literature review on water and sanitation

Literature review: Water quality and public health problems in developing countries

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Eni Muryani; Literature review: Water quality and public health problems in developing countries. AIP Conf. Proc. 23 November 2021; 2363 (1): 050020. https://doi.org/10.1063/5.0061561

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Water’s essential function as drinking water is a significant daily intake. Contamination by microorganisms (bacteria or viruses) on water sources and drinking water supplies is a common cause in developing countries like Indonesia. This paper will discuss the sources of clean water and drinking water and their problems in developing countries; water quality and its relation to public health problems in these countries; and what efforts that can be make to improve water quality. The method used is a literature review from the latest journals. Water quality is influenced by natural processes and human activities around the water source Among developed countries, public health problems caused by low water quality, such as diarrhea, dysentery, cholera, typhus, skin itching, kidney disease, hypertension, heart disease, cancer, and other diseases the nervous system. Good water quality has a role to play in decreasing the number of disease sufferers or health issues due to drinking and the mortality rate. The efforts made to improve water quality and public health are by improving WASH (water, sanitation, and hygiene) facilities and infrastructure and also WASH education.

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System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review

Affiliations.

• 1 Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA.
• 2 USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA.
• 3 College of Engineering, George Fox University, Newberg, OR 97132, USA.
• PMID: 31973179
• PMCID: PMC7037755
• DOI: 10.3390/ijerph17030702

Endemic issues of sustainability in the water, sanitation, and hygiene (WASH) sector have led to the rapid expansion of 'system approaches' for assessing the multitude of interconnected factors that affect WASH outcomes. However, the sector lacks a systematic analysis and characterization of the knowledge base for systems approaches, in particular how and where they are being implemented and what outcomes have resulted from their application. To address this need, we conducted a wide-ranging systematic literature review of systems approaches for WASH across peer-reviewed, grey, and organizational literature. Our results show a myriad of methods, scopes, and applications within the sector, but an inadequate level of information in the literature to evaluate the utility and efficacy of systems approaches for improving WASH service sustainability. Based on this analysis, we propose four recommendations for improving the evidence base including: diversifying methods that explicitly evaluate interconnections between factors within WASH systems; expanding geopolitical applications; improving reporting on resources required to implement given approaches; and enhancing documentation of effects of systems approaches on WASH services. Overall, these findings provide a robust survey of the existing landscape of systems approaches for WASH and propose a path for future research in this emerging field.

Keywords: WASH; grey literature; systematic literature review; systems approaches.

Publication types

• Research Support, U.S. Gov't, Non-P.H.S.
• Systematic Review
• Sanitation*
• Water Supply / standards*

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Attainment of water and sanitation goals: a review and agenda for research

• Original Article
• Published: 23 August 2022
• Volume 8 , article number  146 , ( 2022 )

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• Sanjeet Singh   ORCID: orcid.org/0000-0001-6103-2346 1 , 2 &
• R. Jayaram 2  

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One-fourth of the global population is without basic drinking water and half of the global population lacks sanitation facilities. The attainment of water and sanitation targets is difficult due to administrative, operational, political, transborder, technical, and policy challenges. Conducted after 5 years from the adoption of sustainable development goals by the United Nations reviews the initiatives for improving access, quality, and affordability of water and sanitation. The bibliometric and thematic analyses are conducted to consolidate the outcomes of scientific papers on sustainable development goal 6 (SDG 6). Africa is struggling in relation with water and sanitation goals, having 17 countries with less than 40% basic drinking water facilities and 16 countries with less than 40% basic sanitation facilities. Globally, the attainment of water and sanitation goals will be depended on economic development, the development of revolutionary measures for wastewater treatment, and creating awareness related to water usage, water recycling, water harvesting, hygiene, and sanitation. Behavioral changes are also required for a new water culture and the attainment of water and sanitation goals by 2030.

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Introduction

The world is rapidly moving towards a global water crisis (United Nations Department of Economic and Social Affairs, 2014 ). In this background, the “Water Action Decade” (2018–2028) has been initiated by UN General Assembly (United Nations Organisation-Sustainable Development Goals, 2021 ). Sustainable Development Goal (SDG) 6 aims at ensuring clean water and sanitation for all. According to the United Nations Department of Economic and Social Affairs (UN DESA), 2 billion people are struggling for safe drinking water; 4 billion people for sanitation requirements, and 3 billion people are facing challenges for basic hand wash facilities (United Nations Department of Economic and Social Affairs, 2021 ). Six billion people are in the practice of open defecation (UN-Regional Information Centre for Western Europe, 2021 ). A study on Global water status by UN-Water (2020–21) points out that 26% of the world population are struggling for drinking water, 46% for sanitation, and 44% of households are without proper wastewater treatment (United Nations, 2021 ). Anthropogenic wastewater can create serious concern on life on land and water bodies (López-Pacheco et al., 2019 ). The threat of anthropogenic wastewater and lagging performance in this respect is a serious threat to humanity.

The SDG 6 involves 8 targets and 11 indicators, focusing on clean and safe drinking water, reducing the open defecation practices, integrated water resource management by improvement of water quality; enhancing wastewater treatment, promoting water recycling, and eliminating all types of water wastages. The other targets of SDG 6 involve transboundary water co-operations; protection and restoration of water-related ecosystems; local community participation and building networks for the attainment of water and sanitation goals.

A country-wise analysis into the attainment of SDG 6 by Sustainable Development Report 2021 of the Cambridge University Press (Sachs et al., 2021 ) indicates a serious water crisis among African countries. Eight African countries are with less than 50% of basic drinking water facilities and 15 countries are in the categories below 60% attainment (SDG Index. Org 2021 ). The report exhibits that the average per capita GDP of poorly performing African countries is 762 dollars and the average share of agriculture in GDP is 28.46%. This points out the need for reducing excessive dependence on agriculture, improving economic activities, per capita GDP, and investments in African regions. Sanitation is another challenge in achieving the targets of SDG 6. Both Asian and European countries are on the way to attain sanitation goals. Twelve Asian countries and four South American countries are lagging in their performance related to sanitation goals. The African region is facing severe challenge in providing basic sanitation facilities to its citizen, especially 12 African countries are with below 20% attainment of basic sanitation facilities. Twenty-two countries are successful in providing basic sanitation to the entire population of the country. The average per capita GDP of these countries is 46460 dollars and the percentage of agriculture GDP in gross GDP is 3.19% (United Nations Organisation- Sustainable Development Goals, 2021 ). Seven European countries and Singapore have attained reasonable progress in creating proper facilities for the treatment of anthropogenic wastewater. The average per capita GDP of these countries is 64,560 dollars and the share of agriculture in gross GDP is 2.42%. Fifty countries are without any facilities for proper treatment for anthropogenic wastewater. Sixteen leading countries (countries providing basic sanitation, drinking water, and treatment for anthropogenic wastewater to at least 90% of the population) represent 3.71% of the global population. These countries has an average per capita GDP of 58,209 dollars; average per capita exports of 19,020 dollars; share of exports on GDP stood at 32.76% and share of agriculture in GDP is 2.98% (United Nations Organisation- Sustainable Development Goals, 2021 ). The leading economies like the United States of America, India, China, Japan, Brazil, France, Italy, and Canada are lagging in performance related to sanitation and treatment for anthropogenic wastewater. Urgent actions are needed for ensuring the provision for the treatment of anthropogenic wastewater. Any delay in performance of ensuring treatment for anthropogenic wastewater can negatively affect the access and quality of drinking water and can be a costly and dangerous choice for the goals of safe drinking water and sanitation of future generations (Bondur and Grebenuk, 2001 ; Gelsomino et al., 2006 ; Abdesselem et al., 2012 ). The comparison of ten countries, leading in GDP and performance of SDG 6 is shown in Fig.  1 .

