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Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

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

Affiliation Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Writing – original draft, Writing – review & editing

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

Affiliation Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

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

Affiliations Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, CDC Foundation, Atlanta, Georgia, United States of America

Roles Data curation, Methodology, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing

Affiliations Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Roles Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Roles Data curation, Formal analysis, Supervision, Writing – review & editing

Affiliation Infectious Diseases Institute, Makerere University, Kampala, Uganda

Roles Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing

Roles Project administration, Supervision, Writing – review & editing

Affiliation Safe Water and AIDS Project, Kisumu, Kenya

Roles Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Supervision, Writing – review & editing

Affiliation Washington State University, Nairobi, Kenya

Roles Project administration, Resources, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Affiliation Universidad del Valle de Guatemala, Guatemala City, Guatemala

Roles Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Washington State University, Pullman, Washington, United States of America

Roles Investigation, Supervision, Writing – review & editing

Roles Writing – review & editing

Affiliation Epidemiology Department, Ministry of Health, Santo Domingo, Dominican Republic

Roles Data curation, Investigation, Supervision, Writing – review & editing

Affiliation Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts, United States of America

Affiliation Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Affiliations Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America, Belize Ministry of Health and Wellness, Belmopan, Belize

Affiliation Belize Ministry of Health and Wellness, Belmopan, Belize

Roles Data curation, Formal analysis, Project administration, Supervision, Writing – review & editing

Affiliation UNICEF, Kinshasa, Democratic Republic of Congo

Affiliation UNICEF, Ouagadougou, Burkina Faso

Roles Data curation, Formal analysis, Investigation, Project administration, Writing – review & editing

Roles Investigation, Project administration, Supervision, Writing – review & editing

Affiliation UNICEF, New York, New York, United States of America

Roles Data curation, Investigation, Project administration, Supervision, Writing – review & editing

Affiliation Department of Hygiene and Public Health, Ministry of Health, Kinshasa, Democratic Republic of Congo

Affiliation CARE Canada, Ottawa, Ontario, Canada

Affiliation CARE International in Uganda, Kampala, Uganda

Roles Project administration, Resources, Writing – review & editing

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Kampala, Uganda

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Guatemala City, Guatemala

•  [ ... ],

Roles Conceptualization, Investigation, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

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• David Berendes, 
• Andrea Martinsen, 
• Matthew Lozier, 
• Anu Rajasingham, 
• Alexandra Medley, 
• Taylor Osborne, 
• Victoria Trinies, 
• Ryan Schweitzer, 
• Graeme Prentice-Mott, 

• Published: June 15, 2022
• https://doi.org/10.1371/journal.pwat.0000027
• Reader Comments

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

Citation: Berendes D, Martinsen A, Lozier M, Rajasingham A, Medley A, Osborne T, et al. (2022) Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19. PLOS Water 1(6): e0000027. https://doi.org/10.1371/journal.pwat.0000027

Editor: Silvia Monteiro, Universidade de Lisboa Instituto Superior Tecnico, PORTUGAL

Received: February 17, 2022; Accepted: May 21, 2022; Published: June 15, 2022

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: Data is available in Supporting Information S1 Data .

Funding: This work was funded through CDC cooperative agreements as part of emergency response to the COVID-19 pandemic (DB, MLo, JM, and TH received funding within CDC; AMwa, MLa, MKN, DC, KOM, PYO, OEH, AMat received funding on partner side-outside of CDC). The funders had no role in study design, data collection, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As of November 5, 2021, there have been more than 248 million confirmed cases of coronavirus disease 2019 (COVID-19), of which almost 60 million (a conservative estimate) were in Southeast Asia, Africa, and the Western Pacific regions [ 1 ]. Multiple waves of COVID-19 cases continue to threaten low- and middle-income countries (LMICs) [ 2 ]. As of the same date, almost 8 billion doses of COVID-19 vaccines have been administered globally, though comparatively few in LMICs; less than 6% of people in low-income countries have received at least one dose of a COVID-19 vaccine [ 3 ]. International collaborative vaccination efforts, such as the COVID-19 Vaccines Global Access (COVAX) project, have procured and shipped 236 million doses to date [ 4 ]; however, goal levels for COVAX represent doses sufficient for only about 20% of those in LMICs. Reaching high vaccine coverage takes time in these populations: prevention and community mitigation measures to combat COVID-19—such as screening, isolation, quarantine, social distancing, masking, hand hygiene, and regular cleaning (with disinfection as-needed) of surfaces—remain critical to prevention and control of further waves of COVID-19 in LMICs [ 5 , 6 ].

Functional water, sanitation, and hygiene (WASH) infrastructure and consistent practice of key WASH behaviors are critical for prevention of respiratory and enteric infections [ 6 , 7 ]. Regular hand hygiene is a foundational, individually-actionable, and non-pharmaceutical strategy for combatting transmission of COVID-19 [ 8 , 9 ], whether through handwashing with soap and water or using an alcohol-based hand rub (ABHR) with at least 60% alcohol content. Sources, treatment, and storage of water in quantities sufficient for basic needs (drinking, washing hands) is essential, especially if an individual must isolate or quarantine after infection or recent exposure. Similarly, isolation or quarantine may require functional, well-managed sanitation facilities, including enhanced cleaning and disinfection measures for shared facilities [ 10 ].

COVID-19-focused community mitigation guidance for LMICs that incorporates WASH can be developed from existing WASH standards [ 7 ]. The Joint Monitoring Program (JMP) of the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) have published normative criteria for water, sanitation, and hygiene ladders whose “basic” or “safely-managed” criteria can act as minimum standards for WASH access in households [ 11 ], schools [ 12 ], and healthcare facilities (HCFs) [ 13 ]. In humanitarian emergencies, Sphere guidance includes minimum standards for core WASH services that may apply to the COVID-19 pandemic, including minimum water quantities for drinking and personal use (e.g., hygiene) and standards for hygiene promotion and hygiene items [ 14 ]. For displaced populations, the United Nations High Commissioner for Refugees (UNHCR) has identified critical WASH practices to prevent the spread of COVID-19 in refugee locations with high population density and shared WASH services [ 15 ].

