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Challenges and Strategies for Water, Sanitation, and Hygiene: A Case Study of Pandua, West Bengal, India

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• Lopamudra Ganguly   ORCID: orcid.org/0000-0002-1808-4439 3 ,
• Moumita Saha   ORCID: orcid.org/0000-0002-4473-3092 4 ,
• Subhadip Mondal   ORCID: orcid.org/0009-0004-8709-5467 5 &
• Saptadipa Chakraborty   ORCID: orcid.org/0009-0005-4854-794X 5  

Introduction : The aim of WASH program is to centralize the development plan, with a specific sector target (SDG 6) aiming for universal, sustainable, and equitable access to safe drinking water, sanitation, and hygiene by 2030, as well as the elimination of open defecation.

Methodology : A descriptive and cross-sectional research of women in the designated districts was carried out. The sampling technique was utilized to choose 90 Santali women from the population, and data on WASH-related difficulties is being collected. The data was analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0, which included descriptive and inferential statistics.

Results : The community is plagued by determinants of considerable barriers to accessing water, sanitation, and hygiene. Gender differences, unfair societal standards, cultural taboos, poverty, and a lack of necessities all pose difficulties. The lack of toilets, water, and waste disposal facilities in their homes complicates matters. Furthermore, women avoid using public washrooms since they are in poor condition and frequently lack running water; as a result, they are only used in extreme circumstances.

Conclusion : The research looks into the factors that influence women’s roles as home water collectors and focuses on how different socioeconomic layers in society results in the difference in WASH program among them.

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Dr. Lopamudra Ganguly

Department of Biotechnology, Techno India University, Kolkata, West Bengal, India

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Department of Geography, Vedanta College, Kolkata, West Bengal, India

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Ganguly, L., Saha, M., Mondal, S., Chakraborty, S. (2024). Challenges and Strategies for Water, Sanitation, and Hygiene: A Case Study of Pandua, West Bengal, India. In: Alam, A., Rukhsana (eds) Public Health and Diseases. Springer, Cham. https://doi.org/10.1007/978-3-031-57762-8_12

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Water, sanitation, and hygiene (wash) in schools: a catalyst for upholding human rights to water and sanitation in anápolis, brazil.

1. Introduction

The human right to water and sanitation in brazil, 2. materials and methods, 2.1. study site, 2.2. data collection, 2.3. data analysis, 2.4. microbiological analysis, 3. results and discussion, 3.1. drinking water, 3.2. sanitation, 3.3. hygiene and education, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Pereira, C.T.; Sorlini, S.; Sátiro, J.; Albuquerque, A. Water, Sanitation, and Hygiene (WASH) in Schools: A Catalyst for Upholding Human Rights to Water and Sanitation in Anápolis, Brazil. Sustainability 2024 , 16 , 5361. https://doi.org/10.3390/su16135361

Pereira CT, Sorlini S, Sátiro J, Albuquerque A. Water, Sanitation, and Hygiene (WASH) in Schools: A Catalyst for Upholding Human Rights to Water and Sanitation in Anápolis, Brazil. Sustainability . 2024; 16(13):5361. https://doi.org/10.3390/su16135361

Pereira, Carmencita Tonelini, Sabrina Sorlini, Josivaldo Sátiro, and Antonio Albuquerque. 2024. "Water, Sanitation, and Hygiene (WASH) in Schools: A Catalyst for Upholding Human Rights to Water and Sanitation in Anápolis, Brazil" Sustainability 16, no. 13: 5361. https://doi.org/10.3390/su16135361

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Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: A scoping review

Nkeka p. tseole.

1 School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Howard Campus, Durban, South Africa

Tafadzwa Mindu

Chester kalinda.

2 Bill and Joyce Cummings Institute of Global Health, University of Global Health Equity (UGHE), Kigali, Rwanda

3 Institute of Global Health Equity Research (IGHER), University of Global Health Equity (UGHE), Kigali, Rwanda

Moses J. Chimbari

4 Department of Behavioural Science, Medical and Health Sciences, Great Zimbabwe University, Masvingo, Zimbabwe

Associated Data

All relevant data are within the paper and its Supporting Information files.

A healthy and a dignified life experience requires adequate water, sanitation, and hygiene (WaSH) coverage. However, inadequate WaSH resources remain a significant public health challenge in many communities in Southern Africa. A systematic search of peer-reviewed journal articles from 2010 –May 2022 was undertaken on Medline, PubMed, EbscoHost and Google Scholar from 2010 to May 2022 was searched using combinations of predefined search terms with Boolean operators. Eighteen peer-reviewed articles from Southern Africa satisfied the inclusion criteria for this review. The general themes that emerged for both barriers and facilitators included geographical inequalities, climate change, investment in WaSH resources, low levels of knowledge on water borne-diseases and ineffective local community engagement. Key facilitators to improved WaSH practices included improved WaSH infrastructure, effective local community engagement, increased latrine ownership by individual households and the development of social capital. Water and sanitation are critical to ensuring a healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities due to lack of WaSH infrastructure compared to urban settings. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in SDG 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments in WaSH infrastructure, inadequate knowledge on water-borne illnesses and lack of community engagement.

Introduction

Inadequate water, access to improved sanitation, and hygiene (WaSH) are global health challenges affecting about one-third of the world’s population [ 1 , 2 ]. Improved sanitation and hygiene are essential because they reduce environmental health risks [ 3 ]. Global diarrheal disease statistics show that more than one million annual deaths are related to poor WaSH practices as over one-third of the world’s population do not have basic sanitation [ 4 ]. Although adequate WaSH coverage is critical for improving quality of life, globally about 2 billion people do not have access to clean water [ 5 ] and over 263 million people walk long distances to collect water from rivers, streams and lakes. Furthermore, at least 159 million people drink water from unsafe sources [ 5 ].

In Africa, about 70 percent of rural water schemes are non-functional or intermittently functional at any given time [ 6 ] resulting in compromised human wellbeing [ 7 ]. Due to poor WaSH practices in Africa, about 28 percent of the population in the region still practice open defecation [ 1 ]. Unsafe sanitation behaviours are responsible for around 775, 000 world deaths annually of which 5 percent are in low-income countries [ 1 ]. Universal, affordable, and sustainable access to WaSH is one of the key public health and developmental issues. Plans to improve WaSH coverage are instituted in the Sustainable Development Goals (SDG) goal 6 which seeks to ensure availability and sustainable management of water and sanitation for all by 2030 [ 8 ]. Even though this SDG advocates for progressive reduction of inequalities related to hygiene and universal access to clean water and sanitation [ 8 ], continued inequalities in access to clean water and improved sanitation between rural and urban settings are still a challenge [ 8 – 11 ].

Improved WaSH practices have the potential to reduce the prevalence of diseases such as schistosomiasis, cholera, diarrhea, polio, and typhoid which are prevalent in most sub-Saharan African countries. However, people still lack adequate information on WaSH leading to poor sanitation and hygiene practices. Southern Africa is among regions with very low rates of WaSH coverage in the world [ 8 ]. The provision of clean water to most rural communities in Southern Africa is insufficient and this exacerbates challenges associated with sanitation and hygiene [ 12 ]. For instance, hand washing is a cost-effective and simple approach used for the control of water-based infections and yet despite its simplicity and effectiveness it is not widely used [ 13 ].

Mitigating inequalities linked with access to WaSH is therefore critical. Understanding patterns of inequalities in WaSH practices, and how these are influenced by different facilitators and barriers is vital to providing effective interventions to mitigate inequalities in WaSH coverage in Southern Africa. Using a scoping review guided by the methodological framework for scoping, we examined facilitators and barriers to effective WaSH practices in Southern Africa and identified knowledge gaps on the same [ 14 ].

Materials and methods

We conducted a scoping review of published peer-reviewed articles on barriers and facilitators to WaSH practices in Southern Africa. The use of scoping review studies allows researchers to identify and analyze existing evidence from published peer-reviewed journal articles related to specific research areas. Scoping reviews are conducted to understand the status of knowledge related to a topic of interest [ 14 ]. Our review included studies published from 2010 to May 2022 and was guided by Arksey and O’Malley’s 2005 scoping review framework which describes six stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) recording data; (5) organizing, summarising and reporting the results and (6) consultation exercise [ 14 ]. The optional six step is usually conducted with key stakeholders to inform and validate study results [ 14 ]. We did not include that in our review.

Search strategy

Our review focused on peer-reviewed journal articles, both quantitative and qualitative studies published from 2010 to May 2022 to identify facilitators and barriers to WaSH practices. We conducted a systematic electronic search of peer-reviewed journal articles from various databases including PubMed, EbscoHost, Medline and Google scholar using the following keywords: “ facilitators; barriers ; water ; sanitation ; hygiene ; WaSH practices and Southern Africa .” Using the keywords, we developed “index terms” by combining keywords and their synonyms and used the Boolean operators “AND”, “OR” and truncations to create search strings: “ Water AND sanitation AND hygiene AND Facilitators (AND motivators) AND barriers (OR hindrances) AND WASH practices AND Southern Africa” . After eliminating all the duplicates for extracted articles, we identified relevant articles by screening the titles and abstracts. Full articles of the selected titles and abstracts were selected for eligibility. These articles were further screened (full-text) for relevance in terms of their focus and aims.

