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Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework.

ABSTRACT: In low- and middle-income countries (LMICs), access to water, sanitation and hygiene (WASH) is associated with nutritional status including stunting, which affects 144 million children under 5 globally. Despite the consistent epidemiological association between WASH indicators and nutritional status, the provision of WASH interventions alone has not been found to improve child growth in recent randomized control trials. We conducted a literature review to develop a new conceptual framework that highlights what is known about the WASH to nutrition pathways, the limitations of certain interventions and how future WASH could be leveraged to benefit nutritional status in populations. This new conceptual framework will provide policy makers, program implementors and researchers with a visual tool to bring into perspective multiple levels of WASH and how it may effectively influence nutrition while identifying existing gaps in implementation and research.

SUBMITTER: Zavala E

PROVIDER: S-EPMC8189228 | biostudies-literature | 2021 Jul

REPOSITORIES: biostudies-literature

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Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework.

Zavala Eleonor E King Shannon E SE King Shannon E SE Sawadogo-Lewis Talata T Roberton Timothy T

Maternal & child nutrition 20210514 3

In low- and middle-income countries (LMICs), access to water, sanitation and hygiene (WASH) is associated with nutritional status including stunting, which affects 144 million children under 5 globally. Despite the consistent epidemiological association between WASH indicators and nutritional status, the provision of WASH interventions alone has not been found to improve child growth in recent randomized control trials. We conducted a literature review to develop a new conceptual framework that ...[more]

PMID: 33988303

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

Project description:ObjectiveTo explore linkages between water, sanitation and hygiene (WASH) and maternal and perinatal health via a conceptual approach and a scoping review.MethodsWe developed a conceptual framework iteratively, amalgamating three literature-based lenses. We then searched literature and identified risk factors potentially linked to maternal and perinatal health. We conducted a systematic scoping review for all chemical and biological WASH risk factors identified using text and MeSH terms, limiting results to systematic reviews or meta-analyses. The remaining 10 complex behavioural associations were not reviewed systematically.ResultsThe main ways poor WASH could lead to adverse outcomes are via two non-exclusive categories: 1. 'In-water' associations: (a) Inorganic contaminants, and (b) 'water-system' related infections, (c) 'water-based' infections, and (d) 'water borne' infections. 2. 'Behaviour' associations: (e) Behaviours leading to water-washed infections, (f) Water-related insect-vector infections, and (g-i) Behaviours leading to non-infectious diseases/conditions. We added a gender inequality and a life course lens to the above framework to identify whether WASH affected health of mothers in particular, and acted beyond the immediate effects. This framework led us to identifying 77 risk mechanisms (67 chemical or biological factors and 10 complex behavioural factors) linking WASH to maternal and perinatal health outcomes.ConclusionWASH affects the risk of adverse maternal and perinatal health outcomes; these exposures are multiple and overlapping and may be distant from the immediate health outcome. Much of the evidence is weak, based on observational studies and anecdotal evidence, with relatively few systematic reviews. New systematic reviews are required to assess the quality of existing evidence more rigorously, and primary research is required to investigate the magnitude of effects of particular WASH exposures on specific maternal and perinatal outcomes. Whilst major gaps exist, the evidence strongly suggests that poor WASH influences maternal and reproductive health outcomes to the extent that it should be considered in global and national strategies.

Project description:BackgroundAccording to the most recent estimates, 842,000 deaths in low- to middle-income countries were attributable to inadequate water, sanitation and hygiene in 2012. Despite billions of dollars and decades of effort, we still lack a sound understanding of which kinds of WASH interventions are most effective in improving public health outcomes, and an important corollary-whether the right things are being measured. The World Health Organization (WHO) has made a concerted effort to compile comprehensive data on drinking water quality and sanitation in the developing world. A recent 2014 report provides information on three phenotypes (responses): Unsafe Water Deaths, Unsafe Sanitation Deaths, Unsafe Hygiene Deaths; two grouped phenotypes: Unsafe Water and Sanitation Deaths and Unsafe Water, Sanitation and Hygiene Deaths; and six explanatory variables (predictors): Improved Sanitation, Unimproved Water Source, Piped Water To Premises, Other Improved Water Source, Filtered and Bottled Water in the Household and Handwashing.Methods and findingsRegression analyses were performed to identify statistically significant associations between these mortality responses and predictors. Good fitted-model performance required: (1) the use of population-normalized death fractions as opposed to number of deaths; (2) transformed response (logit or power); and (3) square-root predictor transformation. Given the complexity and heterogeneity of the relationships and countries being studied, these models exhibited remarkable performance and explained, for example, about 85% of the observed variance in population-normalized Unsafe Sanitation Death fraction, with a high F-statistic and highly statistically significant predictor p-values. Similar performance was found for all other responses, which was an unexpected result (the expected associations between responses and predictors-i.e., water-related with water-related, etc. did not occur). The set of statistically significant predictors remains the same across all responses. That is, Unsafe Water Source (UWS), Improved Sanitation (IS) and Filtered and Bottled Water in the Household (FBH) were the only statistically significant predictors whether the response was Unsafe Sanitation Death Fraction, Unsafe Hygiene Death Fraction or Unsafe Water Death Fraction. Moreover, the fraction of variance explained for all fitted models remained relatively high (adjusted R2 ranges from 0.7605 to 0.8533). We find that two of the statistically significant predictors-Improved Sanitation and Unimproved Water Sources-are particularly influential. We also find that some predictors (Piped Water to Premises, Other Improved Water Sources) have very little explanatory power for predicting mortality and one (Other Improved Water Sources) has a counterintuitive effect on response (Unsafe Sanitary Death Fraction increases with increases in OIWS) and one predictor (Hand Washing) to have essentially no explanatory usefulness.ConclusionsOur results suggest that a higher priority may need to be given to improved sanitation than has been the case. Nevertheless, while our focus in this paper is mortality, morbidity is a staggering consequence of inadequate water, sanitation and hygiene, and lower impact on mortality may not mean a similarly low impact on morbidity. More specifically, those predictors that we found uninfluential for predicting mortality-related responses may indeed be important when morbidity is the response.

Project description:BackgroundUniversal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.MethodsWe used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.FindingsAcross LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.InterpretationOur estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.FundingBill & Melinda Gates Foundation.

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Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework.

Publications

Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework.

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