Before the pandemic, access to essential WASH services in LMICs was poor. Worldwide, 60% of households and 53% of schools had basic hygiene, defined as a handwashing station (HWS) with soap and water, but for United Nations-categorized least developed countries (LDCs), only 28% of households and 26% of schools had this infrastructure [ 11 , 16 , 17 ]. About 74% of HCFs in LDCs had hand hygiene at points of care [ 18 , 19 ]. Although water quantity is not directly measured, 74% of households globally—but only 37% in LDCs—had onsite water sources available when needed [ 11 ]. Onsite water sources were present in 74% of HCFs and 69% of schools globally, but only 50% and 53%, respectively, in LDCs [ 12 , 13 ]. Private (unshared) sanitation (categorized as at least basic sanitation) at households was 78% globally, but only 37% in LDCs [ 11 ]. According to publicly-available data from UNHCR, in 119 sites that submitted data in March 2020, only 34% of refugee households had access to private sanitation; most sanitation facilities were shared (median: 14 people per facility) [ 20 ].

The COVID-19 pandemic adds new considerations to deploying and managing WASH in LMICs ( Table 1 ). For example, hand hygiene technologies—ABHR, handwashing with soap and water, soapy water, or use of chlorinated water—each present benefits but also challenges to ensuring quality control, use at appropriate times, user acceptability, and feasibility of maintenance under high-use conditions. Although there is no evidence to date that SARS-CoV-2 is transmitted through water or feces [ 21 , 22 ], public water sources and sanitation facilities may require additional COVID-19 mitigation measures to reduce crowding and ensure frequently-touched surfaces are cleaned regularly. Increased and competing demand for water for hygiene may also challenge water availability at public sources and storage capacity at households.

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https://doi.org/10.1371/journal.pwat.0000027.t001

Combining existing WASH guidance with community mitigation guidance for COVID-19, we partnered with organizations and governments in LMICs in Latin America and the Caribbean (LAC) and Africa to assess WASH conditions and practices and deploy and manage WASH interventions to mitigate COVID-19. We focused assessments and interventions by setting (HCFs, community institutions, and households), primarily focused on hand hygiene initially. Results from these and other evaluations will strengthen the evidence base for WASH mitigation measures for COVID-19 in LMIC settings and identify new challenges or persisting gaps where further improvements are needed. By building partner capacity to conduct mixed-methods monitoring and evaluation, these projects may also improve sustainability of WASH services.

Selection of locations and assessment approach

Countries were prioritized based on existing partnerships, CDC country office collaboration, and anticipated risk of COVID-19 transmission and consequences based on existing country resources. Within countries, HCFs were selected by governmental and non-governmental partners based on risk for COVID-19 transmission, program viability, and in-country partner presence. Community institutions that were perceived to be high risk for COVID-19 transmission (e.g., had population mixing in densely-populated areas) were prioritized based on country partner or governmental guidance. In districts or regions with international borders or points of entry (POE), and therefore highly mobile populations, the CDC Population Connectivity Across Borders (PopCAB) toolkit [ 23 ] helped identify priority community settings associated with mobile populations, including additional POE and checkpoints, schools, markets, and other priority non-HCF community institutions. Household-level assessments were prioritized through partnerships with organizations that had existing health- or WASH-focused programs in low-resource locations of high-COVID-19 transmission risk, for example densely-populated informal settlements and internally displaced persons (IDP) camps. For all settings, priority locations selected and methods used varied slightly by the population served (e.g., refugee, IDP population, or general community). All settings (HCFs, community institutions, households) underwent WASH assessments and collection of qualitative data [focus group discussions (FGDs) or key informant interviews (KIIs)]; methods in HCF and community institutions were similar because new tools required for community institutions were generally derived from HCF-specific tools ( Table 2 ).

https://doi.org/10.1371/journal.pwat.0000027.t002

Quantitative: WASH assessments, knowledge, attitudes, and practice surveys, hand hygiene observations

Where feasible, baseline assessments of WASH conditions used existing tools for assessing WASH in the given setting that were modified to focus on hand hygiene needs for COVID-19. In HCFs, tools included the water and sanitation for health facility improvement tool (WASH FIT), which identifies WASH gaps in HCFs and prioritizes interventions using national and international standards and can be used on a continuous cycle of improvement by facility staff [ 24 ]. A second tool was the CDC assessment form for HCFs, which focuses on facility services and staff, water supply, sanitation, and hand hygiene resources (appropriate hand hygiene technologies present: ABHR or handwashing stations with soap and water for HCFs specifically [ 22 ]) at points-of-care [ 25 ]. In community institutions, WASH assessments were adapted from HCF-specific tools to target water supply and hand hygiene resources (appropriate hand hygiene technologies present: ABHR, handwashing stations with soap and water, or chlorinated water solutions [only when the other technologies were not available) for community locations [ 22 ]) at location entrances and exits [prioritized for hand hygiene by WHO during COVID-19 pandemic [ 26 ]] and outside toilets. For households, WASH assessments were adapted from JMP questions to assess household hygiene and water ladders [ 11 ] and knowledge, attitudes, and practices (KAP) survey questions were adapted from existing CDC and partner WASH KAP tools with an increased emphasis on handwashing and water access. Questions were added to household WASH and KAP assessment tools on knowledge of COVID-19 prevention and perceptions of local response and mitigation measures. WASH assessments were conducted in all HCFs, community institutions, and households selected. KAP surveys were conducted in all households selected.