Inclusion and exclusion criteria

The review included articles describing interventions on WaSH practices in Southern Africa with a particular focus on facilitators and barriers. Articles included in the study were published in the English language from 2010 to May 2022. We excluded reviews, i.e. systematic, scoping and meta-analysis that were published before 2010. Our review also excluded reports, working papers and articles published before 2010. Our exclusion criteria further excluded articles that were published in other languages other than English.

Quality assessment

We assessed all selected articles for quality using a mixed methods appraisal tool (MMAT) [ 15 ]. MMAT is used as a tool to appraise the quality of different study designs [ 15 ]. For each study, we used scores ranging from 0 to 10, where 0–4 = “Low” quality, 5–7 = “Moderate” quality and 8–10 = “High” quality. The majority of the articles selected scored moderate. No studies scored “Low”, 17 articles scored “Moderately” and one article scored “High”. Indicators used for quality scores included: (a) a clear definition of the study objective and aim, (b) study design appropriate for stated aims, (c) justified sample size, (d) targeted population defined, (e) risk factor and outcome variables measured, (f) methods clearly described, (g) study results described, (h) discussions and conclusions justified, (i) study limitations discussed and (j) ethical approval for the study attained.

Data extraction and analysis

In the data extraction phase, a total of 18 articles were selected ( Fig 1 ) based on the inclusion and exclusion criteria. All records were downloaded using Zotero software and duplicates were removed. We created a data extraction table ( Table 1 ) that captured the following information: authors, year of publication, objectives of the study, the type of the study, geographical location from where the studies were conducted and the summary of the main findings from each study.

Our electronic search from PubMed provided 1252 records, EbscoHost 62 records and 75 records from Google scholar. The electronic title search provided a total of 1389 articles ( Fig 1 ) from which 24 duplicates were removed. One thousand, three hundred and one (1301) articles were deemed illegible and were removed after screening their titles. Sixty-four (64) articles that remained were screened based on their relevance by abstracts and of these, twenty-one (21) articles were removed. Full-text screening for the remaining 43 articles was done and 30 articles were removed due to irrelevant focus and aim concerning the objective of this review. Among those removed, one article covered a scope outside Southern Africa, another article used secondary data collected between 1995–2006 although the paper was published in 2015. One article was a working paper, and the other excluded studies were reports, systematic and scoping reviews. We remained with 13 legible records deemed relevant. Five (5) additional records were identified from the reference lists of eligible articles and were included as grey literature for full-text review resulting in a total of 18 articles ( Fig 1 ).

Characteristics of the selected articles

Distribution by country.

Out of 18 articles reviewed, most (n = 5, 27%) of the studies were conducted in Zambia while from Botswana, Lesotho, Mozambique, South Africa and Zimbabwe, ten studies (two studies from each country) were reviewed ( Table 1 ). Three studies (one from each country) were from Malawi, Eswatini and Namibia. Six studies were quantitative [ 16 – 20 ], four were qualitative [ 21 – 24 ], while nine used mixed methods approach [ 25 – 27 , 29 – 32 ].

Barriers to WaSH practices

The key themes that emerged with regards to barriers to WaSH practices in Southern Africa from the articles reviewed comprised (a) inadequate financing, (b) population growth, (c) inadequate knowledge of waterborne diseases, (d) ineffective local community engagement in WaSH interventions, and (d) climate change.

Inadequate financing

Lack of skilled personnel and poor laboratory equipment was reported to compromise the quality of water and water supply services owing to insufficient funds [ 19 ]. The situation compromises clean water supply, and resulting in poor sanitation and hygiene practices [ 19 , 22 ]. Due to insufficient funding, in some places where there was WaSH infrastructure in place, there was poor or no maintenance on the damaged infrastructure. The challenge of broken WaSH infrastructure contributes negatively to improved sanitation and hygiene practices. Inadequate funding led to inadequate WaSH infrastructure especially in rural areas [ 27 , 31 ]. Water quality and supply from many countries was reported to be compromised due to a lack of WaSH infrastructure. Some studies reported poor and inadequate protection of water sources, poor access to clean water and dependency on contaminated water from unprotected sources [ 30 ]. There were reports of water sources contamination by human excreta because of a shortage of latrines, or lack thereof. Inadequate investment in WaSH infrastructure was reflected by poor maintenance of the existing infrastructure. Geographical inequalities were identified as an existing barrier to improved drinking water supply, sanitation and hygiene particularly in rural areas of Southern Africa.

Population growth

It was evident that there was strain on WaSH services predominantly in urban areas where demands for WaSH services increased due to rapid population growth [ 25 , 30 ]. For example, the challenge with population growth in some countries as evidenced by the inability to efficiently provide clean water services for the growing informal settlement population. In some instances, rapid population growth led to congestion thereby compromising sanitation and hygiene practices especially in places where sanitation facilities were shared. Overcrowded spaces in some countries were reported in different studies as a major factor contributing to pollution and poor neighbourhood sanitation and hygiene practices. From the studies reviewed, concerns about space/land emerged especially with regards to replacing pit latrines that filled up quickly owing to population growth.

Inadequate knowledge on healthy WaSH practices

People’s perceptions, knowledge and reported behaviors regarding WaSH facilities such as latrines reflect their knowledge of healthy WaSH practices. Due to inadequate knowledge on the importance of improved sanitation and hygiene, some people are reluctant to change their behavior and learn how to use the introduced latrine facilities [ 29 – 31 ]. This was seen in places where community members practiced open defecation. Some community members were reluctant to accept and use latrines. Inadequate knowledge on the transmission of diseases associated with poor WaSH practices was reported as one of the challenges to healthy lifestyle change.

Ineffective local community engagement

Effective local community engagement in interventions for WaSH practices is critical. From the studies reviewed, there is evidence that ineffective local community engagement in interventions results in a lack of monitoring and healthcare awareness [ 26 , 27 ]. Engaging local community members from the design of interventions to their implementation is crucial. Some studies reviewed alluded to successful community-led total sanitation implementation resulting from effective local community engagement.

Climate change

Climate change exacerbates public health issues associated with poor sanitation and hygiene practices. The findings from some of the reviewed studies reported drought as one of the influencers to barriers to improved WaSH practices. Inadequate water supply, especially during the dry seasons was described as a constraint to improved hygiene including handwashing [ 33 ]. Different countries in Southern Africa experience droughts due to climate change and that compromises WaSH practices. Among other challenges, drought seasons experienced in Southern Africa contribute to the existing challenge of disease control in endemic regions where improved WaSH facilities are most needed [ 25 , 26 ]. The following themes emerged as key facilitators to WaSH practices in the region, (a) effective local community engagement, (b) increased investment on WaSH infrastructure, (c) increased latrine/toilet ownership by individual households and (d) development of social capital within small community units.

Local community engagement

The reviewed studies indicated the importance of the local community’s engagement in WaSH related interventions that promote improved sanitation and hygiene practices in society [ 16 , 26 , 29 ]. Initiatives such as community-led sanitation and hygiene were easily introduced in places where the local community members were effectively engaged [ 17 , 27 ]. In places where communities used community latrines, community-led sanitation programs led to easy decision-making processes because local communities were practically engaged in interventions [ 21 ].

Investment in WaSH infrastructure

WaSH infrastructure is critical for improved WaSH services. Some of the studies reviewed, from South Africa reported the benefits gained from increased investment in WaSH infrastructure [ 31 ]. Such benefits include improved access to sanitation and hygiene facilities. Investments on WaSH infrastructure also improved safe-water-storage minimizing contamination [ 30 ].

Toilet ownership

The studies reviewed showed that latrine ownership by individual households played an important role in practicing healthy WaSH behaviors. Increases in individual households’ ownership of a latrine reduces open defecation practice, and the use of shared latrines and promotes a healthy lifestyle [ 21 ]. The reviewed studies indicated informal settlements as some of the places at which community members struggle to maintain improved sanitation and hygiene [ 21 , 22 ].

Social capital development

The importance for any society to have established networks of relationships was evident in the reviewed articles. Such social capital networks contribute positively towards improved WaSH facilities and positive attitudes and behaviors [ 21 ]. The studies reviewed indicated that the development of social capital was easily established in small communities leading to effective communication essential to creating healthy living awareness in these settings.

