR 0.49; CI 0.38–0.63; p ≤ 0.001). Risk perceptions were important determinants of use of basic services. The findings point to risk perceptions motivating the application of positive WaSH-related and health-protective behaviours. This suggests that well-designed health risk communication strategies may be effective for engaging households in healthy WaSH behaviour.

Assessing operational performance benefits of a Water Safety Plan implemented in Southwestern France

AIMS

The World Health Organization (WHO) has recommended Water Safety Plans (WSPs) since 2004 as a means to reduce drinking water contamination and risks to human health. These risk management programs have shown promise across several potential areas of evaluation, such as economic benefits and regulatory compliance. Since WSPs are largely carried out by people who interact with water treatment equipment and processes, operational performance indicators may be key to understanding the mechanisms behind desirable WSP impacts such as water quality and public health improvement.

METHOD

This study reports performance measures collected at a WSP implementation location in southwestern France over several years.

RESULTS

Quantitative assessment of performance measures supported qualitative reports from utility managers. Results indicate significantly reduced duration of low-chlorine events at one production facility and a significant decrease in customer complaints related to water quality, manifesting reported improvements in operational performance and the customer service culture.

CONCLUSION

The findings demonstrate some success stories and potential areas of future performance tracking. Cyclical iteration of the WSP can help to achieve continuous quality improvement. Successfully applied evaluation criteria such as the number of water quality complaints or alarm resolution time might be useful across other locations.

The role of energy in health facilities: A conceptual framework and complementary data assessment in Malawi

Background

Modern energy enables health service delivery. Access to electricity is, however, unreliable in many health facilities in developing countries. Little research has explored the relationships between energy and service delivery.

Methods

Based on extensive literature searches and iterative discussions within the research team, we first develop a conceptual framework of the role of energy in health facilities. We then use this framework to explore how characteristics of electricity supply affect distinct energy uses in health facilities (e.g. lighting), and how functional or non-functional lighting affects the provision of night-time care services in Malawi. To do so we apply descriptive statistics and conduct logistic and multinomial regressions using data from the Service Provision Assessment (SPA) of the Demographic and Health Surveys (DHS) for all health facilities in Malawi in 2013/2014.

Results

The conceptual framework depicts the pathways from different energy types and their characteristics, through to distinct energy uses in health facilities (e.g. medical devices) and health-relevant service outputs (e.g. safe medical equipment). These outputs can improve outcomes for patients (e.g. infection control), facilities (e.g. efficiency) and staff (e.g. working conditions) at facilities level and, ultimately, contribute to better population health outcomes. Our exploratory analysis suggests that energy uses were less likely to be functional in facilities with lower-quality electricity supply. Descriptive statistics revealed a critical lack of functional lighting in facilities offering child delivery and night-time care; surprisingly, the provision of night-time care was not associated with whether facilities had functional lighting. Overall, the DHS SPA dataset is not well-suited for assessing the relationships depicted within the framework.

Conclusion

The framework conceptualizes the role of energy in health facilities in a comprehensive manner. Over time, it should be empirically validated through a combination of different research approaches, including tracking of indicators, detailed energy audits, qualitative and intervention studies.

Pro-poor governance in water and sanitation service delivery: evidence from Global Analysis and Assessment of Sanitation and Drinking Water surveys

Aims:

The Sustainable Development Goal (SDG) for water and sanitation seeks to achieve universal and equitable access to safe and affordable drinking water and access to adequate and equitable sanitation and hygiene. This article examines what governments are doing to achieve this, paying particular attention to actions that governments report taking to better serve the poor and other vulnerable populations (i.e. pro-poor governance). This article also assesses the extent to which, and how, UN-Water’s Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) has tracked governments’ efforts to reach the poor since the inception of this global monitoring effort.

Method:

This article employs qualitative document analysis and iterative coding to identify pro-poor governance themes examined in GLAAS reports from 2008 to 2016 and provides a quantitative summary of findings related to pro-poor governance from the most recent GLAAS surveys.

Results:

The dimensions of pro-poor governance and number of questions related to pro-poor governance in GLAAS surveys have increased from 2008 to 2016. While the majority of countries report taking actions to promote equity, many countries did not provide information about specific actions they were taking to provide better services to the poor. Moreover, several actions countries reported taking (e.g. implementing an increasing block tariff) are likely to be ineffective.

Conclusion:

The findings of this study raise concerns about the extent to which governments are taking – or are positioned to take – effective action to meet the SDG aspiration of safe and affordable water and sanitation services for all. Without information on what countries are doing to promote equity, policy makers and researchers are unable to discern which policies are effective in different contexts.

Seasonality, water use and community management of water systems in rural settings: Qualitative evidence from Ghana, Kenya, and Zambia

The sustainability of rural, community-managed water systems in sub-Saharan Africa depends in part on the ability of local water committees to repair breakdowns and carry out the operation and maintenance (O&M) of the system. Much of sub-Saharan Africa has two distinct seasons that affect the availability of water sources and how people use water. Little is known about how seasonality affects water system management. This qualitative study is based on 320 interviews and focus group discussions and examines the effects of season on community water use and management in Ghana, Kenya and Zambia. Participants revealed that seasonality affects water availability, water system breakdowns, resource mobilization, committee activity, and external support availability. In the rainy season, participants typically reported spending less time and money on water collection because rainwater harvesting and seasonal streams, ponds, wells and reservoirs are available. In the dry season, people used improved groundwater sources more often and spent more money and time collecting water. Although seasonal changes in household water demand and use have been examined previously, our data suggest that seasonality also influences community management through differential water system use, system breakdowns and management characteristics. We found that water committees generally have less money, time and access to external support during the rainy season, making them less able to carry out O&M. Our results suggest that community engagement should take place over a long period of time so that seasonal patterns in management can be understood and incorporated into water committee training. External support actors should make a more targeted effort to understand the cultural and economic patterns in a community in order to train committees with appropriate management strategies.

Evidence-based decision-making on water quality in domestic water supply in Malawi, Ecuador, and Brazil

Scholars and practitioners advocate evidence-based decision-making (EBDM) because facts lead to beneficial outcomes. At the same time, EBDM to reduce risks in water quality is under-studied. We examine types of decision-making by water utilities and government agencies, and the nature and origin of evidence available to them in their work on delivering safe drinking water to households. Using qualitative content analysis, we comparatively analyze water utilities and government agencies in Malawi, Ecuador, and Brazil. The results show that the water utilities perform combinations of decision-making types on water quality such as implementation, intelligence-gathering, and evaluation and choice, while government agencies perform more intelligence gathering. Sources and types of information are mainly water consumers, guidelines for water quality standards, and self-monitoring from water utilities. The analysis is useful in establishing a foundation for developing evidence-based management within water supply services, and potentially other water resources management activities.