Hand hygiene observations were conducted in HCFs and community institutions. In HCFs, observers followed a single provider for three to five patient encounters and noted whether hand hygiene was performed (and the technology used, if performed) before and after patient contact as described for those moments in WHO hand hygiene observation guidance [ 27 ]. To minimize bias, observers were introduced as observing quality of patient-provider care interactions (similar to structured observations using a mystery shopper method [ 28 ]) or as observing general hygiene practices (Guatemala). In community institutions, hand hygiene observations were conducted at locations where hand hygiene materials were present and expected to be used: location entrances and exits and outside latrines [ 26 ]. Similar to HCFs, practicing/not practicing hand hygiene and the technology used were noted, along with the approximate age of the participant (child, adolescent, adult) to target future messaging. In HCFs, a goal of 3–5 patient contacts for each of 90 providers in HCFs per site (generally 3–5 providers at each HCF in a site). If the goal number of patient contacts could not be attained after 30 minutes following a given provider, the observer was instructed to move on to the next provider at that HCF. In community institutions, observers stood in an inconspicuous location, as far away from a given hand hygiene station as possible while still being able to observe it, and randomly observed someone entering/exiting the facility or a random latrine known to be in use and visually followed the individual until either they had performed hand hygiene or passed by the hand hygiene station, whichever came first. For these observations, approximately half of available locations (e.g. individual markets, POE) were selected for hand hygiene observations with a goal of observing a total of 20 hand hygiene events per location. Hand hygiene observations were in locations not serving IDPs or refugee populations.

Qualitative: Focus Group Discussions (FGDs), Key Informant Interviews (KIIs)

Qualitative data—whether collected by FGDs or KIIs—were collected in all settings with differing target participants ( Table 2 ). In most HCFs, FGDs were originally planned, but due to social distancing concerns and limits on the number of individuals in a single space, KIIs usually replaced FGDs (though FGDs were successfully conducted in Belize). KIIs were conducted with healthcare providers, maintenance staff, and administrators to assess behavioral motivators and barriers to practicing hand hygiene before and after patient contact and challenges to managing hand hygiene at the facility. In community institutions, KIIs were conducted with staff and managers to understand barriers and motivators to hand hygiene in that setting and any existing management structures for hand hygiene, if they existed. FGDs were conducted separately with vendors and shoppers at markets to assess challenges to hand hygiene adherence. In households, FGDs were conducted with recipients of handwashing stations and hygiene kits and community volunteers to assess motivators and barriers to hand hygiene. Qualitative tools used in community institutions and households were designed from those used in HCFs. In general, KIIs were conducted at 50% of targeted HCFs and community locations. FGDs in markets were set at five for vendors and five for shoppers.

Schematics.

Schematics were a methodology used in community institutions, but not HCFs or households. Facilitators helped location managers to create drawings showing key locations where hand hygiene should be placed (e.g., entrances/exits, latrines, vendors, public gathering or eating locations), which was subsequently used to identify current hand hygiene resources and future needs.

Guidance for interventions.

Interventions were initiated after—and based on—baseline WASH assessments. Areas of intervention can be found in Table 3 . The guidance used or developed for the specific interventions settings is listed below:

https://doi.org/10.1371/journal.pwat.0000027.t003

HCFs . JMP service ladders and concurrent normative WASH guidance exist for HCFs as of 2017 [ 13 ]. Additionally, WHO guidance describes WASH-related practices that are important for mitigating the spread of SARS-CoV-2 in HCFs, including engaging in frequent and proper handwashing with soap and water or use of ABHR, implementing regular environmental cleaning and disinfection practices, managing excreta safely, and safely managing healthcare waste produced by COVID-19 cases [ 22 ].

Community institutions . Schools are the only community institution where normative WASH assessments exist via JMP-established service ladders [ 12 ]. In POE, although governments may provide guidance for national POE, there are no global recommendations for WASH at POE. In 2020, CDC, the WHO and other organizations developed operational considerations and recommendations for COVID-19 mitigation in community institutions in LMIC settings, including markets, schools, humanitarian settings, and high-density urban areas [ 10 , 29 – 36 ]. These recommendations were based on existing CDC and partner guidance where available (e.g., USAID guidance for safe and functioning food markets; WHO guidance for disinfecting environmental surfaces) and emphasized the importance of increasing access to hand hygiene and enhancing environmental cleaning and other control measures in high-use areas such as shared toilets.

Household . Following existing normative WASH standards, ensuring access to at least basic hygiene infrastructure (handwashing materials on premise with both water and soap) is an important global hygiene standard [ 11 , 16 ]. Guidance on behavioral messaging focused on key times to practice hand hygiene both generally (e.g., after the toilet, before eating, after coughing or sneezing or blowing one’s nose) [ 9 ] and during the pandemic (e.g., after being in public spaces) [ 8 , 37 ].

Broadly, the WASH assessments conducted and presented in this manuscript were exempt from formal institutional review board (IRB) approvals in Uganda, Kenya, Guatemala, Burkina Faso, and the Democratic Republic of the Congo because they were part of ongoing emergency public health response measures by CDC and local partners to the COVID-19 pandemic. Data collection in Belize and the Dominican Republic required IRB review given it was nested within ongoing data collection efforts. In Belize, protocols for data collection were approved by Baylor College of Medicine and the Belize Ministry of Health and Wellness. In the Dominican Republic, protocols for data collection were approved by the National Council of Bioethics in Health, Santo Domingo; the IRB of Pedro Henriquez Urena National University, Santo Domingo; and Mass General Brigham Human Research Committee, Boston, USA. No deviations to protocols occurred after approvals. Verbal or written informed consent (as suggested by the local partner or review board based on cultural acceptability and other factors) was obtained from healthcare workers prior to observations. Additional information regarding ethical, cultural, and scientific considerations to inclusivity in global research is included in S1 Text . All data are available in S1 Data .

Results, interventions, and monitoring and evaluation

Healthcare facilities.