Our review of published articles on WaSH practices in Southern Africa identified and analyzed facilitators and barriers to the effective implementation of WaSH. The following barrier themes emerged from the analysis: (1) geographical inequalities, (2) climate change, (3) low investment in WaSH infrastructure, (4) low knowledge levels on waterborne diseases, (5) ineffective local community engagement. Facilitators for WaSH practices that emerged from the analysis included: (a) effective local community’s engagement in WaSH interventions, (b) increased investment on WaSH infrastructure, (c) local community’s engagement in WaSH interventions, (d) increased latrine ownership and (e) development of social capital within small community units.

Geographical inequalities

While notable advances have been made in the provision of drinking water supply and sanitation worldwide [ 34 ], poor sanitation and inadequate clean drinking water supply especially in rural areas remain an important challenge in most African countries [ 22 ]. The existing barriers to improved drinking water supply and sanitation are the geographical inequalities experienced in most rural areas in Southern Africa where there are generally poor basic services provision resulting in unhealthy living conditions [ 29 ].

Climate change was noted as a significant challenge to water and sanitation services posing risks like damage to infrastructure due, for example, to flooding, depletion of water sources due to declining rainfall and increasing demand; and compromised water quality [ 35 ]. We noted that climate change has affected both surface and groundwater flow. Understanding the interaction between climate change, land usage, the demographic and economic activities in the region is essential in ensuring that there is water security in Southern Africa [ 25 ].

Low investment in WaSH infrastructure

The results of the review showed that Southern Africa is among the regions with the lowest basic sanitation coverage of homes that have access to clean and safe drinking water. Poverty [ 19 ], and sharing of sanitation facilities were noted as contributing factors to poor WaSH practices in Southern Africa [ 21 ]. Insufficient investment on sanitation and hygiene resources [ 32 ] in Southern Africa contributes tremendously as a hindrance to improved WaSH practices. Addressing this requires a political will of governments to increase investments targeted to improve WaSH infrastructure. The current low investment in WaSH resources in most of the Southern African countries has led to poor implementation of water safety plans [ 19 , 26 ]. Due to low investment in WaSH infrastructure, compliance of small water treatment plants to accepted standards of drinking water quality and management has resulted in inadequate provision of water supply and sanitation facilities especially in rural areas remains a challenge [ 19 ]. Rapid urbanization has added to the strain on investments that could be used to improve sanitation infrastructure in Southern Africa. We have noted that urbanization has concentrated people in areas but not matched that with sanitation development This has led to failure to meet the growing urban population’s improved WaSH needs [ 25 ].

Low knowledge levels on water borne diseases

An increase in knowledge related to water-borne diseases may contribute to a decrease in the prevalence of water-borne diseases. However, low levels of knowledge on water-borne diseases and their transmission routes have been reported in Southern Africa [ 31 ]. This may be improved through health education on the role of WaSH practices in reducing water-borne diseases [ 26 , 36 ].

Effective local community’s engagement in WaSH interventions

This review indicated that effective community engagement plays a critical role in ensuring that interventions succeed [ 37 ]. Implementation challenges comprising cultural practices, possible negative attitudes and poor communication during the intervention can be eliminated through effective local community engagement. In addition to overcoming several implementation challenges, effective community engagement encourages positive attitudes in community-led intervention programs [ 17 , 27 , 32 ].

The major facilitators to WaSH practices in this review were: (1) increased investment on WaSH infrastructure, (2) effective local community engagement, (3) increased latrine/toilet ownership by individual households, and (4) development of social capital within small community units.

Increased investment in WaSH infrastructure

Increased investment in WaSH infrastructure was identified as an important facilitator to improved WaSH practices [ 26 ]. Although the SDGs for safe drinking water have been achieved globally [ 18 ], many people, in rural Africa are still dependent on unsafe water sources such as rivers and unprotected wells for domestic use. Through increased investments in WaSH infrastructure, some countries in Southern Africa have improved access and availability of clean water [ 26 ] and stepped up effective promotion of hygiene practices [ 16 ], improved knowledge, attitudes and practices towards hygiene and sanitation [ 26 ]. Another benefit of increased investment for WaSH infrastructure is the improvement of water source protection [ 27 ] which is a major challenge in most Southern African communities. Furthermore, improved infrastructure can contribute toward better water storage at home [ 20 ].

Local community’s engagement in WaSH interventions

Our study findings indicated effective local community engagement in WaSH interventions as one of the important facilitators to WaSH practices [ 32 ]. Effective engagement of local communities in interventions stimulates interest in interventions and results in increased levels of knowledge on water-borne diseases [ 26 ]. Through effective engagement, community-led sanitation and hygiene education programs are easily introduced and executed [ 17 ]. Furthermore, engaging the local community assists in mobilizing the adaptation of new sanitation technologies such as ecological sanitation (ecosan) [ 29 ], a technique that makes it possible to safely use human excreta in agriculture [ 29 ]. In cases where the community uses shared latrines, effective community engagement makes promotes collective decision-making among shared larine users easier [ 21 ].

Increased latrine ownership

Open defecation is mainly a rural phenomenon ascribed to poor latrine ownership at the community and household levels [ 38 ]. The results from the review showed that increased latrine ownership by individual households contributes to improved WaSH practices in a community [ 21 ]. Lack of sanitation facilities leads to uncontrolled disposal of household and human waste into surrounding water bodies leading to pollution and an increased risk for water-borne infections in society [ 18 ].

Development of social capital within small community units

Developing social capital was identified as an effective strategy for health improvements especially in small communities. The development of networks of relationships among people who lived and worked in some societies in Southern Africa enabled such communities to function effectively in facilitating improved WaSH practices [ 21 ].

Limitations

We reviewed articles from almost all the countries in Southern Africa but limited the search of articles to only those published in English thus possibly missing experiences from some countries in the region. We may also have missed some critical literature because we only focused on literature published in peer-reviewed journals. We acknowledge that the application of filters during database search may have excluded other studies that could have been relevant to the review. Despite these limitations, we believe that our search strategy was comprehensive, and that we reviewed relevant literature in public health and the subject matter we explored.

Water and sanitation are critical to ensuring healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities compared to urban settings. Studies focusing on the mitigation of the existing inequalities related to WaSH developments should be conducted. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in the SDGs 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments to WaSH infrastructure, inadequate knowledge of water-borne illnesses and lack of community engagement. The review also identified facilitators to WaSH practices comprising social capital development, increased latrine ownership, effective local community engagement and increased investment to WaSH infrastructure. A knowledge gap exists in the continued monitoring of progress in facilitators and barriers to improved WaSH practices in the region. There is also a gap in the literature on solutions to mitigating existing barriers to improved WaSH practices in Southern Africa.

Supporting information

S1 checklist, s1 protocol, acknowledgments.

The authors acknowledge the input from the editors and anonymous reviewers who helped in improving the content and quality of this paper.

Funding Statement

This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme (16/136/33), UK and the University of KwaZulu-Natal. We also acknowledge University Administration Support Program (UASP) funding for this manuscript.

Data Availability

• PLoS One. 2022; 17(8): e0271726.

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21 Apr 2022

PONE-D-21-26335

Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: a scoping review

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Reviewer #1: Manuscript Number: PONE-D-21-26335

Full Title: Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: a scoping review

Short Title: Barriers and facilitators to Water, Sanitation and Hygiene practices in Southern Africa:a scoping reviews

General Comment

1. “ Rural areas are the most affected by barriers to improved WaSH facilities compared to urban settings.

Is that population growth is a barrier for rural set up or urban in southern Africa? One of the team is population growth,

Specific Comment

2. “ The general themes that emerged included geographical inequalities, climate change, investment on WaSH resources, low levels of knowledge on water borne diseases and ineffective local community engagement”

Is this general for barriers and facilitator for WASH, please it need to specify and indicate clearly for the reader?

Introduction:

3. The second paragraph in References citation indicated that “Inadequate water, access to improved sanitation, and hygiene (WaSH) are global health challenges affecting about one-third of the world’s population [8, 10].” since, the reference system style of the journal is Vancouver (number system) , better start with 1, then 2 , 3.4…..in an ascending manner. rather than start with 8? Like [8, 10] indicated the manuscript.

4. Paragraph 3 line four, “ However, people still lack adequate information on WaSH leading to poor sanitation and hygiene practices.” It needs citation or evidence to this sentence?

5. Inclusion and Exclusion section “ We excluded reviews, i.e. systematic, scoping and meta-analysis.” It is not clear that, was there any systematic review and metanalysis in similar topic in the study setting? if that is the case, what is the importance of this review? How many did you get the three systematic, scoping, and metanalysis?

6. In the eligibility criteria; “ Five (5) additional records were identified from the reference lists of eligible articles and were included for full text review” This is not clear for your inclusion, is that a grey literature ? or you already acknowledge as a limitation as included only published articles?

7. In the first summary paragraph “The following barrier themes emerged from the analysis: (1) geographical inequalities, (2) climate change, (3) low investment on WaSH infrastructure, (4) low knowledge levels on waterborne diseases, (5) ineffective local community engagement.