Comparative performance of top 10 economies. Source: Sustainable Development Report 2021

Forty-six countries are outside the 80–100 bracket of achievement of ensuring basic drinking water provisions. Out of the 46 poorly performing countries, 28 countries are in the 60–80 bracket of achievement; 17 countries on the 40–60 bracket; and Chad is in the range of 20–40% achievement. 71 countries are outside the 80–100 bracket of achievement of ensuring basic sanitation provisions. 20 countries are in the 60–80 bracket; 16 countries are in the 40–60 bracket; 22 countries are in the 20–40 bracket and 13 countries are in 0–20 bracket of achievement.

These inequalities in the attainment of basic services of water and sanitation are alarming and smart initiatives towards sanitation goals are essential. The underdevelopment of economic activities, poor per capita GDP, poor per capita exports, and over dependencies in agriculture can be the major causes for the difference in the achievement of water and sanitation goals. The difference in culture, education, and skills, traditions, and habits may also be influential factors for the same.

The existing literature mainly concentrated on efforts to improve access, quality, and affordability of water. Several articles focused on challenges for achieving water and sanitation goals. The findings of this paper can be useful for academicians and scholars for researching SDG 6.

Future empirical studies are essential for concrete proof of the influence of the above factors on the attainment of water and sanitation goals. The analysis and discussion on SDG 6 are very important for the timely achievement of water and sanitation goals by 2030.

Research objectives

To understand the global status of achieving targets of SDG 6.

To consolidate the literature related to SDG 6 from the database of Web of Science.

To develop research themes for future research.

Research questions

What are the challenges for achieving the targets of SDG 6?

What are the initiatives for achieving the targets of SDG 6?

What is the indicator-wise performance of countries on achieving SDG 6?

This paper recommends research on the water and sanitation crisis faced by African countries. Further research can also be on measures for improving quality, access, and affordability for water and sanitation. Research can also be on solutions for problems and challenges faced in ensuring basic drinking water and sanitation for people across the world. The successful models and implementation strategies of leading nations can provide valuable insights for better implementation of policies and schemes. The policymakers and administrators can develop strategies for meeting various challenges associated with SDG 6, especially the challenges associated with the treatment of anthropogenic wastewater. Reforms of the industrial environment, investments, innovative technologies, strong political will, and leadership are essential for achieving the goals of anthropogenic wastewater treatment.

This paper has been divided into six chapters. The introduction of SDG 6 and performance at the global level is included in the first section. The review methodology and the major themes and sub-themes are discussed in the second section. Bibliometric results are discussed in the third section and a thematic analysis by rapid review is the fourth section of this paper. The future agenda for research is the fifth section and the conclusion of the paper is presented in the sixth section.

Review methodology

This review on SDG 6 is based on a single-source, Web of Science. Web of Science provides access to multiple databases, covering about 79 million records and 171 million platforms. Moreover, it covers over 256 disciplines. This single-source was used as it is one of the biggest databases of scientific papers and journals on sustainability and SDGs. The single-source-based model is successfully used in the review related to “Variations of the Kanban system” (Lage Junior and Godinho Filho, 2010 ); “review on environmental training in organisations” (Jabbour, 2013 ); and “systematic review on sustainable investments” (Talan and Sharma, 2019 ). The review frameworks and structure of this paper are adopted from the above three inspirational reviews, based on a single data source. Moreover, the review structure, and model adopted in the rapid review on “COVID-19 and Environmental Concerns” (Gagan Deep Sharma et al . , 2020 ) is another motivation behind design and structure of this review. The keywords "Sustainable Development Goal 6" and "SDG 6" are used on 01/07/2021 for drawing papers. 234 papers are obtained on the first query and used for the review. Thematic analysis was conducted after reading the title, abstract, and details. The details of paper selection are highlighted in Fig.  2 . This paper has followed PRISMA guidelines for paper selection. The criteria for paper and journal selection are that, it should be dealing with water and sanitation-related SDGs and the paper should be written after the introduction of sustainable development goals. This paper has conducted a bibliometric review and rigorous and rapid thematic analysis. Relevant papers of any country are included in this study, and there are no inclusion and exclusion criteria for selecting papers on the basis of country but done on the basis of relevance with the topic.

Paper identification and screening process

Bibliometric analysis was conducted on selected papers. The details of the bibliometric analysis are described in the following paragraphs.

Journal analysis

The source analysis of the leading nine journals is shown in Fig.  3 . The journals are analyzed by h-index, g-index, and m-index, highlighting the source impact. “Science of the Total Environment” published articles related to water quality monitoring using citizen science, global water scarcity, microbial contamination in drinking water, water governance, seasonal drinking water quality, potential solutions for water security, inequality in access of water, water stress indicators, water crisis, and SDG 6 targets in Africa. “Water” focuses on water access, water supply networks, surface water extraction, groundwater vulnerability, integrated water resource management, water governance, water collecting systems, sanitation, fog water collection, remote-sensing technologies, water footprints, and domestic demand and supply of water. The themes published in “Sustainability” are related to water supply networks, use of citizen science monitoring for water-related goals, access to sanitation, citizen and educational initiatives, water supply tariffs, water service sustainability, cross country water co-operations, and water quality governance. The “Journal of Environmental Management” took interest in publishing topics related to fecal sludge management, sanitation, citizen science in sanitation, and water treatment systems. “Journal of Cleaner Production” published on industrial wastewater, groundwater quality, rainwater harvesting, smart waste management systems, and impact of urbanization on water infrastructure. The major themes published in “Journal of Water, Sanitation and Hygiene for Development” are hygiene in healthcare facilities, application of decision support system for attaining water and sanitation targets, urban sanitation, water quality, shared sanitation, toilet waste management, access and affordability of water, and need for behavioral changes for attaining water and sanitation targets. The topics published in “International Journal of Environmental Research and Public Health” are related to drinking water and health; sanitation and solid waste management. Fecal pathogen flow and health risks, and innovative sources for clean water are the topics published on the “International Journal of Hygiene and Environmental Health”. The major works on water and sanitation goals in the journal “Applied Sciences-Basal” are related to soil aquifer treatments, rural water supply, groundwater salinity, and fluoride content in groundwater.

Top journals and source impact

Analysis of authors

Kalin Robert M (University of Strathclyde, Scotland) is the leading researcher on topics related to SDG 6. Twelve documents (all 12 documents are open access) have been written by this author on topics related to SDG 6, with a total of 50 citations and an average citation of 4.17. These 12 documents are published in the years 2021 (2 articles), 2020 (7 articles), and 2019 (2 articles). The h-index of these articles is four. The other influential author of this research domain is Rivett Michael O (University of Strathclyde, Scotland). The author has written nine articles (all 9 documents are open access) with a total citation of 41 and an average of 4.6 citations per article. These nine articles are published in 2021 (2 articles), 2020 (4 articles), and 2019 (3 articles). The h-index of these articles is four.

Both the authors had co-authored nine articles. Four articles had been published in the journal “Water” and obtained 18 citations. The articles in “Water” dealt with groundwater vulnerability (Addison et al., 2020a , b ), integrated water resource management (Banda et al., 2019 ; Banda et al., 2020 ), and stranded asset-based investment strategies for SDG 6 (Kalin et al., 2019 ); three articles are on Applied Science-Basel and got six citations. The articles in this journal focused on focusing on sustainable rural water supply (Leborgne et al., 2021 ), groundwater salinity and rural water supply challenges (Rivett et al., 2020 ), and Human and health implications of Fluoride content in groundwater (Addison et al., 2020a , b ), one article on Sustainability are without any citations. The articles focused on the cost of sustainable water supply through network kiosks (Coulson et al., 2021 ) and the article published on Science of the Total Environment (17 citations). This article is related to salinity in aquifers and technologies beyond hand-pumps (Rivett et al., 2019 ).