WASH baseline assessments have been conducted at 114 HCFs across six countries ( Table 4 ) and observations of healthcare providers at 54 HCFs in five countries ( Table 5 ). HCF assessments have been completed in Belize (all government-supported hospitals and several priority outpatient clinics), Burkina Faso (Centre Nord and Est Regions, which served internally-displaced persons; HCFs prioritized by UNICEF and Ministry of Health), Dominican Republic (two large hospitals not in Santo Domingo: HCFs prioritized through participation in an acute febrile illness surveillance system to ensure geographic coverage and logistical feasibility of intervention delivery), Guatemala (five municipalities within Quetzaltenango Department: HCFs prioritized through participation in an acute febrile illness surveillance system to ensure geographic coverage and logistical feasibility of intervention delivery), Kenya (Nyando and Nyakach sub-counties in Kisumu County: all HCFs prioritized due to existing partner collaborations and displacement and concurrent flooding risks), and Uganda (community/non-refugee or IDP populations: Amuru and Tororo Districts: HCFs prioritized among non-refugee/IDP populations via PopCAB assessment; refugee/IDP populations: Adjumani, Arua, Madi-Okollo, and Terego Districts: HCFs prioritized by Ministry of Health, UNHCR, and local WASH partners).

https://doi.org/10.1371/journal.pwat.0000027.t004

https://doi.org/10.1371/journal.pwat.0000027.t005

HCF infrastructure.

Most HCFs had access to an onsite, improved water supply (100% of HCFs in Belize, Dominican Republic, and Kenya program sites, 95% in Guatemala sites, 80% in Uganda sites, 66% in Burkina Faso sites, Table 4 ). However, hand hygiene resources at points-of-care were less prevalent: two HCFs surveyed in Belize (18%), three HCFs in Uganda (25% of those surveyed in non-refugee/IDP populations), and two HCFs in Kenya (5%) had access to hand hygiene resources at all points-of-care. All HCFs assessed in Guatemala had hand hygiene resources at 75–99% of points-of-care; 47% in Burkina Faso, 46% in Belize, 33% in Uganda (non-refugee/IDP), 31% in Uganda (refugee/IDP), 5% in Kenya, and 0% in Dominican Republic met this criterion.

HCF hand hygiene adherence.

Healthcare providers in participating HCFs had moderate to low levels of hand hygiene adherence around patient contact (49% in Belize, 38% in Uganda, 30% in Guatemala, <25% each in Dominican Republic and Kenya, Table 5 ). In all sites, providers practiced hand hygiene more frequently after patient care (range: 25–62% by site) than they did before patient care (9–39%).

Interventions.

In all HCFs, interventions included HWS or ABHR at points-of-care and entrances and exits [ 26 ], and HWS at toilets ( Table 3 ), with an objective of 100% coverage per HCF. In HCFs serving refugee populations and IDPs, interventions also included distribution of environmental cleaning and hygiene kits (via antenatal clinics), as well as hygiene promotion sessions and trainings on COVID-19 prevention for health facility staff and patients. In HCFs serving general populations, partners implemented ABHR programs using the WHO Guide to Local Production of ABHR [ 38 ] to train local technicians in production and distribution models specific to their facility, district, or national needs. Findings from qualitative baseline assessments are also being used to develop behavior change interventions in HCFs.

Monitoring and evaluation.

To measure the feasibility, acceptability, use, and sustainability of interventions, monitoring and evaluation tools were developed from baseline assessments. Tools focused on monitoring functionality, availability of soap and water, and water quality at HWS; quantity and quality of ABHR at production facilities; and functionality of dispensers and levels of ABHR consumption by HCFs. Hand hygiene observations will be repeated periodically, with data shared with HCF leadership to provide a feedback loop to inform further trainings and encourage improved hand hygiene adherence. Similarly, repeat assessments will be conducted for water storage capacity and environmental cleaning supply quantities.

Community institutions

To-date, WASH assessments of community institutions have been conducted in Uganda (10 markets, 15 POE, 7 schools) and DRC (27 schools, Table 6 ). Hand hygiene observations have been conducted at all community institutions in Uganda, as well as five vendor- and five shopper-focused FGDs and 16 KIIs. Community institution assessments have been completed in Uganda (Amuru and Tororo Districts) and the DRC (North Kivu and Kasai-Central provinces). In Uganda, schools, POE, lodging locations, markets, and religious institutions were identified via the PopCAB assessment as priority locations with high population mixing in Amuru and Tororo Districts. In the DRC, schools were selected in Goma and Kananga to complement ongoing CDC work on cholera and in key areas identified for COVID-19 mitigation.

https://doi.org/10.1371/journal.pwat.0000027.t006

Markets in Uganda had poor access to water (44% had an improved water source onsite) and HWS (50% had any HWS, Table 6 ). Observed hand hygiene at key times was moderate and better than other community settings observed: 58% of people entering/exiting markets were observed to clean their hands and 63% of people cleaned their hands after using the latrine ( Table 7 ).

https://doi.org/10.1371/journal.pwat.0000027.t007

KIIs with market managers in Uganda revealed support for both HWS (for vendors and visitors whose hands get heavily soiled) and ABHR (for speed and convenience) onsite and suggested that hand hygiene should be enforced by a monitor at market entrances. Managers felt staff and customers would need education on effective hand hygiene and suggested using posters with strong visual aids.

FGDs among vendors and shoppers found that hand hygiene stations at entrances/exits, though considered essential, were not easily accessible for vendors. Additional stations within the market were recommended to improve access. Additionally, most HWS installed in the early months of the pandemic were no longer functioning due to lack of management plans or identified responsibilities. Both vendors and shoppers believed that hand hygiene was effective for preventing COVID-19 and were motivated to practice hand hygiene to protect themselves, their children, and friends from disease, as well as to feel and appear clean.