In the data abstraction sheet both barriers and facilitators are put clearly, while in this paragraph Please also show the facilitators in this summary finding paragraph?

Reviewer #2: The paper is relevant and indeed brings out the key issues underlying constrains on the progressive development of the WASH sector. Below are comments: On the abstract, in these days we now refer to access not coverage, so kindly review. Regarding the geographical inequalities, kindly expand more on what you mean on that, (ie, is it access by road, or underdeveloped areas. Just checking regarding your area on in adequate knowledge on WASH practice- " in your review no paper mentioned issues of culture and norms as barriers to knowledge" I thought this could have come out. Regarding low investments, no paper mentioned the role of policies or by laws and technology that can support such interventions. " just checking if you missed, as this is a critical piece for sustainability.

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Submitted filename: Scoping review_PONE-D-21-26335.docx

Author response to Decision Letter 0

10 Jun 2022

Your feedback was useful and it helped us to develop our manuscript. Thank you vey much.

Submitted filename: Response to Reviewers.docx

Decision Letter 1

PONE-D-21-26335R1

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Short Title: Barriers and facilitators to Water, Sanitation and Hygiene practices in Southern Africa: a scoping review.

The author addressed all comments in the revised version manuscript.

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Acceptance letter

18 Jul 2022

Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: a scoping review

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• Open access
• Published: 28 June 2024

Burden and trends of infectious disease mortality attributed to air pollution, unsafe water, sanitation, and hygiene, and non-optimal temperature globally and in different socio-demographic index regions

• Qiao Liu 1 ,
• Jie Deng 1 ,
• Wenxin Yan 1 ,
• Chenyuan Qin 1 ,
• Yaping Wang 1 ,
• Shimo Zhang 1 ,
• Min Liu 1 , 2 &
• Jue Liu   ORCID: orcid.org/0000-0002-1938-9365 1 , 2 , 3 , 4 , 5  

Global Health Research and Policy volume  9 , Article number:  23 ( 2024 ) Cite this article

45 Accesses

Metrics details

Environmental factors greatly impact infectious disease-related mortality, yet there's a lack of comprehensive global studies on the contemporary burden and trends. This study aims to evaluate the global burden and trends of infectious disease mortality caused by air pollution, unsafe water, poor sanitation, and non-optimal temperature across Socio-Demographic Index (SDI) regions from 1990 to 2019.

This observational study utilized data from the Global Burden of Diseases Study to examine mortality rates from infectious diseases attributed to environmental risk factors between 1990 and 2019, including air pollution, unsafe water, sanitation, handwashing facilities (UWSH), and non-optimal temperatures. Age-standardized mortality rates (ASMRs) and estimated annual percentage change (EAPC) were utilized to present infectious disease mortality, and its trajectory influenced by environmental risk factors over the years. Nonlinear regression was conducted to explore the association between the SDI and ASMRs across regions from 1990 to 2019.

In 2019, global infectious disease deaths linked to air pollution, UWSH, and non-optimal temperature reached a startling 2,556,992. Disease mortality varied widely across SDI regions, with the highest number of deaths due to air pollution and UWSH in Low SDI regions, and deaths from non-optimal temperature primarily in High SDI regions. Age disparities emerged, with children under five and the elderly most affected. However, an increasing mortality trend was observed among seniors (65–69, 75–79, and over 80) in High SDI regions due to enteric infections linked to UWSH. Globally, a consistent decrease in ASMR was seen from 1990 to 2019 for all diseases connected to these factors, except for respiratory infections linked to non-optimal temperature.

Conclusions

Our study underscores the significant impact of air pollution, UWSH, and non-optimal temperatures on global infectious disease mortality, particularly among vulnerable groups such as children and the elderly. It's important to tackle these challenges with targeted interventions aiming to enhance environmental quality, improve water and sanitation systems, and control extreme temperatures. In addition, international cooperation is essential for bridging regional disparities and driving global public health initiatives forward, thereby helping achieve Sustainable Development Goals more effectively.

Introduction

Human well-being is significantly impacted by various environmental factors. According to the World Health Organization (WHO), in 2016, 13.7 million deaths, constituting 24% of global mortality, were attributed to modifiable environmental risks, underscoring that nearly one in four global deaths was linked to environmental conditions [ 1 ]. Specifically, air pollution, a contributor to both communicable and noncommunicable diseases, was responsible for approximately one in eight deaths [ 2 ]. Furthermore, cholera, primarily transmitted through faecally contaminated water or food, has affected 47 countries, with an annual report of about 2.9 million cases [ 2 ]. Additionally, inadequate water, sanitation, and hygiene lead to 829 thousand preventable deaths from diarrheal diseases each year, including 297 thousand deaths of children aged 5 and under [ 2 ]. It was also estimated that 1.69 million deaths were attributable to non-optimal temperature globally in 2019 [ 3 ]. These compelling statistics underscore the imperative to recognize and address the pervasive impact of environmental factors on health. The emphasis on the profound influence of environmental factors on global mortality rates necessitates increased awareness and concerted efforts to foster healthier living environments worldwide.

The impact of environmental factors on health is prominently demonstrated in the domain of infectious diseases. Environmental conditions play crucial roles in disease transmission and prevalence, shaping patterns that significantly contribute to global morbidity and mortality. Recent reports have highlighted the close association between emerging infectious diseases and environmental factors, particularly the rise in diseases originating from wildlife [ 4 ]. Previous studies have validated a correlation between common air pollutants and death from lower respiratory infections, revealing that nitrogen dioxide (per 10 μg/m 3 ) and black carbon (per 0.5 10 −5  m −1 ) are linked to a 10% to 12% increase in combined mortality from pneumonia and influenza [ 5 ]. In contrast to air pollution, which primarily leads to noncommunicable disease-related deaths, illnesses resulting from unsafe drinking water predominantly manifest as infectious diseases, including diarrhea and parasitic infections. Prior research has demonstrated that interventions to improve drinking water, sanitation, and hygiene can effectively reduce the incidence of childhood diarrhea in low- and middle-income countries [ 6 , 7 , 8 , 9 ]. However, despite these findings, as of 2020, 2.0 billion people lacked access to safely managed drinking water services, 3.6 billion lacked access to safely managed sanitation services, and 2.3 billion lacked access to handwashing facilities with soap and water at home [ 10 ]. Moreover, climate and weather significantly influence the duration, timing, and intensity of disease outbreaks, reshaping the global landscape of infectious diseases [ 11 ]. For example, a study in China has revealed that each 5 °C increase in average temperature above 10 °C was associated with a 22% (95% CI, 17% to 28%) increase in malaria cases [ 12 ]. Furthermore, the potential expansion of pathogen or vector ranges due to climate change, coupled with increased global connectivity, can potentially facilitate a faster dissemination of pathogens into new areas [ 13 ].

Considering the paramount significance of environmental factors and their profound influence on global welfare, they emerge as vital touchstones within the framework set by the Sustainable Development Goals (SDGs). Notably, they feature prominently in Goal 3 – “Ensure healthy lives and promote well-being for all at all ages”, Goal 6 – “Ensure availability and sustainable management of water and sanitation for all”, and Goal 13 – “Take urgent action to combat climate change and its impacts” [ 14 ]. In this context, the intersection of environmental factors and infectious diseases becomes a critical focus of inquiry. However, a noticeable dearth exists in global-scale studies examining the contemporary burden and trends of infectious diseases attributed to environmental factors, representing a significant gap hindering the realization of SDGs.

This study, acknowledging the existing research void, aims to shed light on the global burden and trends in infectious disease mortality linked to certain environmental factors, focusing on different Socio-Demographic Index (SDI) regions from 1990 to 2019. Through a meticulous exploration of this inquiry, our findings have the potential to offer valuable insights into the evolving landscape of infectious diseases influenced by certain environmental factors and the regional variations therein. This contribution seeks to enhance our nuanced understanding of the intricate interplay between global health and environmental conditions, ultimately contributing to the fulfillment of SDGs.

Study design

This was an observational study using data obtained from the 2019 Global Burden of Disease study (GBD 2019) result tools. The GBD results, a comprehensive regional and global research program encompassing hundreds of diseases, injuries, and risk factors, allows researchers access to a wealth of global health data [ 15 ]. This observational study capitalized on this extensive dataset to analyze and draw conclusions about particular health concerns.