The individual publications of Kalin Robert M include an article on rural water supply tariffs, published in the journal “Sustainability” with six citations (Truslove et al., 2020 ); one article each on Environmental Science Water Research Technology (1 citation) dealt with barriers to hand pump serviceability in Malawi (Truslove et al., 2020 ); and Journal of Hydrology Regional Studies (2 citations), article related to transboundary aquifers (Fraser et al., 2020 ).

Analysis of countries

The existing literature mainly focused on countries struggling with water and sanitation goals, especially African countries. The contribution of the top five countries has been evaluated on the parameters of several documents, funded documents, total citations, average citations, co-authorship links, and h-index in Fig.  4 . The research collaborations of countries are shown in Fig.  5 . The country collaboration map also shows the most prominent countries. The most prominent countries are in dark blue, and by this, the most influential countries are the United States of America and England. The United States of America is the most influential country in terms of document publications, citations, funded documents, co-authorship links, and h-index (Table 1 ).

Summary of contributions of top five countries on research related to SDG 6

Country collaboration map

Keyword analysis

The keyword analysis was shown in the conceptual structure map, as shown in Fig.  6 . The most prominent keywords are shown in sanitation (5 occurrences), water (3 occurrences), sustainable development goals (20 occurrences), SDG 6 (15 occurrences), water quality (5 occurrences), groundwater (7 occurrences), and drinking water (3 occurrences). The details of articles details and keywords are provided in the supplementary files.

Conceptual structure map

Scholarships

The leading funding agencies, offering sponsorship for research related to SDG 6 targets for basic drinking water, sanitation, and wastewater treatments are the UK Research Innovation (UKRI) of the United Kingdom, Bill Melinda Gates Foundation of the United States of America, and European Commission. UK Research Innovation (UKRI) of the United Kingdom funded projects on water quality, remote monitoring of water systems in rural areas, governance issues, seasonal drinking water quality, and water resources. Bill Melinda Gates Foundation of the United States of America funded projects on the fecal sludge management system, water quality, and sanitation. The funded projects of the European Union are related to industrial wastewater, ecosystem services, drinking water, sanitation, and crop-water productivity.

Thematic discussion

The major themes and sub-themes as shown in Fig.  7 have been described in this section. The major themes of research in SDG 6 are initiatives and challenges. The major niches for research on initiatives are the efforts for improving access, quality, and affordability. Similarly, the major sub-themes of research regarding challenges of SDG 6 are pollutants, transboundary contracts, politics, climate factors, open defecation, administrative challenges, operational challenges, and technical challenges.

Key themes, sub-themes, and associated keywords

Initiatives in favor of SDG 6 goals

Several initiatives has been researched and documented, towards the attainment goals of SDG 6. The initiative can be for improving access, quality, and affordability of clean water. These three concepts are taken as sub-themes under the initiatives in favor of SDG 6. There is positive news related to access to water, but the quality and affordability of water and sanitation remain a serious challenge and it defeats the objective of access to clean water (Coulson et al., 2021 ) (Mitlin and Walnycki, 2020 ). All these three factors are interlinked and should be existing for the successful attainment of SDG 6 (Diaz-Alcaide et al., 2021 ). Water and sanitation taxes, the density of population, revenue of the local government, and income of local people can also be crucial factors for the attainment of SDG 6 (Martinez-Cordoba et al., 2020 ). Similarly, active forums can play a significant role in the attainment of SDG 6 (Paerli and Fischer, 2020 ).

The SDG 6 should be achieved across all cross-sections of society including involuntarily displaced sections of society (Behnke et al., 2018 ). SDG 6 is heavily linked with health-related goals. The initiatives for quality health are related to the availability of clean water and sanitation goals (SDG 6). The prime focus should be on ensuring sanitation, cleanliness, and hygiene in healthcare facilities and proper waste management for prevention and control of infections (Torres-Slimming et al., 2019 ; Abu and Elliott, 2020 ; Abu et al., 2021 ). The improvement in the access and quality of water and sanitation services includes the development of an integrated water database, measuring the cost and affordability (Bressler and Hennessy, 2018 ).

Efforts for improving access

There are several challenges to ensuring access to clean water (Marshall and Kaminsky, 2016 ). One such challenge is the problems associated with fecal sludge management systems. Fecal sludge management is posing a severe threat to the goals of clean water and sanitation, which directly hinders the efforts for access to clean water and sanitation (Devaraj et al., 2021 ; Yesaya and Tilley, 2021 ). The major factors affecting access to clean water are collection time, distance from the household, water quality, affordability, and reliability of water sources, etc. (Diaz-Alcaide et al., 2021 ). The supply of water in the majority of places is intermittent water supply and has several challenges to provide complete access to clean water and achieving SDG 6. This points out the need for migration to a continuous supply of clean water and a hybrid hydraulic model in this regard was developed (El Achi and Rouse 2020 ).

The model of distribution is a challenge in the case of drinking water and the conflict on the model of distribution of water between formal and informal suppliers should be addressed with innovative hybrid models (Agbemor and Smiley, 2021 ). Alternative policies and partnership models would be the key to enhancing access to clean water. Replacement of public distribution models by community-based water supply models together with increased local monitoring of policies and implementations is recommended as a solution for improving access to clean water in Sub-Saharan Africa (Adams et al., 2019 ). A similar shift from the government-regulated water supply chain to unregulated systems is visible in the research outcomes (Fischer et al., 2020 ). The application of the decision support system for the selection of best water and sanitation technology can improve the access of clean water facilities and sanitation (Bouabid and Louis, 2021 ); similarly, the Earth observation and cloud computing for the attainment of SDG 6 targets (Li et al., 2020 ). The promotion of public standpipes, community boreholes, and household water treatments can be some measures towards access to clean and safe water (Abubakar, 2019 ). Rainwater harvesting can be a suitable and economical alternative for improving access to clean water (Dao et al., 2017 ; Alim et al., 2020 ; Bui et al., 2021 ).

The key water management strategies recommended for improving access to water are importing virtual water; water reallocation; strengthening of law and integrated basin management, creation of water market and wastewater network and treatment facilities, and reusing wastewater (Banihabib et al., 2020 ). The other suggestions for improving access for water are water foot prints (Berger et al., 2021 ); integrated water resource management and fresh water health index (Bezerra et al., 2021 ); shared sanitation (Foggitt et al., 2019 ); aquifer recharge and treatment measures (Gronwall and Oduro-Kwarteng, 2018 ); asset audit and using stranded assets for ensuring access of water (Kalin et al., 2019 ); fog water collections is an alternative strategy for improving the access for clean water (Lucier and Qadir, 2018 ; Qadir et al., 2018 ); however, the main challenges in fog water harvesting are lack of expertise, support, affordability, and inequalities (Qadir et al., 2018 ); water service franchising and distribution of bottled water (Walter et al., 2017 ; Lyne, 2020 ); rain water harvesting, water treatment, better distribution and water recharging (Udmale et al., 2016 ); desalination and wastewater reuse (Van Vliet et al., 2021 ); use of smart pumps can enhance the usage and monitoring of water sources and thereby move close towards the goal of improving access for clean water (Swan et al., 2018 ).