Many, but not all, POE had access to an improved water source onsite (71%) and HWS (60%), including at entrances and exits (71%, Table 6 ). However, only 19% of people entering or exiting the POE cleaned their hands and only 42% of people cleaned hands after using the latrine ( Table 7 ).

Based on KIIs, ABHR was identified as a more convenient method for hand hygiene due to the high volume of travelers and number of contact events between POE staff and travelers. However, poor access to and high cost of ABHR, as well as the layout of some POE, challenged consistent access to hand hygiene for staff and travelers. Although some POE received ABHR from local HCF, increasing and sustaining ABHR access and improving access to HWS was viewed as a critical priority.

In Uganda, all schools had access to an improved water supply onsite (100%) and most had handwashing stations (86%), including at entrances/exits (71%, Table 6 ). In DRC, although 67% of schools had either temporary or permanent HWS, only 30% had an improved water source available on the premises ( Table 6 ).

Observed hand hygiene adherence was poor in schools in Uganda: 17% of students or staff entering/exiting the school were observed to clean their hands and only 39% were observed to clean hands after using the latrine ( Table 7 ).

Based on data from KIIs in Uganda, head teachers felt that it would be best for students to use HWS but that ABHR would be good for visitors and teachers, and particularly for head teachers since they interact with many visitors. ABHR was prohibited from use by children in schools in Kenya by the Ministry of Education due to concerns over their ability to safely and appropriately use it [ 39 ].

Market and POE interventions focus on improving access to HWS and locally-produced ABHR, as well as hygiene education materials, at key locations (entrances and exits and outside latrines) for staff or visitors ( Table 3 ). Amount of hand hygiene resources required for staff and travelers will vary based on the location size, existing infrastructure or layout, and local regulations. School interventions will focus on ensuring access to hand hygiene at entrances, exits, within classrooms, and within 5 meters of toilets/latrines; hand hygiene promotion; and ensuring sufficient water supply for increased hand hygiene and cleaning needs.

Monitoring will focus on functionality of hand hygiene stations (including resources available, usability, and water quality) and ABHR quality and use (where present; Table 3 ). Periodic evaluations will include intercept interviews with users to assess acceptability of hand hygiene, KIIs and FGDs with staff or managers to assess feasibility of management, observations to assess use, water quality testing of free chlorine residual, and targeted evaluations assessing appropriateness of use cases for ABHR in communities. Tools used will be adapted from baseline assessments.

To-date, household WASH assessments and KAP surveys have been conducted at 405 households in Burkina Faso ( Table 6 ). Assessments have been completed in households in areas prioritized by the Ministry of Health in Burkina Faso (Diabo Commune, Est Region; Boroum Commune, Centre Nord Region).

Access to WASH at household level.

Almost all households (96%) in sites in Burkina Faso used water from an improved source; however, few (2%) had a handwashing station present ( Table 6 ).

Household reported hygiene knowledge, motivators, and barriers.

In sites in Burkina Faso, 49% (199/405 household surveyed) reported using water only (no soap) during regular handwashing. In Kenyan informal settlements, FGD participants highlighted that placement of HWS near a doorway served as a reminder to wash hands, but this benefit may not exist where HWS are shared among several households. In such cases, disrepair or abandonment might occur due to perceptions of diminished responsibility. FGD participants discussed the need for inter-household agreements to rotate costs of supplying water and soap.

Initial interventions—freestanding, temporary HWS in high traffic areas to maximize the number of households reached per HWS—quickly broke down due to misuse, damage, or theft because resources for full-time operators were not available. Interventions subsequently shifted to household- or compound (groups of households sharing a space)-level HWS. Objectives were to achieve access to at least basic hygiene in households or compounds; to identify barriers, motivators, and gaps to hand hygiene adherence in communities for message development and dissemination; and to monitor utilization and sustainability of approaches to hand hygiene access and messaging. Households received hand hygiene kits (e.g., HWS, 20-L water storage containers, and bars of soap) complemented by awareness campaigns organized with local community health workers to improve knowledge of COVID-19 mitigation measures. In some contexts, hygiene kits were distributed through maternal, newborn and child health activities in HCFs: expectant mothers received a hygiene kit plus face masks, ABHR, and communications materials at their first prenatal visit. Community health workers subsequently provided hygiene promotion messages during prenatal household visits.

To sustain interventions, periodic monitoring and evaluation will be conducted via repeat visits or text/phone-based assessments of functionality of HWS and interviews about acceptability and feasibility of HWS designs and maintenance ( Table 3 ). Tools were adapted from baseline assessments with additional questions focusing on barriers to maintaining hand hygiene stations and adherence.

Discussion, future directions, challenges and limitations, and conclusions

The need for at least basic levels of WASH in HCFs, community institutions, and households has only increased during the COVID-19 pandemic. The focus on WASH in HCF just before 2020, accompanied by existing guidance and standards for WASH in schools and households, provided multiple appropriate WASH assessment tools that could be readily adapted for COVID-19-focused assessments. However, in other community institutions such as markets or POE, CDC and WHO created new operational guidance based on existing WASH guidance for other settings and added COVID-19-specific considerations.

Data from baseline assessments conducted to-date demonstrate poor access to hand hygiene resources at key public locations—points-of-care in HCFs, entrances/exits and at toilets in community institutions—despite most, except schools in DRC and markets in Uganda, having access to an improved, onsite water supply. Other enabling factors for hand hygiene, such as sufficient water quantity and management plans for restocking supplies and repairing HWS, may need to be prioritized. Local ABHR production may be a cost-effective complement to HWS in appropriate settings and projects are currently scaling the WHO protocol [ 38 ] to district, regional, and national levels in five countries.

