Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis

Wolf, Jennyfer; Hubbard, Sydney; Bräuer, Michael; Ambelu, Argaw; Arnold, Benjamin F.; Bain, Robert; Bauza, Valerie; Brown, Joe; Caruso, Bethany A.; Clasen, Thomas; Colford, John M.; Freeman, Matthew C.; Gordon, Bruce; Johnston, Richard B.; Mertens, Andrew; Prüss‐Üstün, Annette; Ross, Ian; Stanaway, Jeffrey D; Zhao, Jeff T; Cumming, Oliver; Boisson, Sophie

doi:10.1016/s0140-6736(22)00937-0

Cited by 142 publications

(122 citation statements)

References 86 publications

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“…Poor water quality and poor hygiene practices are disastrous for young and school-aged children who spend a lot of time at school. Children frequently contract illnesses in school [37]. The inadequate water supply system and lack of water treatment technologies in schools may be the leading causes.…”

Section: Discussionmentioning

confidence: 99%

Factors influencing access to basic water, sanitation, and hygiene (WASH) services in schools of Bishoftu Town, Ethiopia: a cross-sectional study

et al. 2023

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Access to basic water, sanitation and hygiene services is the most effective mechanism to reduce many infectious diseases. WASH in schools related to better educational outcomes although adequate water, sanitation, and hygiene services were unavailable to millions of school-age children in Ethiopia. Therefore, it is crucial to assess the level of WASH coverage and identify factors affecting access to basic water, sanitation, and hygiene services. A cross-sectional study was carried out among 82 school facilities. A structured questionnaire and an observational checklist were used to gather the data. Water samples were taken from the schools' water storage. Descriptive and multivariable logistic regression analyses were used to analyze the data. In this study, 74.7%, 61. 3% and 37.3% of the schools had access to basic drinking water, sanitation, and hygiene services, respectively. Additionally, 21.3%, 29.4%, and 30.7% of the schools had access to limited drinking water, sanitation, and hygiene services, respectively. However, 4%, 9.3%, and 32% of the schools lacked water, sanitation, and hygiene services, respectively. We discovered that schools with male heads were 7% less likely to have access to basic hygiene services (AOR = 0.07 with 95% CI 0.01–0.5) than those with female directors. In addition, schools with hygiene and environmental health clubs had an 11.8-fold higher access rate to basic hygiene services (AOR = 11.8 with 95% CI 1.35–104) than schools without such clubs. Besides, schools that conduct WASH lessons at least once a week were 8.63 times more likely to use basic hygiene services (AOR = 8.63; 95% CI 1.18–63.22) than schools that did not. This study offers scientific evidence that could be used for sound decisions to fill the school WASH gaps. This is a unique study in determining the level of WASH coverage and identifying factors affecting access to basic hygiene services. The investigation provides some insights into how access to WASH services can be improved at the grassroots level. Federal and regional governments should implement effective interventions that assist schools to attain Sustainable Development Goal 6 by 2030. School administrators and other partner organizations should take proactive measures to enhance and maintain the WASH services.

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Section: Discussionmentioning

confidence: 99%

Factors influencing access to basic water, sanitation, and hygiene (WASH) services in schools of Bishoftu Town, Ethiopia: a cross-sectional study

et al. 2023

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“…Current recommendations for handwashing with soap reflect the literature that suggests that handwashing with soap is an effective means for preventing the transmission of a range of diseases. [3][4][5][6][7][8][9] Regarding when to practice hand hygiene, future guidelines could focus key moments on those most likely to interrupt the transmission of infectious diseases in domestic, public, and institutional settings. These might include after using the toilet to reduce the transmission of diarrhoea-causing pathogens, 9 and after touching high-contact surfaces or after coughing or sneezing to reduce the risk of respiratory infections.…”

Section: Effective Hand Hygienementioning

confidence: 99%

“…1 Handwashing with soap has been found to be a cost-effective intervention 2 that can reduce the risk of both diarrhoeal disease and acute respiratory infections (ARIs) by over 20%. [3][4][5][6][7][8][9] Handwashing with soap has also been linked to the reduction of certain neglected tropical diseases (NTDs), including trachoma and some soil-transmitted helminth infections. 10,11 Recently, handwashing with soap and the use of ABHRs were advised as one of the key control measures during the COVID-19 pandemic 12,13 and were found to be effective.…”

Section: Introductionmentioning

confidence: 99%

Improving hand hygiene in community settings: a scoping review of current international guidelines