Efforts for improving quality and affordability

A framework for water quality and usage monitoring is developed (Charles et al., 2020 ). Similarly, water quality indices can be used for improving the quality of water by restricting the pollutants in water (Bouhezila et al., 2020 ); a scorecard is developed for monitoring the major dimensions of access, availability, quality, acceptability, and affordability of clean water sources (Ezbakhe et al., 2019 ).

A study covering 63% of green star hotels in Egypt had claimed that green hotel practices like energy saving, optimized water consumption, waste management, and waste reduction can positively contribute to the attainment of SDG 6. This can significantly improve the quality of drinking water (Abdou et al., 2020 ). Water quality monitoring is a major challenge (Cronin et al., 2017 ). Appropriate measures for reduced discharge of untreated pharmaceutical contents in wastewater and better treatment of the same can be some measures towards improving the quality of water and waste management (Acuna et al., 2020 ). The use of citizen science can be a strong alternative for efficient monitoring of SDG 6 and thereby quality improvement economically and conveniently (Bishop et al., 2020 ; Capdevila et al., 2020 ; Fraisl et al., 2020 ; Freihardt, 2020 ; Hegarty et al., 2021 ).

The other measures for improving water quality include monitoring sanitation progress through total service gap (Kempster and Hueso, 2018 ); rural–urban water link, wastewater treatment, and reuse, efficient water quality monitoring, innovative ways of fecal management, and change in community behaviors (Kookana et al., 2020 ); local groundwater balance model for groundwater monitoring (Lopez-Maldonado et al., 2017 ); chlorination of drinking water at the point of the collection can be some measures towards the quality improvement of water (Pickering et al., 2019 ); policy implementation, proper monitoring, and data management are key to improvement of quality (Roy and Pramanick, 2019 ); monitoring, treatment, and education and training of water-related technology (Sogbanmu et al., 2020 ).

The issue of affordability of clean water is closely connected with water-related emotional distress. Research has found that emotional challenges can be developed due to poor affordability to water, despite the access and quality (Thomas and Godfrey, 2018 ).

Challenges for the attainment of SDG 6

Several studies across the globe have identified the challenges for access to safe and clean water; clean water, sanitation, and hygiene are in heavily associated with health-related goals (Anthonj et al., 2018 ).

Challenges associated with pollutants, transboundary contracts, climate, open defecation, and politics

The major challenge for the attainment of SDG 6 can be untreated pharmaceutical contents in wastewater (Acuna et al., 2020 ). The discharge of untreated pollutants to water can be a serious threat to access and quality of water (Bouhezila et al., 2020 ). The other challenges associated with pollutants can be a high concentration of fluoride content in weathered basement aquifers, which increases the risk of dental fluorosis (Addison et al., 2020a , b ; Banda, et al., 2020 ); increased levels of Cadmium and Chromium in water sources can also pollute the water sources and increase the risk of non-communicable disease like cancer (Ahmed and Bin Mokhtar, 2020 ); nitrate and phosphate levels can pollute the water (Hegarty et al., 2021 ). The salinity of the water is a major challenge for clean water (Rivett et al., 2019 ; Rivett et al., 2020 ); contamination of water resources through human and animal fecal matter (Buckerfield et al., 2020 ); E. coli contamination (Usman et al., 2018 ; Charles et al., 2020 ) chlorine content, usage of latrine waste as fertilizer and wastewater discharge (Mraz et al., 2021 ); nitrogen and phosphorous content (Van Puijenbroek et al., 2019 ). The fecal contamination, poor sanitation services, and the presence of no fecal matter in fecal sludge (Hurd et al., 2017 ; Quarshie et al., 2021 ).

Politics is an important determinant in ensuring access to clean water, especially in tension-laden areas. The relations of Palestine and Israel can be crucial in the attainment of SDG 6 goals in Palestine (Al-Shalalfeh et al., 2018 ). Hydro-political risks are another issue affecting the SDG 6 and strong transboundary co-operations are essential for the peaceful access of water in the future (Farinosi et al., 2018 ; Hussein et al., 2018 ; Wright-Contreras, 2019 ; Fraser et al., 2020 ; Jimenez et al., 2020 ; Strokal, 2021 ; Yalew et al., 2021 ). Unfavorable climatic factors are major challenges to water and sanitation-related goals (Hurd et al., 2017 ; Fleming et al., 2019 ; Darwish et al., 2021 ). Negative environmental impacts and population pressures are serious threats for SDG 6 (Salmoral et al., 2020 ). Open defecation is a serious challenge for SDG 6, and the major factors promoting open defecation are found to be the poor promotion of programs at the field level, intimidation of adults, and lack of support in families (Akov and Satwah, 2019 ).

Administrative, technical, and operational challenges

Integrated water resource management is the key to the successful attainment of SDG 6. Despite best efforts for improving access and quality of water, ensuring an integrated water management system is still a challenge (Al-Noaimi, 2020 ). The other administrative challenges can be poor water management and investments, corruption (Adams et al., 2019 ); poor institutional capabilities and fear of failure in monitoring (Rayasam et al., 2020 ) infrastructure-related challenges, and funding and policy challenges (Nhamo et al., 2019 ; Romano and Akhmouch, 2019 ).

The major technical and operational challenges can be the unprotected sources of water and poor coverage of piped water connections (Usman et al., 2018 ; Abubakar, 2019 ). Scarcity of water, rapidly growing populations, unsustainable development, poor management in the usage of water, lack of technical, financial, and institutional performances (Al-Noaimi, 2020 ). Another serious issue to be addressed is the inequality in access to drinking water (Anthonj et al., 2020 ). The issues of capacity shortages and poor law enforcement (Darwish et al., 2021 ); poor accountability and complex governance structure (Gronwall, 2016 ); administration challenges, conflicting goals of other indicators, challenges in local implementation of global goals (Herrera, 2019 ).

The other technical issues include the unaffordability of water and poor coordination of responsibilities (Jama and Mourad, 2019 ); poor latrine constructions and seasonal flooding (Jewitt et al., 2018 ); political will, poor economic background, poor environmental and manpower development, attitude and lack of will of administrative and legislative systems; and poor technological tools are challenges proper water governance (Mycoo, 2018 ); technical, scale and operational efficiencies of water utilities are a serious challenge for goals of clean water (Ngobeni and Breitenbach, 2021 ); installation failures, damages, poor maintenance, non-availability of spare parts and affordability issues and financial constrains (Truslove et al., 2020 ; Coulson, et al., 2021 ); issues associated with poor infrastructure (Udmale et al., 2016 ); affordability, markets, and behavior are the strongest barriers for attainment of SDG 6 (Wight et al., 2021 ) The poor human development, capacity challenges for monitoring sanitation and lack of sufficient data for monitoring and wrong conclusions are creating challenges for SDG 6 (Rahaman et al., 2021 ; Komakech et al., 2019 ; Kirschke et al., 2020 ); behavioral issues, barriers, and habits are posing severe threat to attainment of SDG 6 goals (Mathew et al., 2020 ).

Research suggestions

By reviewing the existing literature, future research can be on improving access, affordability, and quality of drinking water provisions and sanitation. The research on wastewater treatment is an unexplored area. More, specifically, the future research can be in drinking water provisions of African countries; sanitation provisions of African and low-income countries, and the research can be in the wastewater treatment provisions of any countries except a few, those had attained the targets. The detailed agenda for future research has been included in the following section.