The number of deaths with its 95% uncertainty interval (UI) per year, and their mortality rates with 95% UIs of infectious diseases attributed to environmental risk factors were extracted. Infectious diseases included enteric infections (diarrheal diseases, specifically referring to infectious diarrheal diseases), respiratory infections (lower respiratory infections, upper respiratory infections, and otitis media), and other infectious diseases (encephalitis and meningitis). Environmental risk factors in this study included air pollution (ambient particulate matter pollution and household air pollution from solid fuels), non-optimal temperature (high temperature and low temperature), and unsafe water, sanitation, and handwashing (UWSH) (unsafe water source, unsafe sanitation, and no access to handwashing facility). The Socio-demographic Index (SDI) of 21 GBD regions from 1990 to 2019 was also extracted from the GBD 2019 result tools. The SDI is a composite indicator of development status strongly correlated with health outcomes. It is the geometric mean of 0 to 1 indices of total fertility rate under the age of 25, mean education for those ages 15 and older, and lag distributed income per capita. As a composite, a country with an SDI of 0 would have a theoretical minimum level of development relevant to health, while a country with an SDI of 1 would have a theoretical maximum level. Low SDI was between 0 and 0.455, Low-middle SDI was between 0.455 and 0.608, Middle SDI was between 0.608 and 0.690, High-middle SDI was between 0.690 and 0.805, and High SDI was between 0.805 and 1 [ 16 ].

Data collection and processing

Data was gathered from the GBD 2019 result tools, established by the GBD group [ 15 ]. The general methodological approaches to estimate the mortality were described elsewhere [ 17 ]. Briefly, all available data on causes of death and exposure of risk factors were standardized and pooled into a single database used to generate cause-specific estimates by age, sex, year, and geography; then multiple models, such as cause of death ensemble modelling, disease model-Bayesian meta-regression, comorbidity correction and so on were used to estimate comparable data of different diseases across the world [ 17 ]. Furthermore, GBD study used a model to link the death rates of infectious diseases to environmental risk factors. The GBD measured how people are exposed to these risks, how these exposures are related to health outcomes, and the percentage of deaths that would be prevented by reducing exposure to these risks. This approach, however, may vary, and captures uncertainty regarding the quality of data and the certitude of the used models [ 18 ].

We reported the death results of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature, in five SDI regions (High, High-middle, Middle, Low-middle, and Low SDI regions) and the global total data from 1990 to 2019, and arranged incidence and death data into successive 5-year age intervals from < 5 years to 75–79 years, plus the 80 + years group.

Statistical analysis

The absolute number of deaths represented the actual impact of infectious disease mortality attributed to environmental risk factors in each SDI region and at global level, and its relative change was defined as \(\frac{{Number}_{2019}-{Number}_{1990}}{{Number}_{1990}}\times 100\%\) , which showed the overall change between 1990 and 2019. Age-standardized mortality rate (ASMR), which were directly extracted from the GBD result tool, [ 15 ] were calculated by applying the age-specific rates to a GBD World Standard Population, and were used to compare populations with different age structures or for the same population over time in which the age profiles changed accordingly.

The Estimated Annual Percentage Change (EAPC) is a commonly used tool to quantified the rate trend over a specific interval [ 19 , 20 ]. A regression line was fitted to the natural logarithm of the rates ( y  =  α  +  βx  +  ε , where y = ln(rate) and x = calendar year). EAPC was calculated as \(({e}^{\beta }-1)\times 100\%\) , with 95% confidence intervals (CIs) obtained from the linear regression model. In this study, overall EAPC was calculated by the annual ASMR of each category of infectious diseases attributed to environmental risk factors in five SDI regions and at global level, and EAPC in different age groups was calculated by the age-specific mortality rate. The term “increase” was used to describe trends when the EAPC and its lower boundary of 95% CI were both > 0. In contrast, “decrease” was used when the EAPC and its upper boundary of 95% CI, were both < 0. Otherwise, the term “stable” was used.

The population attributable fraction (PAF), which represents the proportion of risk that would be reduced in a given year if the exposure to a risk factor in the past were reduced to an ideal exposure scenario [ 17 ]. In this study, we extracted mortality data for all causes of infectious diseases and calculated the PAF of certain risk factors for certain infectious diseases in each year by the formula: \(\frac{death\;number\;attributed\;to\;certain\;risk\;factors}{death\;number\;by\;all\;causes}\times100\%\) .

Finally, we conducted a non-linear regression (second order polynomial) to explore the association between SDI and ASMRs in 21 GBD regions throughout 1990 to 2019. A regression curve was fitted to the ASMR ( y  =  α  +  βx  +  γx 2 , where y = the value of ASMRs and x = SDI).

All the statistical analyses were conducted using the R program (version 4.4.1).

Burden and trends of infectious disease mortality attributed to air pollution, UWSH, and non-optimal temperature from 1990 to 2019

In 2019, global infectious disease deaths attributed to environmental risk factors reached a staggering 2,556,992, with contributions from air pollution, UWSH, and non-optimal temperature of 763,291, 1,656,887, and 245,814 deaths, respectively. The predominant cause of infectious disease deaths associated with air pollution was respiratory infections, contributing to 749,254 fatalities globally in 2019 (95% UI, 573,848 to 959,290). UWSH primarily resulted in deaths from enteric infections, while non-optimal temperature mainly caused respiratory infections, with 1,386,769 (95% UI, 978,063 to 2,009,500) and 245,814 (95% UI, 174,760 to 342,302) deaths, respectively, in 2019.

Examining different SDI regions in 2019, the highest number of infectious disease deaths attributed to air pollution and UWSH occurred in the Low SDI region, with 330,074 (95% UI, 250,942 to 423,208) respiratory infections attributed to air pollution, 6,546 (95% UI, 5,096 to 8,419) enteric infections attributed to air pollution, 2,529 (95% UI, 1,962 to 3,317) deaths from other infectious diseases attributed to air pollution, 640,329 (95% UI, 480,412 to 858,264) enteric infections attributed to UWSH, and 130,090 (95% UI, 58,429 to 200,590) respiratory infections attributed to UWSH. However, in the case of respiratory infections attributed to non-optimal temperatures, the highest death toll was observed in High SDI regions, with 69,216 (95% UI, 51,479 to 88,585) deaths in 2019 (Table  1 ).

On a global scale, enteric infections, attributed to UWSH, were responsible for the highest number of deaths from 1990 to 2019, ranging from 52.01% to 54.67%. This trend persisted in Middle, Low-middle, and Low SDI regions, where enteric infections attributed to UWSH constituted 44.88% to 49.03%, 59.35% to 61.57%, and 55.10% to 56.89% of all deaths, respectively, from 1990 to 2019. Conversely, in the High-middle SDI region, respiratory infections attributed to air pollution dominated deaths from 1990 to 2015 (34.65% to 38.30%). Subsequently, respiratory infections attributed to non-optimal temperature became the primary cause of deaths from 2016 to 2019, accounting for over 37%. Moreover, in the High SDI region, respiratory infections attributed to non-optimal temperature constituted more than 60% of deaths from 1990 to 2019 (Fig.  1 ).

Proportions of deaths of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature from 1990 to 2019, globally and by SDI regions. SDI, Socio-Demographic Index; UWSH, unsafe water, sanitation, and handwashing

Among the three categories of infectious diseases tied to air pollution, respiratory infections had the highest ASMR both in 1990 (27.71 per 100,000 population, 95% UI, 21.66 to 34.76) and 2019 (10.38 per 100,000 population, 95% UI, 7.89 to 13.28). UWSH and non-optimal temperature primarily resulted in enteric infections and respiratory infections, with ASMRs of 18.94 (95% UI, 13.59 to 26.96) and 3.41 (95% UI, 2.42 to 4.77) per 100,000 population in 2019 (Table  1 ).

All infectious diseases attributed to air pollution, UWSH, and non-optimal temperature exhibited declining trends in ASMR globally from 1990 to 2019, with the most rapid decrease observed in enteric infections attributed to air pollution (EAPC = -5.20%, 95% CI, -5.52% to -4.78%). This category decreased from 0.74 (95% CI, 0.52 to 0.93) per 100,000 population in 1990 to 0.16 (95% CI, 0.13 to 0.20) per 100,000 population in 2019. Following closely were enteric infections attributed to UWSH, exhibiting an average annual decrease of 3.73% (95% CI, 3.60% to 3.85%), declining from 8.44 (95% UI, 3.63 to 12.97) per 100,000 in 1990 to 3.74 (95% UI, 1.66 to 5.83) per 100,000 in 2019.

Analyzing within different SDI regions, the highest ASMRs of infectious diseases associated with air pollution, UWSH, and non-optimal temperature were consistently observed in Low SDI regions, in both 1990 and 2019. Across all SDI regions, the ASMRs of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature demonstrated declining patterns from 1990 to 2019 (all p  < 0.05) (Fig.  2 ).