Where hand hygiene resources were available, healthcare providers and community members had low adherence overall. Healthcare providers were more likely to clean hands after than before patient contact, suggesting that behavioral interventions to improve compliance should increase emphasis on protecting the patient in addition to protecting oneself. Hand hygiene in healthcare contexts requires a multimodal approach, including systems-level change to improve access to hand hygiene materials but also training and education, monitoring of practices, reminders and nudges, and establishment of a culture to reinforce practices [ 40 – 42 ]. Community members were more likely to clean hands after the toilet than at entrances/exits, suggesting a need for greater communication of other key times to wash hands, especially during the pandemic [ 22 , 26 , 37 ]. However, models such as the Integrated Behavioral Model for WASH (IBM-WASH) suggest that multiple levels, beyond the individual, should be considered in uptake of WASH behaviors: these include societal, community, interpersonal, and habitual levels [ 43 , 44 ]. For example, the context of the pandemic itself may factor into the drivers of hand hygiene uptake, but these behaviors need to be matched to the appropriate technology as well. Further research into methods to prolong outbreak-associated (short-term) behavior change is needed, though evidence suggests that awareness/knowledge-based methods may have limited effect if not addressing multiple societal levels [ 43 – 47 ].

Similar to community and HCF locations, household use of improved water sources was high but access to HWS was poor. HWS targeted to multiple households—via shared or otherwise freestanding community infrastructure—suggest cost-efficient ways to temporarily increase community coverage; however, the absence of management considerations may cause infrastructure to become unusable. Community HWS attached to retail points, schools, and other community institutions can help improve responsible management; however, household- or compound-focused interventions may be more feasible, manageable, and help achieve basic hygiene access for longer term prevention capacity [ 16 ].

Future directions

The new WASH-focused guidance necessitated by the COVID-19 pandemic—including guidance for public places: placement, management, and behavior change communication about hand hygiene in markets, POE, and other community institutions, and who is responsible for these aspects—must be implemented, monitored, evaluated, and improved to maximize feasibility and acceptability while maintaining effectiveness. Though human rights to accessing WASH services in public places has been emphasized by the United Nations General Council [ 48 ] and individual nations may have guidance, systematic, global guidance for WASH standards in public places is a gap. The microbiological quality of water for handwashing is not currently incorporated into the hygiene ladder [ 16 ] and thus is an area of new guidance. Although limited evidence suggests that non-potable water with low-to-moderate E . coli contamination still may be effective when used for handwashing [ 49 ], the potential for dual-use of water from handwashing stations being consumed because of limited access to basic and safely-managed water services [ 11 ] suggests that potable levels of water quality may be necessary in many areas. Within our sites, water for handwashing will be tested at the source and at the handwashing station for free residual chlorine (except if only soapy water for handwashing is present, as this may affect accuracy of chlorine residual measurements). If free residual chlorine levels are <0.2mg/L, an additional sample will be collected for assessment of presence or absence of fecal indicator bacteria.

Sanitation management—for example, development of standard operating procedures (SOPs) to clean and manage public toilets in densely-populated locations and improvement of personal protective equipment (PPE) use by manual pit emptiers to protect themselves and their customers while entering households—should be prioritized as essential services [ 7 ]. Access to public toilets may be the only means of sanitation access for many globally, and should be managed so as to avoid added risk from communal spaces [ 7 ], with similar arguments for improving the hygienic practices of pit emptiers. SOPs for public facilities have often focused on managing fecal waste, but improvements to cleaning and disinfection guidance, social distancing while queuing, and other changes may be necessitated.

ABHR is an effective complement to HWS in HCFs and has logistical and financial savings if produced locally; however, appropriate supply chains for and appropriate use in community settings must be evaluated. In community settings, CDC recommends ABHR when handwashing with water and soap are not practically available [ 9 ] because soap and water may be more effective at removing a broader array of microbes, as well as other unknown chemical or organic materials, that may be present on hands [ 50 ]. Furthermore, ABHR is effective against microbes specifically, but is less likely to effectively inactivate them if hands are visibly dirty [ 51 ]. Before expanding ABHR in these settings in the short to medium term, evaluations should ensure targeted community settings are appropriate for use of ABHR, with concurrent messaging if necessary to guide users on when to use soap and water vs. ABHR.

In our program sites, access to ABHR in community institutions does not have clear supply chains. In previous work in Uganda, locally-produced ABHR at POE followed HCF supply chains because of Ebola preparedness efforts, but markets, schools, or other key community locations were not included. To ensure sustainable access to ABHR in LMICs, there is a need to evaluate whether HCF-based local production and distribution to non-HCF locations is feasible or if non-HCF-based production and distribution models are needed.

Challenges and limitations

Sustaining hand hygiene behavior change remains the largest challenge to-date, requiring consistent access to functional hand hygiene stations at key locations, behavioral nudges or reminders to perform hand hygiene at key moments, and local, regional, and national support for hand hygiene integrated across programs [ 16 ]. Installation of hand hygiene facilities must include plans for their management and repair, including identifying supplies and repair parts and personnel responsibilities for restocking, cleaning, maintenance, and repair [ 52 ]. As in many outbreak situations, rapid deployment of HWS in project sites without concurrent maintenance plans led those stations to quickly deteriorate or become unusable within a year despite longer advertised lifespans [ 53 ], which wastes resources and reduces access to hand hygiene. Lack of consistent access to hand hygiene resources may inhibit changes to behavior and development of hand hygiene as a habit [ 47 , 54 ]. To ensure sustained hand hygiene access and behavior change, support must come from multiple disciplines (e.g., healthcare, education, WASH partners, community) integrating hand hygiene into new and existing work plans, rather than isolated or temporary initiatives [ 16 ].

There are several limitations to consider within the context of these assessments and guidance. Notably, data are site- and context-specific and may not be generalizable to other settings. Although inclusiveness of WASH services by persons with disabilities are priorities for the WASH SDGs, including design of HWS [ 16 ], and are being accounted for in design of interventions, they were consistently not enumerated in baseline assessments. Additionally, WASH interventions are one of many tools, including masking, social distancing, and vaccination, that should be implemented for comprehensive community mitigation of COVID-19.