Future research agenda

The existing literature points out the various ways of water wastage and pitfalls in water distribution. This badly affects the access to clean drinking water provisions. Future research can be for various methods for improving access to clean water by controlling wastage of water and improving water supply chains. Several studies had been country-based and the wider acceptance of those concepts and theory validation can be done by extending those country-based studies to similar countries facing challenges on clean water. Future research can be on reducing discharge pollutants, innovative solutions for facilitating treatment for anthropogenic wastewater. Future research can also be on measures for reducing these pollutants and initiating policy measures, the scope for technology changes to control the water pollution.

Research on behavioral changes, affordability, and awareness can be conducted to stop the open defecation practices. Future research can be on developing awareness programs, hygiene and sanitation camps. Empirical studies on the role of education and economic development in solving water and sanitation goals can throw light on the connection between literacy, exports, income, and other related variables on the achievement of water and sanitation goals.

Research can be on international politics and transboundary contracts for improving accessibility to water. The policy initiatives for peaceful contracts, improving the proportion of transboundary contracts can be the future actions for the sustainability of water sources.

The water and sanitary goals are at the mercy of climate in many places. This condition should be changed and future research can be developing climate-resistant initiatives and policies for water security and sanitation. Proper policy initiatives and reform models can be developed in the future to tackle several administrative, technical, and operational challenges. Future research can be for solutions for challenges and constraints related to funding, technology, and skill management associated with water and sanitation goals.

Several technological solutions and innovative strategies for water and sanitation improvement has been documented in the existing literature and future research can be on techno-economic feasibility and practicality in solving the challenges associated with SDG 6. Researches can also be on industrial adaptability to these technological changes. The highlights of the future agenda for research are shown in Fig.  8 .

Conclusions

Access to clean and safe drinking water, sanitation, and proper hygiene are very essential for sustainable living. However, a significant section of the global population is outside the basic facilities for drinking water, sanitation, and hygiene. SDG 6 focuses on the targets of ensuring basic drinking facilities, sanitation, and treatment facilities for wastewater for all. This paper has been tailored to understand the status of water and sanitation-related targets of SDG 6 by consolidating the literature from Web of science and other external sources. Both thematic analysis and bibliometric analysis of existing literature on SDG 6 have been conducted and the future scope for research is discussed. This research on the status of water and sanitation-related goals has found that the provision for drinking water had been reached to the majority of the global population except in few countries of the African region. The poor achievement of targets related to the treatment of wastewater and sanitation is also a global concern.

Even though the implementations are at the country level, this paper invites the need for global attention for solving the challenges of poorly performing regions, especially the African continent, which struggles for provisions of water, sanitation, and wastewater treatment. Out of 54 countries in the continent, 45 countries are lagging to provide basic drinking water solutions. In the case of sanitation, there are 13 countries where more than 70% of the population are outside the provisions for basic sanitation facilities. Similarly, there are 16 African countries with provision of wastewater treatment below 2%. The Asian countries are relatively better performing in respect of providing provisions for drinking water, except Afghanistan and Yemen. Thirteen Asian countries are struggling for providing basic sanitation facilities for the population. All Asian countries except Israel, Bahrain, and Singapore are well behind in the achievement of providing proper facilities for the treatment of anthropogenic wastewater. All the European countries are in above 75% achievement brackets in respect of provisions for basic drinking water facilities and basic sanitation facilities. The 18 European countries are in the 80–100 achievement bracket and the remaining 26 countries are lagging in respect of providing basic provisions for the treatment of anthropogenic wastewater. All the North American and Latin American countries are in 80–100 brackets in providing provisions for basic drinking water and in respect of sanitation, except Bolivia (60.7% achievement) and Nicaragua (74.4% achievement). However, the performance of North American and Latin American countries in providing provisions for wastewater treatment is not robust except Chile (71.9%) and Canada (67.4).

The underachievement of targets related to wastewater treatment is still a global concern except for a few countries. What are the challenges and reasons for this underachievement of water and sanitation goals? This review of scientific papers from the Web of Science database points out the major challenges as water and sanitation taxes, high density of population, resource constraints of local government, poor fecal sludge management practices, long wait for collecting water, pollutants and poor wastewater treatment, transboundary contracts and politics, climatic factors, open defecation, and administrative, technical, and operational challenges.

The literature provides several solutions to water and sanitation targets by engagement of active forums; use of integrated water database; recharging and treatment of; decision support systems; rainwater harvesting; desalination and wastewater reuse; smart pumping; water reallocation; strengthening of law and integrated basin management, creation of water market and wastewater network; asset audit; fog water collections; and chlorination of drinking water.

The outcomes of this paper can be a strong motivation for developing policies for the improvement of skill sets and education of the local population, which can economically empower the poor and enhance their affordability to water and sanitation solutions. Similarly, the awareness related to sanitation, hygiene, water recycling, need for reducing water consumption, and preservation are inevitable in inculcating a new culture among people. Moreover, this paper recommends strengthening the water and sanitation supply chain by streamlining water distribution, reducing wastages, and scientifically treating the wastewater. The performance of global economies towards the treatment of anthropological wastewater is discouraging. Strong policy actions based on research should be initiated to improve the provisions for the treatment of anthropological wastewater. Academicians and scholars can use the outcomes of this paper for enhancing their research networks and developing new themes for research. This paper had recommended several thematic, methodological, and policy propositions for the attainment of sustainable development goal 6-related targets by 2030. The future themes specified in this paper can be used for taking scholarships and funded projects related to water, sanitation, hygiene, and sustainability of water resources.

Scholarships and funded projects can be targeted in the research related to providing solutions for anthropological wastewater treatment, technologies, implementation plans, and associated policy reforms. Future research should consider the avoidable challenges and develop inclusive reforms by taking care of all stakeholders. Scholars can focus on the African continent and some pockets of Asia and Latin America, the regions faced by acute shortage for drinking water and sanitation. Future projects can be on the solutions for improving access, affordability, and improving quality of basic provisions for water and sanitation. Minor projects can also be on the achievement strategies on drinking water and sanitation by European and North American countries.

The research outcomes of this paper should be read along with the limitations of using secondary sources. Similarly, the scope for future research and scholarships are not offers but the outcomes of thematic and bibliometric analysis.

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Singh, S., Jayaram, R. Attainment of water and sanitation goals: a review and agenda for research. Sustain. Water Resour. Manag. 8 , 146 (2022). https://doi.org/10.1007/s40899-022-00719-9

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Research Article

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

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

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

Roles Data curation, Methodology

Roles Supervision, Writing – review & editing

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

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

• Nkeka P. Tseole, 
• Tafadzwa Mindu, 
• Chester Kalinda, 
• Moses J. Chimbari

• Published: August 2, 2022
• https://doi.org/10.1371/journal.pone.0271726
• Peer Review
• Reader Comments

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.

Citation: Tseole NP, Mindu T, Kalinda C, Chimbari MJ (2022) Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: A scoping review. PLoS ONE 17(8): e0271726. https://doi.org/10.1371/journal.pone.0271726

Editor: Balasubramani Ravindran, Kyonggi University, REPUBLIC OF KOREA

Received: September 12, 2021; Accepted: July 6, 2022; Published: August 2, 2022

Copyright: © 2022 Tseole et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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

Funding: 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.

Competing interests: There are no competing interests for this manuscript.

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.

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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

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. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist..

https://doi.org/10.1371/journal.pone.0271726.s001

S1 File. Search strategy–PubMed.

https://doi.org/10.1371/journal.pone.0271726.s002

S2 File. Quality of individual studies.

https://doi.org/10.1371/journal.pone.0271726.s003

S1 Protocol.

https://doi.org/10.1371/journal.pone.0271726.s004

Acknowledgments

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

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Water and Sanitation in Schools: A Systematic Review of the Health and Educational Outcomes

Christian jasper.