Trends of ASMRs of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature from 1990 to 2019, globally and by SDI regions. ASMR, Age-standardized mortality rate; SDI, Socio-Demographic Index; UWSH, unsafe water, sanitation, and handwashing

Age disparities of infectious disease mortality attributed to air pollution, UWSH, and non-optimal temperature

Figure  3 illustrated the global mortality rates of infectious diseases that are attributable to air pollution, UWSH, and non-optimal temperature, in various SDI regions, and across different age groups for the years 1990 and 2019. Notably, air pollution was exclusively linked with deaths from enteric infections and other infectious diseases only in children under the age of 5, with this correlation not being observed in other age groups. The highest mortality rates were observed in the Low SDI region in 2019: 3.83 (95% UI, 2.98 to 4.93) per 100,000 for enteric infections and 1.48 (95% UI, 1.15 to 1.94) per 100,000 for other infectious diseases.

Mortality of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature in different age groups, in 1990 and 2019, globally and by SDI regions. SDI, Socio-Demographic Index; UWSH, unsafe water, sanitation, and handwashing

In cases of respiratory infections attributed to air pollution, non-optimal temperature, UWSH, and enteric infections due to UWSH, both children under five years old and the elderly were significantly impacted. In 2019, the global mortality rates for these conditions in children under 5 were 45.90 (95% UI, 33.50 to 60.41), 8.69 (95% UI, 4.90 to 16.17), 17.24 (95% UI, 7.78 to 27.39), and 71.02 (95% UI, 54.77 to 92.29) per 100,000 population, respectively. In individuals aged over 80, the rates were 101.96 (95% UI, 74.03 to 135.37), 66.46 (95% UI, 49.13 to 87.47), 33.08 (95% UI, 14.11 to 52.85), and 202.05 (95% UI, 116.59 to 330.79) per 100,000 population, respectively. Low SDI regions consistently reported the highest mortality rates across all age groups.

From 1990 to 2019, most age brackets showed a downward trend in mortality rates for respiratory infections resulting from air pollution, non-optimal temperature, UWSH, along with enteric infections attributed to UWSH. Children under the age of 5 exhibited the most significant decline in all diseases and SDI regions. However, in High SDI region, there were increasing trends in mortality rates for enteric infections attributed to UWSH among individuals aged 65–69 (EAPC = 0.38%, 95% CI, 0.02% to 0.75%), 75–79 (EAPC = 0.61%, 95% CI, 0.02% to 1.20%), and over 80 years (EAPC = 1.81%, 95% CI, 1.20% to 2.42%) (Fig.  4 ).

EAPC of mortality of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature in different age groups, from 1990 to 2019, globally and by SDI regions. EAPC, Estimated Annual Percentage Change; SDI, Socio-Demographic Index; UWSH, unsafe water, sanitation, and handwashing

PAF of environmental risk factors for infectious disease mortality

On a global scale, diarrheal diseases emerged as the predominant cause of death among infectious diseases linked to environmental risk factors, with lower respiratory infections following closely. The primary contributors to diarrheal disease deaths were unsafe sanitation, an insecure water source, and lack of access to handwashing facilities. Ambient particulate matter pollution and household air pollution from solid fuel played subsidiary roles in a minority of diarrheal disease deaths. Lower respiratory infections were attributed to factors such as the absence of handwashing facilities, ambient particulate matter pollution, household air pollution from solid fuel, high temperature, and low temperature. These conditions persisted across Middle, Low-middle, and Low SDI regions. However, in High and High-middle SDI regions, lower respiratory infections accounted for the majority of infectious disease deaths (Fig.  5 ).

Contribution Proportion of air pollution, UWSH, and non-optimal temperature to Infectious Disease Mortality, in 1990 and 2019, globally and by SDI regions. SDI, Socio-Demographic Index

Examining the global scenario, for deaths related to diarrheal diseases, the highest PAF in 2019 was associated with an unsafe water source (PAF = 80.17%), followed by unsafe sanitation (49.31%), and lack of access to handwashing facilities (23.32%). Concerning lower respiratory infections, household air pollution stemming from solid fuels had the highest PAF (16.96% in 2019), followed by ambient particulate matter pollution (13.09%), and the absence of handwashing facilities (10.83%). Moreover, the PAF of household air pollution played a central role in lower respiratory infections across Middle, Low-middle, and Low SDI regions. In contrast, High and High-middle SDI regions were primarily impacted by low temperature (17.43% in High SDI region and 11.77% in High-middle SDI region, in 2019). Notably, the PAF of ambient particulate matter pollution for lower respiratory infections exhibited an upward trend from 1990 to 2019. This trend was consistent in Middle (from 13.10% to 16.77%), Low-middle (from 7.62% to 18.16%), and Low (from 4.79% to 10.33%) SDI regions. Similarly, the PAF of high temperature for lower respiratory infections also exhibited an upward trajectory in these three SDI regions, rising from 2.50% to 2.61%, 5.12% to 5.58%, and 5.09% to 5.41%, from 1990 to 2019 respectively (Table  2 ).

Association between SDI and infectious disease mortality attributed to air pollution, UWSH, and non-optimal temperature in 21 GBD regions

For enteric infections attributed to air pollution and UWSH, as well as other infectious diseases attributed to air pollution, and respiratory infections attributed to air pollution and UWSH, there was a consistent decrease in the ASMR of infectious diseases with the rise in SDI. The second order polynomial regression revealed a strong correlation (R-squared ranging from 0.78 to 0.91). Nonetheless, for respiratory infections triggered by non-optimal temperatures, the association between ASMR and SDI lacked statistical significance (R-squared of the second order polynomial regression was lower than 0.1).

On analyzing particular diseases, the Caribbean displayed the highest ASMR for enteric infections and other infectious diseases resulting from air pollution, surpassing other regions with similar SDIs. In contrast, Central, Western, and Southern Sub-Saharan Africa reported the highest ASMR for respiratory infections attributed to air pollution and UWSH compared to other regions with comparable SDIs. Additionally, South Asia recorded the highest ASMR for enteric infections attributed to UWSH when compared to regions with similar SDIs (Fig.  6 ).

The correlation between ASMR of infectious diseases attributed to air pollution, UWSH, and non-optimal temperature and SDI in 21 GBD regions. ASMR, Age-standardized mortality rate; SDI, Socio-Demographic Index; GBD, Global Burden of Disease Study; UWSH, unsafe water, sanitation, and handwashing

To the best of our knowledge, this study represented the first comprehensive effort to outline the current burden of infectious disease mortality attributed to air pollution, UWSH, and non-optimal temperature, both globally and within various SDI regions, encompassing the estimation of its longitudinal trends over the past three decades. In summary, the analysis highlights the significant impact of certain environmental risk factors on global infectious disease mortality. Respiratory infections attributed to air pollution and enteric infections attributed to UWSH were particularly noteworthy, causing a substantial number of deaths globally, with the Low SDI region recording the highest infectious disease deaths. Both children under five years old and the elderly bore the greatest impact from air pollution, UWSH, and non-optimal temperature. While overall mortality rates showed a declining trend from 1990 to 2019, an increasing trend was observed in the High SDI region in mortality rates for enteric infections attributed to UWSH among individuals aged 65–69, 75–79, and over 80 years. Interestingly, non-optimal temperatures served as the main causes for respiratory infection deaths in High and High-middle SDI regions, while household air pollution was a fundamental contributor in lower respiratory infections across Middle, Low-middle, and Low SDI regions. Furthermore, specific infectious diseases exhibited higher mortality rates in the Caribbean, Sub-Saharan Africa (especially Central, Western, and Southern regions), and South Asia. A thorough understanding of these intricate trends and geographical variations is essential in crafting targeted interventions and policies to mitigate the impact of environmental risk factors on infectious disease mortality.

In our study, we found that respiratory infections attributed to air pollution was particularly noteworthy, contributing to 749,254 fatalities globally in 2019. This finding underscores the previously acknowledged contribution of air pollution to one in eight deaths from all diseases, emphasizing the substantial impact on infectious disease mortality [ 2 ]. Inhalation of combustion-derived material has been shown to heighten vulnerability to airway infections, as evidenced by Logan's seminal Lancet paper reporting a threefold increase in pneumonia-related deaths during the 1952 London smog, particularly affecting the very young and elderly [ 21 ]. Pneumonia notifications surged 1.4-fold during the smog and 2.4- to 2.7-fold in the following two weeks compared to the 1947–1951 weekly average. Bell et al. estimated pneumonia as a significant cause of the 12,000 excess deaths from the 1952 London smog [ 22 ]. Additionally, various combustion sources, such as environmental tobacco smoke in Vietnam, have been associated with a 1.5-fold increased risk for childhood pneumonia, with 28% of cases attributable to environmental tobacco smoke [ 23 ]. Mechanistic evidence was also emerging for bacterial pneumonia, with urban PM found to enhance pneumococcal adhesion by boosting platelet-activating factor receptor expression on airway epithelial cells, and NO 2 exposure increasing the expression of the rhinovirus entry receptor in nasal epithelial cells [ 24 , 25 ]. However, the precise impact of PM and NO 2 on RSV infection remains uncertain [ 26 ]. Moving forward, policies aimed at reducing air pollution and mitigating its adverse health effects, particularly targeting vulnerable populations, are imperative to combating the burden of infectious diseases associated with air pollution.