Conclusions

Within the COVID-19 pandemic, hand hygiene, water supply, and sanitation—all core components of WASH—have greater importance. In LMICs, we adapted common WASH tools for COVID-19 mitigation via rapid, mixed-methods assessments and adapted WASH guidance for settings without existing WASH standards (e.g., community markets, POE), with a focus on hand hygiene initially. We found inadequate hand hygiene access and behavioral adherence across LMIC contexts and settings—HCFs, community institutions, and households—and a need to improve personal and community capacity to follow guidelines for COVID-19 mitigation. These changes may include a need for greater water supply (for handwashing) and improved management of public sanitation facilities. Management of hand hygiene stations represents an area of elevated importance within the ongoing pandemic, for example, keeping HWS functional and well-stocked and ensuring continuous access to ABHR where available. New evaluation of these areas, and subsequent development and refinement of standards and assessment tools, will help ensure that WASH aspects of community mitigation of COVID-19 are accessible, functional, and usable for all.

Supporting information

S1 text. inclusivity in global health questionnaire (checklist)..

https://doi.org/10.1371/journal.pwat.0000027.s001

S1 Data. Data for manuscript.

https://doi.org/10.1371/journal.pwat.0000027.s002

Acknowledgments

The authors wish to acknowledge the efforts of all local implementation and evaluation partner staff, CDC country office staff, Ministries of Health, and participants.

Disclaimer: The findings and conclusions of this paper are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention (CDC).

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Water, Sanitation and Hygiene, or WASH, are issues that affect the health and wellbeing of every person in the world. Everyone needs clean water to drink. Everyone needs a safe place to pee and poop. And everyone needs to be able to clean themselves. For many people, WASH concerns are taken for granted and their combined impact on life isn’t always appreciated.

But for hundreds of millions of others, water, sanitation and hygiene are constant sources of stress and illness. The quality of water, sanitation and hygiene in a person’s life is directly correlated to poverty, as it is usually joined by lack of education, lack of opportunity and gender inequality.  

What’s the scope of the problem?

780 million people do not have regular access to clean water.

2.4 billion people, or 35% of the global population, do not have access to adequate sanitation.

Inadequate sanitation generally means open defecation. When people defecate in the open without a proper waste management system, then the feces generally seeps into and contaminates water systems. Just standing in an open defecation zone can lead to disease, if, for instance, the person is barefoot and parasites are there.

The problem is concentrated in Sub-Saharan Africa, Southern Asia and Eastern Asia. The country with the most people lacking adequate WASH is India.

Girls are the hardest hit by lack of clean water and sanitation for a few reasons. When schools lack functional toilets or latrines, girls often drop out because of the stigma associated with periods. Also, when families don’t have enough water, girls are generally forced to travel hours to gather some, leaving little time for school. This lack of education then contributes to higher poverty rates for women.

What are the health risks?

There are a lot of health risks associated with inadequate WASH. Just imagine what it would be like if you were drinking contaminated water and everyone in your community defecated in the open.

801,000 kids under the age of 5 die each year because of diarrhea. 88% of these cases are traced to contaminated water and lack of sanitation.

More than a billion people are infected by parasites from contaminated water or open defecation. One of these parasites is called the Guinea Worm Disease, which consists of worms up to 1 meter in size that emerge from the body through blisters.

The bacterial infection Trachoma generally comes from contaminated water and is a leading cause of blindness in the world.

Other common WASH-related diseases include Cholera, Typhoid and Dysentery.

And, again, step back to consider what life without clean water and adequate sanitation would be like. A lot of your time would be spent trying to get clean water and avoid sanitation problems in the first place. And the hours not revolving around these concerns would probably be reduced quality of life because of the many minor health problems associated with poor water quality. Ultimately, inadequate WASH leads to reduced quality of life all the time.

What’s being done?

For every $1 USD invested in WASH programs, economies gain $5 to $46 USD. In the US, for instance, water infrastructure investments had a 23 to 1 return rate in the 20th century. When people aren’t always getting sick, they’re more productive and everyone benefits.

While the numbers are daunting, a lot is being done. And the economic benefits of WASH investments make the likelihood of future investments and future progress much higher.

Some investments are small-scale, others are large-scale. On the smaller side of the spectrum, investments can go toward water purification methods, community wells or sources of water and the construction of community latrines.

For instance, in a slum in Nairobi, Kenya, the government recently installed ATM-style water dispensers that provide clean water to the whole community.

Larger scale investments include piped household water connections and household toilets with adequate sewage systems or septic tanks.

An often overlooked aspect of WASH involves behavioral hygiene, and, more specifically, hand washing. Simply washing your hands with soap can reduce the risk of various diseases, including the number 1 killer of the world’s poorest children: pneumonia .

What progress has been made?

In 1990, 76% of the global population had access to safe drinking water and 54% had access to adequate sanitation facilities.

In 2015, even though the population had climbed by more than 2 billion people, 91% of people had access to safe drinking water and 68% had access to improved sanitation.

That means in 25 years, 2.6 billion people gained access to safe drinking water and 2.1 billion gained access to improved sanitation.

India is currently in the process of an unprecedented WASH investment program. At the 2014 Global Citizen Festival, Prime Minister Narendra Modi committed to end open defecation in the country and has since mobilized substantial resources with the help of The World Bank .

What role does Global Citizen play in all this?

Global Citizen puts pressure on world leaders to focus on and direct money to poverty solutions around the world. When it comes to WASH, global citizens have helped raise awareness of the various associated problems and motivate politicians to invest in specific programs.

Head over to our Impact page to read more about specific achievements. 

Defeat Poverty

Why Clean Water, Sanitation And Hygiene Are So Important

Aug. 23, 2016

Essay on Water Sanitation And Hygiene

Students are often asked to write an essay on Water Sanitation And Hygiene in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Water Sanitation And Hygiene

What is water sanitation and hygiene.