1 The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB #7431, Chapel Hill, NC 27599, USA; Email: ude.htlaehekaw@repsajc

Thanh-Tam Le

2 Department of Biology, University of North Carolina at Chapel Hill, 120 South Road, Chapel Hill, NC 27599, USA; Email: ude.cnu.liame@tel

Jamie Bartram

A systematic review of the literature on the effects of water and sanitation in schools was performed. The goal was to characterize the impacts of water and sanitation inadequacies in the academic environment. Published peer reviewed literature was screened and articles that documented the provision of water and sanitation at schools were considered. Forty-one peer-reviewed papers met the criteria of exploring the effects of the availability of water and/or sanitation facilities in educational establishments. Chosen studies were divided into six fields based on their specific foci: water for drinking, water for handwashing, water for drinking and handwashing, water for sanitation, sanitation for menstruation and combined water and sanitation. The studies provide evidence for an increase in water intake with increased provision of water and increased access to water facilities. Articles also report an increase in absenteeism from schools in developing countries during menses due to inadequate sanitation facilities. Lastly, there is a reported decrease in diarrheal and gastrointestinal diseases with increased access to adequate sanitation facilities in schools. Ensuring ready access to safe drinking water, and hygienic toilets that offer privacy to users has great potential to beneficially impact children’s health. Additional studies that examine the relationship between sanitation provisions in schools are needed to more adequately characterize the impact of water and sanitation on educational achievements.

1. Introduction

The United Nations Millennium Development Goal 2.A is to “ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling” [ 1 ]. Inadequate water and sanitation facilities in the school environment have been reported as a major hindrance towards achievement of this goal. Many schools in developing and developed countries lack adequate water and sanitation services, with associated potential detrimental effects on health and school attendance [ 2 , 3 ].

The goal of this review is to characterize how inadequacies in water and sanitation in the school environment have the potential to or are impacting the health of children and their attendance in schools. We sought to identify all claimed effects of adequate or inadequate water and sanitation access in the school environment by cataloguing peer-reviewed journal articles on the subject, defining the scope of effects, and highlighting possible future research directions within the field. The school environment represents an important setting because many children’s social habits and behaviors are learned at school. School WASH interventions improve overall sanitation, hygiene and daily water intake in both educational and non-educational environments [ 4 ]. According to the World Health Organization, 11% more girls attend school when sanitation is available [ 5 ]. Many children in both developing and developed nations spend time absent from schools due to diseases contracted within the school environment [ 6 ].

2.1. Criteria for Inclusion

Published peer reviewed literature was screened and reviewed and peer reviewed journal articles that documented an educational or health effect associated with provision or absence of water and/or sanitation in schools selected. These impacts include an increase or decrease in school attendance, school dropouts, or any type of physical, social or psychological illness. The review was restricted to studies that explicitly explored the effects of the provision or absence of water, sanitation, and related hygiene materials such as soap, towels, and toilet paper in the school environment; studies that only examined the effects of behavior changes were excluded. Dissertations were not included. Articles without abstracts or full texts available were not included. Studies concerning day care centers were excluded. Studies on hand sanitizers were excluded.

We categorized ‘water’ interventions as either those for hand washing—including water, wash basins, soap, and drying devices, or for drinking. Studies considering only the impact of fluoride in drinking water were also excluded from the review, as the effects of fluoride on oral health in schools have been widely studied. Sanitation was defined as the availability of facilities to urinate or defecate (private, safe toilets, latrines, and availability of toilet paper) or as facilities for women and girls to manage menstruation (private location, and means for management or disposal of menstrual hygiene materials). Studies on the impact of availability of sanitary napkins were not included. The outcomes targeted by this review included health and educational outcomes. Health effects included in the study encompassed all of the defined social health, mental and physical health topics recognized by the National Institute of Health. Educational outcomes included school attendance and academic performance.

Studies were classified into seven non-exclusive categories: intervention trials, randomized control trials, observational studies, participatory research studies, descriptive studies, cross-sectional studies and outbreak investigations. Studies were also organized by economic status and field topic in order to better organize the results of the search.

2.2. Search Strategy for Identification of Studies

The following major scientific, electronic databases were searched during the months of October through December 2010: PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google. In March 2012 a follow-up scan for subsequently published papers was conducted and five articles that met the inclusion criteria were added to the review.

The primary search was based on the keywords: Schools and Water or Sanitation, Gender and Water or Sanitation, Girls and Water or Sanitation, Menstruation and Water or Sanitation, School Absenteeism and Water or Sanitation, School Health Policies and Water or Sanitation, WASH (Water, Sanitation, and Hygiene) and Schools . All references in the bibliographies of included documents were also systematically searched for relevant documents. The study was restricted to documents for which an abstract and article in English was available.

The search included no time or location restrictions. Studies not written in English, or without an English translation available, were not included in this review. A secondary reviewer completed the review independently. Consensus was reached between primary and secondary reviewers in all cases of initial disagreement.

3.1. Inclusion, Exclusion and Yielded Studies

The primary search identified 3,485 publications whose titles discussed water provision, water quality or sanitation facilities in schools. The majority of these references came from scientific databases (n = 3,312), with the majority from PubMed (n = 2,025). The secondary screening based on abstract identified 471 relevant references. Thirty-nine articles met the inclusion criteria for the tertiary, full-text, review. Bibliographies of these articles revealed an additional six articles. Four of the 39 included studies were excluded from the library due to duplication in multiple papers; in these cases the most comprehensive article from each of these studies was included. Forty-one papers were included in the initial systematic review. Six more studies were added after the initial review, making forty-seven included studies used in data analysis (n = 47) ( Figure 1 ).

Results during each screening phase and final number of included documents.

Field Foci addressed in included papers (n = 47). Percentages rounded to the nearest whole number.

Of the forty-seven papers, eleven addressed drinking water (23%), seven addressed water for handwashing (15%), five addressed providing water for drinking and handwashing (11%), six addressed sanitation (13%); four papers addressed sanitation related to menstruation facilities (8%); and fourteen addressed providing water and sanitation combined in schools (30%) ( Table 1 ).

Many of the studies utilized more than one source of data. Twelve of the forty-seven studies included an experimental intervention (25%); twelve studies used interviews, questionnaires, or focus group and site observation (25%); fourteen studies were analyses of publicly-available data or questionnaires (30%); two studies performed solely site observations (4%); and nine studies included microbiological analyses of student stool samples, observations of sites and/or a questionnaire (19%).

The forty-seven included studies comprised nine intervention trials (19%); four randomized control trials (9%); one observational study (2%); one participatory research study (2%); four descriptive studies (9%); twenty-six cross-sectional studies (55%); and two outbreak investigations (4%) ( Table 2 ). Characteristics of studies included in the review are highlighted in Table 3 .

Study types included from the forty-seven included studies (n = 47). Percentages rounded to the nearest whole number.

Characteristics of studies included in the review, grouped by field examined. Dash marks indicate items not reported in the studies.

The health, cognitive and educational outcomes catalogued in the studies were: infectious diseases (including helminth infections, diarrhea, respiratory and other communicable diseases) (n = 20); gastrointestinal issues including constipation, incontinence, and urinary tract infections related to avoidance (n = 7); physical harm, (n = 2); dehydration (n = 6); obesity (n = 2); neuro-cognitive impacts including mental performance (n = 7); psychological outcomes such as shame or discomfort to use the toilet (n = 5); and absenteeism (n = 8). Seven studies documented outcomes of schools failing to serve as role models on hygiene (thereby undermining the efforts of teaching hygiene, which was not quantified) (n = 7). Educational outcomes included educational achievements and school attendance, while eight studies report absenteeism, only one study analyzed academic performance as an educational outcome [ 33 ] ( Figure 2 ).