In addition to air pollution, our study highlights the impact of non-optimal temperature on mortality from lower respiratory infections, particularly in High and High-middle SDI regions. Previous research has demonstrated that low temperatures were the second leading risk factor for respiratory infection deaths in America in 2019, accounting for 15.3% of fatalities, with smoking as the first leading risk factor [ 27 ]. Moreover, studies have shown that a 1 °C increase in maximum temperature was associated with a 4.2% and 3.4% increase in hospital admissions for acute lower respiratory infections among children aged 3–5 years during the dry and rainy seasons, respectively [ 28 ]. While cold effects predominate in most regions, areas with high prevailing temperatures can experience substantial heat-related effects that far exceed the burden attributable to cold temperatures [ 3 ]. Non-optimal temperatures can significantly impact respiratory infections by influencing the formation and development of microbial biofilms, a major factor in respiratory tract infection pathologies, whereby the growth and virulence of pathogenic microorganisms such as Streptococcus pneumoniae and nontypeable Haemophilus influenzae can be enhanced under such stressed conditions, further promoting the recurrence and chronicity of diseases [ 29 , 30 ]. Given these findings, it is imperative to implement strategies aimed at mitigating the adverse health impacts of temperature extremes. This may include initiatives to improve urban planning and infrastructure to mitigate the urban heat island effect and enhance resilience to extreme temperatures. Additionally, targeted public health interventions and awareness campaigns could help vulnerable populations better adapt to temperature extremes and reduce their susceptibility to respiratory infections.

Moreover, we found that the PAF of ambient particulate matter pollution and high temperature for lower respiratory infections exhibited an upward trend from 1990 to 2019, in Middle, Low-middle, and Low SDI regions. In areas with lower SDI, potential issues such as inadequate public health facilities, malnutrition, and low awareness of preventive measures among residents make these populations more susceptible to the impacts of environmental particulate matter pollution and high temperatures. This might be a contributing factor to the observed phenomenon. In one study, Zhao and his team found a clear association between particulate matter pollution and respiratory diseases in Dongguan, China [ 31 ]. High temperatures are another major factor causing an increase in the rate of respiratory infections. A research study by Horne et al. stated that a rise in the concentration of particulate pollution exacerbateed the effects of weather on acute lower respiratory infections [ 32 ]. From these studies, it can be inferred that in low SDI areas, the PAF of lower respiratory infections caused by environmental particulate matter pollution and high temperatures shows an upward trend, reflecting the effects of these factors and regional characteristics on population health.

Enteric infection deaths, primarily stemming from diarrheal diseases and attributed to UWSH, were observed to be of concern across all SDI regions in our study. Even in the High SDI region, there were discernible increasing trends in mortality rates for enteric infections attributed to UWSH among individuals aged 65–69, 75–79, and over 80 years. Diarrhea could have a devastating effect on quality of life in the elderly, and the impact of diarrhea might be more pronounced in the elderly due to various causes, such as age-related structural and functional intestinal changes, consume of preventive and therapeutic drugs, compromised nutrition and hydration to withstand the effect of diarrhea, more frequent hospital admissions and courses of antibiotics, and more subtle clinical presentation than in younger patients [ 33 ]. Moreover, in nations with higher SDIs, robust health surveillance systems enable more accurate detection and documentation of diarrheal cases. However, the reliance on centralized water supply systems in these countries may also be a contributing factor. Despite being more prevalent and reliable in developed societies, these systems may still face water quality challenges, impacting diarrheal incidence [ 34 ]. Conversely, in countries with lower SDIs, the risk of diarrheal transmission may escalate due to insufficient sanitation facilities and limited hygiene education. Water quality issues, even with access to basic water supply, could contribute to diarrheal outbreaks if the water becomes contaminated. For instance, in many African cities, anthropogenic contamination of groundwater often arises from industrial discharge and untreated sewage [ 35 ]. Ensuring safe and readily available water is crucial for public health, whether for drinking, domestic use, and food production, or recreational activities. Improving water supply and sanitation, alongside enhanced management of water resources, can not only enhance economic growth but also significantly contribute to poverty reduction [ 36 ]. The multifaceted benefits of prioritizing safe water management underscore the interconnectedness of water-related initiatives with broader socio-economic goals, highlighting the pivotal role of water resources in advancing overall community well-being.

Children under 5 and the elderly, were disproportionately affected. Globally, acute lower respiratory infection remains one of the leading causes of morbidity and mortality in children younger than 5 years [ 37 ]. Antenatal exposure to air pollution may increase infants' vulnerability to respiratory infections [ 38 ]. This vulnerability could be due to underdeveloped lungs in infants with lower birth weight [ 39 ]. Postnatal lung development is crucial, with early insults potentially having lasting impacts [ 40 ]. In a Czech Republic study monitoring 1,130 children for 4.5 years, a 30% higher risk of bronchitis was found in children under 2 for every 25 mg/m 3 increase in 30-day average PM2.5 [ 41 ]. A recent meta-analysis of 10 European birth cohorts associated PM10 and traffic exposure with increased pneumonia risk in 16,059 children across six countries [ 42 ]. While the specific timing of pollution exposure wasn't pinpointed, chronic exposure to traffic-derived air pollution was strongly linked to heightened childhood respiratory infection risk. Unsafe water, sanitation, and hygiene cause over 1 million infectious disease deaths annually, with children under 5 bearing a disproportionate burden [ 18 , 43 ]. Diarrhea profoundly affects the elderly's quality of life, possibly exacerbated by age-related intestinal changes, medication use, nutritional challenges, frequent hospitalizations, antibiotic courses, and subtle clinical presentations [ 33 ]. To mitigate the impact of environmental factors on vulnerable populations such as children and the elderly, comprehensive protective measures should be implemented. This includes enhancing environmental protection measures for pregnant women to safeguard fetal health and improving the quality of drinking water to prevent contamination-related illnesses in both age groups. Additionally, efforts to monitor and improve air quality are essential to minimize the respiratory health risks posed by air pollution to both children and the elderly. Regular health check-ups for these vulnerable populations, along with prompt identification and management of potential infection symptoms, are crucial steps in safeguarding their overall health and well-being.

In our findings, Low SDI region recording the highest infectious disease deaths attributed to air pollution, UWSH, and non-optimal temperature. Moreover, the Caribbean, Sub-Saharan Africa (especially Central, Western, and Southern regions), and South Asia displayed higher mortality rates for enteric infections attributed to air pollution, respiratory infections attributed to air pollution and UWSH, and enteric infections attributed to UWSH. Given the significant disparities in infectious disease mortality attributed to environmental factors across different regions, strengthening international cooperation and health assistance is imperative. This could involve collaborative efforts in sharing knowledge, expertise, and resources to address the specific challenges faced by each region. Additionally, international aid programs focused on improving healthcare infrastructure, sanitation facilities, and access to clean water can play a crucial role in reducing the burden of infectious diseases attributed to environmental factors in regions with higher mortality rates. By fostering global partnerships and solidarity, we can work towards achieving better health outcomes for all populations, regardless of geographical location.

This study had some limitations. First, the use of yearly data from the GBD database may have led to misestimation of the disease burden in instances where original data were sparse or missing, as estimates were derived from models. Secondly, due to statistical constraints of the GBD results, only six individual diseases and seven individual risk factors were reported. Thirdly, our analysis was limited to regional-level findings, overlooking potential variations at the national level within each region. Fourth, our analysis is based on the GBD 2019 dataset, which does not cover the extensive changes in environmental factors and health outcomes that have potentially been influenced by the global COVID-19 pandemic. Therefore, the findings of this study may not reflect the situation after the COVID-19 onset. As such, a follow-up study with the GBD 2021 dataset is warranted to provide valuable insights into post-COVID-19 changes. However, despite these limitations, our findings underscore the critical need for regional cooperation in addressing infectious disease mortality attributable to environmental factors, serving as a vital call to action for global health initiatives.

Our findings emphasize the significant role that air pollution, UWSH, and non-optimal temperature play in global infectious disease mortality. Respiratory and enteric infections attributed to air pollution and UWSH present considerable challenges, particularly for vulnerable populations such as children under five and the elderly. Addressing these challenges calls for targeted interventions and policies that focus on improving environmental quality, bolstering water and sanitation infrastructure, and controlling temperature extremes. Prioritizing the health and well-being of these vulnerable populations is crucial in reducing the burden of infectious diseases and further advancing global public health. Moreover, fortifying international cooperation is key to bridging the disparities across regions, propelling global public health endeavors, and achieving the SDGs.

Availability of data and materials

Data are available from the corresponding author by request.

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We appreciate the works by the GBD collaborators.

This work was supported by the National Key Research and Development Project of China (grant numbers 2021ZD0114101). The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the paper.