MacLeod

Braun

Chase

et al. 2022

Preprint

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Background: Hand hygiene is an important measure to prevent disease transmission in community settings, such as households, public spaces, workplaces, and schools. There exist various international guidelines with recommendations on how to improve hand hygiene in these settings, but no review to date has been conducted to summarise these recommendations and assess to what extent they are consistent and evidence-based. Methods: To identify international guidelines with recommendations on hand hygiene in community settings, categorised as either domestic, public, and institutional, we performed electronic and grey literature searches and contacted expert organisations and individuals. Recommendations extracted from included guidelines were mapped to four areas related to hand hygiene: i) effective hand hygiene; ii) minimum requirements; iii) behaviour change; and iv) government measures. We assessed if recommendations were supported by peer-reviewed literature and checked their consistency and concordance across settings. Results: We identified 51 guidelines published between 1999 and 2021 by multilateral agencies and international non-governmental organisations containing 923 recommendations. Handwashing with soap is consistently recommended as the preferred method for hand hygiene across all community settings. Most guidelines specifically recommend handwashing with plain soap and running water for at least 20 seconds; single-use paper towels for hand drying; and alcohol-based hand rub (ABHR) as a complement or alternative to handwashing. There are inconsistent and discordant recommendations for water quality for handwashing, affordable and effective alternatives to soap and ABHR, and the design of handwashing stations. Further, there are gaps in recommendations on soap and water quantity, behaviour change approaches, and government measures required for effective hand hygiene. Overall, less than 10% of recommendations are supported by evidence. Conclusion: While current international guidelines consistently recommend handwashing with soap in domestic, public, and institutional settings, the lack of consistent, evidence-based recommendations may constrain global efforts to ensure effective hand hygiene across community settings.

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“…Household-level WASH improvements can result in considerable reductions in diarrheal disease burden in LMICs, and many WASH interventions-such as improved latrines and handwashing with soap-have demonstrable efficacy to reduce fecal exposure 8 . However, recent modest-to-null results from several large-scale WASH randomized controlled trials (RCTs) [9][10][11][12][13][14][15] highlight the need to understand the mechanisms underlying environmental disease transmission.…”

Section: Introductionmentioning

confidence: 99%

“…7 Diarrheal disease is greatly reduced in communities with robust water, sanitation, and hygiene (WASH) infrastructure, with mutually reinforcing levels of community and individual protection. Household-level WASH improvements can result in considerable reductions in diarrheal disease burden in LMICs, and many WASH interventions—such as improved latrines and handwashing with soap—have demonstrable efficacy to reduce fecal exposure 8 . However, recent modest-to-null results from several large-scale WASH randomized controlled trials (RCTs) 9–15 highlight the need to understand the mechanisms underlying environmental disease transmission.…”

Section: Introductionmentioning

confidence: 99%

Understanding the effectiveness of water, sanitation, and hygiene interventions: a counterfactual simulation approach to generalizing the outcomes of intervention trials

Brouwer

Zahid

Eisenberg

et al. 2022

Preprint

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Background: Recent large-scale trials have revealed that interventions improving water, sanitation, and hygiene (WASH) in low-income settings may not confer the expected health gains for young children; evidence-based guidance is needed to inform programs and future studies. Objectives: We aimed to generalize the results of the WASH Benefits Bangladesh randomized controlled trial to other contexts or scenarios using a mechanistic disease transmission model and counterfactual simulations. Methods: A disease transmission model was developed to account for transmission across multiple environmental pathways, multiple interventions (water (W), sanitation (S), hygiene (H), nutrition (N)) applied individually and in combination, adherence to interventions, and the impact of individuals not enrolled in the study. Leveraging a set of mechanistic parameter combinations fit to the WASH Benefits Bangladesh trial (n=17,187) using a Bayesian sampling approach, we simulated trial outcomes under counterfactual scenarios to estimate how changes in intervention completeness, coverage, fidelity and adherence, and efficacy, as well as baseline WASH conditions and disease burden, impacted intervention effectiveness. Results: Increasing community coverage was associated with the greatest impact on intervention effectiveness (e.g., 26.9% and 52.7% median increases in effectiveness in the WSH and WSHN intervention arms when increasing coverage to 20%). The effect of community coverage on effectiveness depended on intervention completeness, i.e., the fraction of transmission that was along pathways modified by the interventions. Intervention effectiveness was reduced in counterfactual simulations with lower levels of preexisting WASH conditions or increased baseline disease burden. Individual interventions had complementary but not synergistic effects when combined. Discussion: Next-generation WASH programs must address coverage and completeness and account for the fact that effect of individual-level WASH improvements will be blunted the further the community is from achieving herd protection.

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Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis

Cited by 142 publications

References 86 publications

Factors influencing access to basic water, sanitation, and hygiene (WASH) services in schools of Bishoftu Town, Ethiopia: a cross-sectional study

Factors influencing access to basic water, sanitation, and hygiene (WASH) services in schools of Bishoftu Town, Ethiopia: a cross-sectional study

Improving hand hygiene in community settings: a scoping review of current international guidelines

Understanding the effectiveness of water, sanitation, and hygiene interventions: a counterfactual simulation approach to generalizing the outcomes of intervention trials

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