Effects catalogued in included studies (n = 47).

Studies were grouped into categories to more effectively describe the results. Articles were also analyzed to determine the differences in responses in developing vs . developed regions, as classified by the United Nations Statistical Division. However, the studies revealed similarities in reported inadequacies in facilities and in the stated benefits of provision of water and sanitation services [ 51 ]. This can be partially attributed to the locations studies were performed within the developed region. Many of the studies in developed countries were self-reported or designated as either from socially deprived, rural or overcrowded urban areas. All studies in South Wales (n = 12) were also considered to be conducted in deprived areas because of the water conditions reported in that part of the United Kingdom, including water shortages and inadequate sanitation facilities [ 11 , 12 , 26 ].

3.2. Water for Drinking

Eleven studies investigated drinking water provision and five examined both water for drinking and for handwashing combined [ 3 , 4 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. All studies that exclusively investigated water for drinking were conducted in developed countries: ten studies in the United Kingdom and in the United States and one in Germany. Seven of the eleven studies measured the change in water consumption from increased water provision in schools [ 3 , 10 , 11 , 13 , 14 , 16 ], while four focused on the water quality issues relating to lead in school water [ 7 , 8 , 9 , 15 ]. All eleven studies reported inadequacies in provision of water for drinking and benefits of improving drinking-water provision in schools.

Two survey studies in schools in the United Kingdom documented inadequate water facilities such as water fountains potentially leading to inadequate hydration [ 3 , 10 ]. These studies cite the established effects of dehydration on health outcomes, such as decreased physical activity, mental capacity, and urinary tract infections. Three intervention studies documented a statistically-significant increase in water consumption when school children were allowed free access to water in school [ 11 , 12 , 13 ]. One further study, a randomized control trial, reported a 31% reduction in the risk of overweight associated with providing drinking water and education in schools in Germany [ 13 ].

In relation to water quality, four studies concerned lead in drinking-water fountains in schools in the United States [ 7 , 8 , 9 , 15 ]. These studies indicate the potential for significant lead exposure to occur due to lead contamination of school drinking water sources. The neurotoxic effects of lead on children, even at low doses, are well understood [ 52 , 53 ]. Though lead was found in school drinking water sources, blood lead levels were not tested in students in three out of the four studies [ 7 , 8 , 9 ]. Sathyanarayana et al ., in 2006 tested the blood lead levels in students in a Washington State school after reports of lead levels above USEPA guidelines [ 15 ]. The study found that lead in school drinking water was not a significant source of lead exposure for students; the worst-case scenario geometric mean blood lead levels for 5–6 year old children in these schools ranged from 1.7–5.0 µg/dL; which is considered low for the state [ 15 ].

3.3. Water for Handwashing and Water for Drinking and Handwashing Combined

Seven studies examined handwashing in schools while five studies examined both water for drinking and for handwashing combined [ 25 , 26 , 28 , 29 , 30 , 31 ]. All studies used surveys or questionnaires, and validated findings through triangulation of data methods such as site observations, and analysis of school records. Three of the five studies that exclusively examine handwashing were conducted in developed countries [ 31 , 33 , 34 ], and all of the studies examining water for drinking and handwashing combined were conducted in developing countries [ 4 , 17 , 18 , 19 , 20 ]. This body of literature provided evidence for provision of water for handwashing and handwashing materials such as soap related to decreased absenteeism and reported illnesses as well as to increased handwashing knowledge.

Schools with scarce supplies for handwashing—such as water provision, soap, or towels—reported less handwashing [ 28 , 30 ]. Scarcity of supplies was noted in a United States survey study in 2007 on a college campus, revealing that 59% of residence halls on campus provided no soap and 90% no paper towels Thirty one percent of respondents indicated they did not wash their hands due to lack of supplies for handwashing [ 34 ]. The findings of the survey by Lopez-Quintero et al ., in Colombia, indicate that children with access to handwashing materials were three times as likely to consistently wash their hands before eating and after toilet usage. In addition, those who reported proper handwashing (before meals, after toilet use) were statistically significantly less likely to report illness such as gastrointestinal and respiratory symptoms, and 20% less likely to be absent [ 28 ]. These surveys provide some evidence for a potential link between provision of handwashing services and handwashing behavior in school environments.

Three randomized control trials targeted at increasing provision of water for handwashing in Israel, China and Egypt reported dissimilar findings [ 25 , 29 , 31 ]. In their study in Israel, Rosen et al. , performed a quasi-blinded handwashing study and found no significant change in rates of communicable illness or absenteeism despite sustained handwashing behavior after six months [ 29 ]. Bowen et al ., conducted an experimental handwashing study in China in which the intervention groups experienced statistically significant lower rates of illness and of absenteeism [ 25 ]. Talaat et al. , conducted a handwashing and education intervention in Cairo, Egypt and reported statistically significant declines in absences caused by illnesses such as diarrhea, conjunctivitis and laboratory confirmed cases of influenza [ 31 ].

Three of the six studies that investigated the combined effects of drinking water provision as well as water for handwashing reported decreased absenteeism and illness rates due to inadequate sanitation materials and facilities [ 17 , 18 , 19 , 20 ]. Blanton et al ., performed interventions at seventeen Kenyan schools which provided handwashing and drinking water treatment sources and education of teachers [ 17 ]. They found a significant increase in household water treatment practices that was sustained over one year and reported a 26% decrease in pupil absenteeism after the implementation of the school-based programs [ 17 ]. Migele et al ., found a statistically significant decrease in visits to the school nurse for diarrheal diseases in response to their interventions in Kenya which involved providing drinking water treatment and handwashing stations [ 19 ].

3.4. Sanitation

Six studies met the pre-defined search criteria for sanitation [ 32 , 33 , 34 , 35 , 36 , 37 ]. Five of the studies were conducted in a developed nation [ 32 , 33 , 34 , 36 , 37 ] and one in a developing [ 35 ]; all six document inadequacies in sanitation provision and the benefits of provision in schools.

Samwel and Gabizon highlight the need to build sustainable toilet facilities indoors in rural areas in Eastern European nations due to avoidance of outdoor toilets located far from the school buildings [ 36 ]. Outdoor toilets surveyed also displayed inadequate sanitation; many facilities had insufficient water availability and floors covered with urine which froze in winter [ 36 ]. Surveys by Barnes and Maddocks in the United Kingdom and Lundblad et al ., in Sweden also documented avoidance of toilets observed as smelly, unclean and lacking privacy [ 32 , 34 ].

Overcrowding in schools was also associated with the avoidance of toilets. Students were reported to avoid using the toilet due to the anxiety of waiting in line during recess or lack of privacy [ 37 ].The avoidance of toilets may contribute to a higher risk of associated continence-related issues like urinary tract infections.

There was only one study that examined academic performance as an educational outcome, a study assessing the condition of school sanitation facilities in New York City by Duran-Narucki [ 33 ]. The study found that the condition of schools, as assessed using multiple indicators including school sanitation facilities, was related to students’ academic success and school attendance. In rundown school buildings students attended fewer days and exhibited poorer performance on math and English standardized tests [ 33 ].

3.5. Sanitation for Menstruation

Four studies focusing on the provision of water and sanitation facilities for menstruation management in the school environment met the search criteria [ 21 , 22 , 23 , 24 ]. Two were conducted in developing countries—South Africa [ 21 ] and Tanzania [ 24 ]—and two in a developed, the United Kingdom [ 22 , 23 ].

