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School sanitation and student health status: a literature review

2023, Journal of Public Health in Africa

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FOUNDATION UNIVERSITY GRADUATE SCHOOL THESIS

Barry Jay Graciadas

Abstract This study aimed to address the problems encountered by schools in maintaining sanitation and hygienic practices and the extent of these practices. The descriptive and correlational designs were used in the study. The research utilized percentage, weighted mean and Spearman rank correlation coefficient in treating the data. The study revealed that school encountered high extent of problems in the area of Food handling while moderate on the following areas; personal hygienic practices, environmental safety, waste segregation and maintenance and use of school health facilities. The extent of practices is high in waste segregation and environmental safety while moderate in areas of food handling, personal hygienic practices and maintenance and use of school health facilities. The degree of relationship between the problems encountered in maintaining school sanitation and hygienic practices and the extent of these practices is “moderate”. The result also revealed that there is a difference in problems encountered by school in maintaining sanitation and hygienic practices when grouped according to their nutritional status. Schools with less than 8% of wasted and severely wasted pupils and schools with more than 8% of wasted and severely wasted pupils encountered different extent of problem in food handling; similar in waste segregation and the same level of problems in personal hygiene, environmental safety and maintenance of school health facilities. Keywords: Sanitation, Hygiene, Practices

Chandrasekhar Vallepalli

Journal of Global Infectious Diseases

Sunita Agarwal

Children are the most vulnerable segment of the population to hygiene and sanitation concerned health hazards and consequently are affected the most The poor health and lack of sanitation facilities are important underlying factors for low school enrolment, absenteeism, poor classroom performance, and early school dropouts. In the nutshell, India is lacking sanitation and hygiene in its rural schools setup which affects the performance of children negatively and increases the chances of acquiring many diseases. Therefore, the present study is planned to assess the current situation of knowledge and practices regarding hygiene in school students of rural Bikaner. In the present study, 1280 students were selected from 32 schools, which comprised of 16 government and 16 private schools. These students were selected by the process of multistage sampling. A self-administered close ended questionnaire was prepared for the study. To find whether there exists a significant difference betwee...

Nana Ackerson

https://www.ijrrjournal.com/IJRR_Vol.7_Issue.4_April2020/Abstract_IJRR0052.html

International Journal of Research & Review (IJRR)

Good sanitation practices in schools are a pathway to better performing children. The objective of this study was to investigate the sanitation practices of primary school pupils in schools located in Abuja, Nigeria. The study was a cross-sectional descriptive study. A total of 1,514 pupils from 24 schools in Abuja were selected using the multistage sampling technique. They were given questionnaires to fill out after getting parental consent. Results obtained showed that 1114 (73.6%) pupils responded "yes" to having toilets in their schools while 400 responded "no". Two hundred and twenty-nine (15.1%) pupils used pit latrine; 404 (26.7%) used ventilated improved pit latrine; 528 (34.9%) used pour flush toilet; 69 (4.6%) used bucket latrine; and 54 (3.6%) used the open field. Four hundred and forty-five pupils said they had 0-2 toilets in their school; 3-5 toilets, 394 (26.0%); 6-8 toilets, 357 (23.6%); 9-10 toilets, 38 (2.5%); above 10 toilets, 280 (18.5%). Two hundred and forty-six (16.2%) pupils said their toilets in school was washed once a week; 246 (16.2%) said their school toilets were washed twice a week; 265 (17.5%) was once a month and 757 (50%) said their school toilets was washed every day. Seven hundred and fifty-six (49.9%) pupils said the generated waste from their school was disposed by open burning; 144 (9.5%) said landfill; 158 (10.4%) said recycling; and 36 (2.4%) said incineration. The level of sanitation among the primary school pupils was found to be unsatisfactory. Government intervention was recommended to improve the level of sanitation practices.

Arinzechukwu Okanya , Toochukwu C . Nwakile (PhD)

This study was designed to examine the effects of sanitation practises on students' health. A case study research design was adopted for the study. It was done in the University of Nigeria, Nsukka. Four research questions guided the study. The population for the study was 197 students in the Faculty of Vocational and Technical Education. Non stratified ransom sampling technique was used to select 100 students comprising of 20 students each from the five departments in the faculty of Vocational and Technical Education. Questionnaire consisting of 30 items was used to elicit information from the respondents. The questionnaire was validated by three experts. Cronbach alpha was used to determine the reliability of the instrument which yielded 0.76 coefficients. The data collected was analysed using mean statistics. The study identified various causes of poor sanitation, the effects of sanitation on student health, the ways in which the school management has provided equipment/facilities to enhance sanitation as well as the strategies for improving school sanitation so as to reduce the negative effects of poor sanitation on student health. The study recommended the following; the school management has to ensure that the various ways of improving sanitation within the institution are used in synergy, the school management has to ensure that those in charge of cleaning the school environment are adequately monitored as well as adequate provision of funds by the Government for the procurement of facilities that will enhance proper sanitation.

International Journal of Environmental Research and Public Health

Jamie Bartram

International Journal of Research in Medical Sciences

Aniruddh Ranga

Background: Schools environment is essential for children to achieve optimal health and development. Faulty construction leads to inadequate ventilation and moisture accumulation which increase the levels of morbidities. Schools should also serve as demonstration centres of good sanitation to the community hence healthful environment and functional toilets and WASH facilities are of utmost importance for school children.Methods: A community-based cross-sectional study includes randomly selected 50 schools of Sonepat district which were functional for more than 5 years. Schools were recruited by PPS. A schedule was used to assess the environment and WASH conditions. Percentage, proportion and Chi-square test were used as statistical methods. The p-value <0.05 was considered statistically significant.Results: 68.4% government schools and 51.6% private schools were located in a rural area. 68% schools were having multi-storied building, 72% schools were located at appropriate land. ...

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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.

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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
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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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https://doi.org/10.1371/journal.pone.0271726.g001

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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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System approaches to water, sanitation, and hygiene: a systematic literature review.

1. Introduction

Study objectives, 2. materials and methods, 2.1. literature identification, 2.2. selection of articles and data extraction, 2.2.1. initial screening, 2.2.2. secondary screening, method attribute, scope attribute, application attribute, 3.1. literature search results, 3.2. method assessment (rq1), 3.3. scope assessment (rq2), 3.4. application assessment (rq3), 4. discussion, 4.1. many methods, more factors, and a myriad of frameworks, 4.2. geographic dispersion of applications, 4.3. reporting on service sustainability, 4.4. reporting on resources and replicability, 4.5. diversifying methods, analytical complexity and wash scope, 4.6. limitations, 5. conclusions, supplementary materials, author contributions, conflicts of interest.

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Valcourt, N.; Javernick-Will, A.; Walters, J.; Linden, K. System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review. Int. J. Environ. Res. Public Health 2020 , 17 , 702. https://doi.org/10.3390/ijerph17030702

Valcourt N, Javernick-Will A, Walters J, Linden K. System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review. International Journal of Environmental Research and Public Health . 2020; 17(3):702. https://doi.org/10.3390/ijerph17030702

Valcourt, Nicholas, Amy Javernick-Will, Jeffrey Walters, and Karl Linden. 2020. "System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review" International Journal of Environmental Research and Public Health 17, no. 3: 702. https://doi.org/10.3390/ijerph17030702

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