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Liu, Q., Deng, J., Yan, W. et al. Burden and trends of infectious disease mortality attributed to air pollution, unsafe water, sanitation, and hygiene, and non-optimal temperature globally and in different socio-demographic index regions. glob health res policy 9 , 23 (2024). https://doi.org/10.1186/s41256-024-00366-x

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Correction to: Water, sanitation and hygiene (WASH) practices and deworming improve nutritional status and anemia of unmarried adolescent girls in rural Bangladesh

• Saira Parveen Jolly 1 , 2 ,
• Tridib Roy Chowdhury 1 , 2 ,
• Tanbi Tanaya Sarker 1 &
• Kaosar Afsana 1  

Journal of Health, Population and Nutrition volume  43 , Article number:  99 ( 2024 ) Cite this article

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The Original Article was published on 13 November 2023

Correction to: J Health Popul Nutr 42, 127 (2023)

https://doi.org/10.1186/s41043-023-00453-8

Following publication of the original article [ 1 ], the authors identified errors in Tables 2 and 3 . The symbol  ±  appeared twice in Table 2 between mean and (95%.) where it shouldn’t have been indicated. The sub-header Mean  ±  SD was missing from the Table 3 sub-header.

The incorrect Table  2 :

The correct Table  2 :

The incorrect Table  3 :

The correct Table  3 :

The correct Tables  2 and 3 have been indicated in this correction article and the original article [ 1 ] has been corrected.

Jolly SP, Roy Chowdhury T, Sarker TT, et al. Water, sanitation and hygiene (WASH) practices and deworming improve nutritional status and anemia of unmarried adolescent girls in rural Bangladesh. J Health Popul Nutr. 2023;42:127. https://doi.org/10.1186/s41043-023-00453-8 .

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Jolly, S.P., Chowdhury, T.R., Sarker, T.T. et al. Correction to: Water, sanitation and hygiene (WASH) practices and deworming improve nutritional status and anemia of unmarried adolescent girls in rural Bangladesh. J Health Popul Nutr 43 , 99 (2024). https://doi.org/10.1186/s41043-024-00579-3

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A PROJECT PROPOSAL ON Water, Sanitation and Hygiene Education in School OF KAVRE DISTRICT SUBMITTED TO Ministry of Education Nepal SUBMITTED BY RURAL DEVELOPMENT SOCIETY NEPAL POKHARI CHAURI KAVRE

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Safe drinking water and improved sanitation of surrounding areas is primary need of people for the healthy life. Nepal government has also promoting the awareness program through different health institutions though rural people have still no adequate access on safe drinking water and sanitation facilities. So, the study was focused to identify the identify the availability of drinking water and sanitation facilities in Solukhumbu, Kathmandu, and Chitwan. The study has compared these facilities among the three different geographical setting. The study is based on the quantitative design. Total 880 households were drowned from the selected villages by using the simple random sampling. Structured questionnaire survey was done to collect the data from selected households. The study found that majority of drinking water sources in these districts were from piped water sources (60.8%) while least was from the river (0.1%). Similarly, majority of (79.4%) respondents of study districts reported that there was no facility of sewer system in their household while very few had underground drain system (2.5%). Researcher found that there was provision of toilet in all household in the study area of Chitwan district. While in Kathmandu, 26.0% of household had no provision of toilet in the studied areas. Similar was in Solukhumbhu (14.7%). Poverty, illiteracy and lack of awareness of safe drinking water and sanitation facilities, still rural people are spending the vulnerable life. So concerned authorities should support to improve their condition and future researcher can study on the hindrances of safe drinking water and sanitation behaviour.

International Journal of Management (IJM)

B Suresh Lal, PhD

Poor water quality and lack of access to improved sanitation continue to pose a significant threat to human health. The burden of disease analysis suggests that lack of access to safe water supply, sanitation and hygiene is the third most significant risk factor for poor health in developing countries with high mortality rates. Diarrhoea is the leading disease associated with unsafe water supply, sanitation and hygiene and is responsible for the deaths. The study observed that out of the 150 respondents, 37% are 31-40 years, followed by 20-30 years with 32%. 130 (86.7%) respondents have got married, and 61% of the respondents are female. 85% adopted the nuclear family system, and 50% of respondents are illiterates in the study areas. 85% of respondents are daily wage earners, 37% are earnings rupees between 2000-2500 per month. 27% of respondents are landless labours, and 37% of households possess below 2 acres of land. 40% of respondents suffer from health problems, and 44% consume rice as their staple food. 62% of respondents have debts, and 33% got from money lenders. 62% of respondents do not have toilet facilities and go open defecation. 92% of respondents stated that toilet makes dignity, saves time and energy, saves their children school days, makes adolescent girls privacy, save wage loss, and toilet makes quality life.

Namaste Shrestha

catchment areas. Abstract Context There’s no recorded history of latrine and hand washing coverage or any sanitation and hygiene promotion efforts in Nepal being made before 1980. In the UN-declared International Drinking Water Supply and Sanitation decade (the 1980s), however, breakthroughs were made in the area of water supply. Although the declaration advocated to some extent on sanitation and hygiene, little progress was made in this area.

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About 4 billion citizens around the world lack access to proper sanitation, meaning they are forced to practice open defecation. The health consequences for those living without using toilets are severe. Approximately 480,000 children under5 year age die annually from diarrhoea caused by unsafe water and a lack of access to proper sanitation. That’s almost 2,000 kids a day. In developing countries like India, 57 per cent of households do not have a toilet. And in Tamil Nadu mainly, it was at 52 per cent. In India, civil societies and local government play a vital role in rural development, and they are responsible for transforming the socio-economic features of the villages in India. The central and state governments are implementing many schemes like the National Rural Health Mission (NRHM), Total Sanitation Campaign (TSC), and so on to protect child and women’s health. Both governments to give reward for full achievement of gram panchayats like Nirmal Gram Puraskar (NGP) and rewar...

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Determinants of diarrhea prevalence among children under 5 years in semi-arid Ghana

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Cornelius K. A. Pienaah , Yoko Yoshida , Sulemana Ansumah Saaka , Frank Nyongnaah Ategeeng , Isaac Luginaah; Determinants of diarrhea prevalence among children under 5 years in semi-arid Ghana. Journal of Water, Sanitation and Hygiene for Development 2024; washdev2024092. doi: https://doi.org/10.2166/washdev.2024.092

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Despite the Sustainable Development Goal (SDG6) of achieving universal access to clean water and sanitation by 2030, many developing countries still face water, sanitation, and hygiene (WASH)-related health issues such as child mortality caused by diarrhea. This study investigated the factors contributing to diarrhea prevalence in rural children, utilizing a cross-sectional survey ( n = 517) of smallholder household representatives from a Risk, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) perspective. Using binary logistic regression, the study found that a high prevalence of diarrhea among children was associated with unsafe/open disposal of child feces, living in the poorest households, poor self-rated health, and residing in the Wa East district. Conversely, children from the Brifo ethnicity and those from larger households were less likely to have a high prevalence of diarrhea. These findings underscore the influence of behavioral, socio-cultural, and socioeconomic factors on the prevalence of diarrhea in rural areas. To achieve SDG6, child-friendly sanitation infrastructure, behavior change communication strategies, and incentivizing WASH infrastructure in Ghana and other regions in Sub-Saharan Africa facing similar conditions are recommended.

The world is not meeting the SDG6 that aims to provide universal access to clean water and sanitation for all.

Diarrhea is a significant cause of mortality among children under five.

Unsafe disposal of child feces contributes significantly to rural children's diarrhea.

Child-friendly infrastructure is needed in WASH design systems.

WASH behavioral change strategies are required to address child diarrhea prevalence.

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• DOI: 10.1016/j.drugpo.2024.104485
• Corpus ID: 270637317

Water, sanitation and hygiene insecurity predict abscess incidence among people who inject drugs in a binational US-Mexico metropolitan area: A longitudinal cohort study.

• Alhelí Calderón-Villarreal , D. Abramovitz , +8 authors Georgia L Kayser
• Published in The International journal on… 19 June 2024
• Medicine, Environmental Science, Sociology
• The International journal on drug policy

52 References

Water, sanitation, and hygiene access among people who inject drugs in tijuana and san diego in 2020–2021: a cross-sectional study, wash insecurity and anxiety among people who inject drugs in the tijuana-san diego border region, prevalence and correlates of the use of prefilled syringes among persons who inject drugs in san diego, ca, high prevalence of abscesses and self-treatment among injection drug users in tijuana, mexico., water, sanitation, and hygiene (wash) insecurity in unhoused communities of los angeles, california, prevalence and correlates of abscesses among a cohort of injection drug users, predictors of skin and soft tissue infections among sample of rural residents who inject drugs, sex work, injection drug use, and abscesses: associations in women, but not men., a community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the united states., prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in london, uk, related papers.

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