All four studies documented female discomfort in the school environment during menses due to inadequacies in the assurance of privacy, disposal of materials for menstruation, or sufficient school water and sanitation facilities. Economically developed countries may have sanitation facilities that enable females to privately manage menses due to an abundant supply of clean water, privacy, affordable sanitary materials and undergarments and may also have supportive female teachers and school nurses for managing menses [ 24 ]. However, deficiencies in sanitation facilities to manage menstruation in schools in the United Kingdom were reported in two cross-sectional studies [ 22 , 23 ]. Post-pubescent female schoolgirls in Tanzania and South Africa reported challenges to travel to and to attend school during menses due to the inability to afford sanitary materials as well as inadequate school facilities such as no running water or broken doors [ 21 , 24 ]. School girls in South Africa also reported a fear of using sanitation facilities due to sexual attacks in school toilets located far from the school building as well as avoiding schools during menstruation [ 21 ].

3.6. Combined Effects of Water and Sanitation

Fourteen studies focus on the combined effects of water and sanitation in schools [ 6 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ]. Six of these studies were conducted in developed countries [ 41 , 43 , 45 , 46 , 47 , 50 ]; all of the studies document inadequacies in water and sanitation provision and the impact of provision in schools sampled. One observational study, eleven cross-sectional and two experimental studies were present in this body of literature.

Three studies reported inadequate water and sanitation facilities in schools through surveys and commentaries [ 41 , 43 , 45 ]. Six studies reported evidence on the lack of adequate sanitation facilities associated with greater risk of gastrointestinal and communicable infections [ 6 , 41 , 43 , 45 , 46 , 50 ]. Koopman’s 1978 epidemiologic study in Colombia reported statistically significant evidence for a causal relationship between the adequacy of toilets (toilet facilities that are not easily broken by students, adequate supply of water, cleanliness, and provision of toilet paper, soap and towels for drying) and diarrhea and vomiting in the schools observed [ 6 ]. In an outbreak investigation, Rajaratnam et al ., documented that students who used toilets for defecation in a primary school in the United Kingdom were statistically significantly more likely to develop Hepatitis A due to inadequate sanitation facilities [ 46 ]. On investigation, the school involved in the outbreak was found to lack toilet paper, hand towels, and soap for handwashing [ 46 ]. Hughes et al ., studied sanitation in the Pacific Islands and reported a decrease in the risk for helminthic infections when children have increased access to water for handwashing and relieving wastes [ 42 ]; reporting, that, regardless of water quality, children who attend schools without water supply are four times more likely to contract helminthiases than children who attend schools with water supply [ 42 ].

4. Discussion

The school environment is an important sector to explore due to the social and health influences schools have on children [ 4 ]. In addition, the school environment is important for interventions aimed at mitigating infectious diseases spread because children may be introduced to more, and more strains of pathogens in the school, due to the fact that more children are present, in contact with, and using the facilities [ 6 ]. This exposure makes the school environment efficacious for performing infectious diseases interventions based on water, hygiene, and sanitation [ 6 ].

In comparing the efficacy of interventions conducted in developing and developed settings, and between regions within these categories, differences in results may be partly explained by varying baseline rates of disease. In similar studies on provision of water for handwashing, Rosen et al. , in Israel found no significant changes in rates of illness or absenteeism, while similar studies in China and Egypt noted significant changes in rates of illness [ 30 , 33 , 35 ]. A feasible explanation for differences in these findings is the variation in prevalence of target illnesses between particular regions at the start of the intervention. Differences in the effect of an intervention in varying areas may be due to confounders that are best controlled for using blinding and randomized control trials. The future use of more high quality epidemiological studies such as this will control for confounders and elucidate the effects of water and sanitation in schools across diverse regions and nations.

The scope of our review with respect to water and sanitation facilities related to management of menstruation in schools was limited. Our criteria excluded papers related to the availability of sanitary napkins in schools. Though there is a large body of evidence within this field, and the outcomes related to it are critical in understanding the role of menstruation on school performance and absenteeism, it was outside the scope of this review. The available evidence supports the claim that a lack of water and sanitation facilities to manage menstruation in schools leads to discomfort and avoidance of school during menstruation. Freeman et al. , have shown a decrease in absenteeism among girls after water and hygiene interventions [ 4 ]. This is particularly significant in light of high drop-out rates among young women in many developing countries [ 54 ]. The relationship between education and women’s health, economic success and educational status has been documented [ 55 ]. Measures that enable women and girls to continue attendance in educational environments are essential to achieving the Millennium Development Goals of universal education and promoting women’s gender equality and empowerment.

This review revealed areas for future research. Future studies should examine the relationship between drinking water and sanitation provision in schools. It has been suggested in the literature that a link may exist between unwillingness to drink water at school in order to avoid using unsanitary school toilets [ 50 ]. This interaction could lead to insufficient hydration and corresponding health effects [ 50 ]. In addition, chemical contaminants such as lead have the potential to impact children’s development, yet little research exists on their prevalence in schools. This is particularly important in resource-poor settings, considering that all studies on this topic were conducted in the United States. In addition, it is unclear whether interventions in the school have the potential to impact the hygiene behaviors of caregivers at home. Blanton et al ., found a significant increase in household water treatment practices that was sustained over one year after their intervention in Kenya [ 17 ]. However in their study, Freeman and Clasen found no significant differences in household uptake of water treatment practices one year after their school intervention in India [ 27 ]. High quality studies of programs targeted at water and sanitation access in schools that monitor the costs, benefits, sustainability and long-term impact on student and caregiver behavior are areas that could be further explored to usefully supplement this body of literature.

Potential errors in study identification and inclusion were mitigated by including a secondary reviewer. As studies were limited in number, used diverse methods and metrics and were conducted in various countries, findings may not be generalizable. No attempt was made to weight the value of the findings of studies according to study quality.

The World Health Organization has issued guidelines for water, sanitation, and hygiene implementation in schools in low cost settings [ 56 ]. Implementation of these regulations at the national level could result in improved water and sanitation conditions in schools. Such regulations would serve to overcome barriers to education, particularly in low resource settings where schools, teachers, and administrators may not recognize the potential impact of water and sanitation on health and education.

5. Conclusions

This review identified the health and educational effects of water and sanitation in schools. The goal of the review was to catalogue and characterize existing studies in the field. The review concluded that studies document higher rates of infectious, gastrointestinal, neuro-cognitive and psychological illnesses where school children were exposed to inadequate water and sanitation facilities. Potential areas for future research were identified. The evidence of widespread inadequate facilities suggests that greater resources and attention need to be invested in this field by school management, bureaucrats and multilateral and civil society organizations.

The overall reasoning behind attention to water and sanitation in schools is logical. Respiratory and gastrointestinal diseases are one of the leading causes of death for children globally [ 57 ]. The evidence summarized in this paper supports there being a link between gastrointestinal and other diseases has important implications for children’s health worldwide. In order to achieve universal access to education as a right for all children, the underlying factors of water and sanitation provision in the school environment and their impacts on health and educational outcomes must be addressed through more rigorous investigation, political attention, and effective intervention.

Acknowledgements

The authors would like to thank the librarians who assisted with the research associated with this publication, Eva Rehfuess of the University of Munich’s Institute for Medical Informatics, Biometry and Epidemiology, Alan Kinlaw of the UNC Epidemiology Department, Claudia Gollop of UNC School of Information and Library Science, and Mark Sobsey of the UNC Environmental Sciences and Engineering Department for all of their support and assistance with this publication. The University of North Carolina at Chapel Hill’s Libraries provided support for open access publication.

Conflict of Interest

The authors declare no conflict of interest.