Water Sanitation and Hygiene, often called WASH, is about keeping water clean, getting rid of waste safely, and keeping hands and bodies clean. These are important for staying healthy, stopping diseases, and living a better life. Clean water is needed for drinking, cooking, and cleaning.

Why is Clean Water Important?

Clean water keeps us from getting sick. Drinking or using dirty water can cause diseases like cholera. That’s why it’s important to have clean water for everyone.

Keeping Our Surroundings Clean

Getting rid of waste the right way stops germs from spreading. Toilets and proper waste systems help keep our environment clean and safe.

Handwashing: A Simple Step

Washing hands with soap is a simple way to stop germs. Doing this before eating or after using the toilet can prevent illnesses. It’s an easy habit with big health benefits.

Working Together

Everyone has a part in making sure we have clean water, proper sanitation, and good hygiene practices. By working together, we can make a healthier world for all.

250 Words Essay on Water Sanitation And Hygiene

Importance of water sanitation and hygiene.

Clean water, proper sanitation, and good hygiene practices are essential for maintaining good health and preventing the spread of diseases. Access to clean water and sanitation is a fundamental human right, and everyone should have access to these basic necessities. Poor sanitation and hygiene practices can contribute to the transmission of diseases, such as diarrhea, cholera, typhoid, and dysentery. These diseases can cause severe illness and even death, and they disproportionately affect vulnerable populations, such as children and the elderly.

Access to Clean Water

Access to clean water is essential for drinking, cooking, cleaning, and sanitation. When people do not have access to clean water, they are often forced to rely on unsafe sources of water, such as contaminated wells, rivers, or lakes. This can lead to waterborne diseases, which can cause a variety of health problems. In addition, lack of access to clean water can make it difficult to maintain good hygiene practices, which can also contribute to the spread of disease.

Sanitation and Hygiene

Sanitation and hygiene practices are also essential for preventing the spread of disease. Proper sanitation includes the safe disposal of human waste and wastewater, as well as the provision of clean and hygienic latrines. Good hygiene practices include washing hands with soap and water, brushing teeth, and bathing regularly. These practices help to remove germs and bacteria from the body and prevent the spread of infection.

Water sanitation and hygiene are essential for maintaining good health and preventing the spread of disease. Access to clean water, sanitation, and good hygiene practices are fundamental human rights, and everyone should have access to these basic necessities. By working together, we can ensure that everyone has the opportunity to live a healthy and productive life.

500 Words Essay on Water Sanitation And Hygiene

Water sanitation and hygiene: staying healthy and happy.

Water, sanitation, and hygiene (WASH) are essential for human health and well-being. WASH refers to the availability of clean water, proper sanitation facilities, and good hygiene practices. These elements work together to prevent diseases, promote good health, and improve overall quality of life.

Clean Water: The Foundation of Good Health

Access to clean water is a basic human right and a prerequisite for good health. Clean water is essential for drinking, cooking, bathing, and washing clothes. It helps us stay hydrated, prevents waterborne diseases, and improves our overall health. Unfortunately, many people around the world do not have access to clean water, making them vulnerable to various health risks.

Sanitation: Keeping Our Surroundings Clean

Sanitation refers to the proper disposal of human waste and wastewater. Adequate sanitation facilities, such as toilets and latrines, help prevent the spread of diseases and ensure a clean and healthy environment. Poor sanitation, on the other hand, can contaminate water sources, attract disease-carrying insects, and create unpleasant odors.

Hygiene: Personal Cleanliness and Healthy Habits

Hygiene refers to personal cleanliness and healthy habits that help prevent the spread of germs and infections. Handwashing with soap and water is one of the most important hygiene practices, as it helps remove germs from our hands and prevents them from spreading to others or our food. Other important hygiene practices include taking regular baths, brushing our teeth, and covering our mouths when we cough or sneeze.

WASH in Schools: Promoting Healthy Learning Environments

Schools play a crucial role in promoting WASH practices among children. By providing access to clean water, toilets, and handwashing facilities, schools can create a healthier environment for students and staff. Children who have access to WASH facilities are less likely to get sick, which means they can attend school more regularly and learn better.

Conclusion: Investing in WASH for a Healthier Future

Investing in WASH is an investment in the health and well-being of individuals and communities. By providing access to clean water, sanitation facilities, and promoting good hygiene practices, we can prevent diseases, improve health, and create a better quality of life for everyone. WASH is a cornerstone of public health and a fundamental human right that should be available to all.

That’s it! I hope the essay helped you.

If you’re looking for more, here are essays on other interesting topics:

• Essay on Water Recycling
• Essay on Water Quality
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Trends of Water, Sanitation, and Hygiene (WASH) Research in Indonesia: A Systematic Review

S. satriani.

1 Department of Environmental Science, The Graduate School, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia; [email protected] (S.S.); [email protected] (I.S.I.)

Izana Saffana Ilma

2 Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, 2628 CN Delft, The Netherlands

3 Department of Health Behaviour, Environment, and Social Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia

Associated Data

The data is contained within the article or Supplementary Material .

This study provides an overview of water, sanitation, and hygiene (WASH) research trends in Indonesia from 1975 until April 2021. The systematic review compiled 272 articles related to the Sustainable Development Goals 6.1 and 6.2 in Indonesia, which were published in the Web of Science and Scopus databases. The results showed that the water-related topic (41%) was discussed more often than sanitation (22%) or hygiene (13%). Furthermore, the social theme (39%) was dominantly found in all these articles, mostly finding determinants of WASH-related behavior. However, few WASH implementation studies or behavioral change interventions were recorded in Indonesia, suggesting a gap between science and policy or implementation. On the other hand, hygiene-related topics (14%) and WASH-related financial themes (6%) were the least studied in Indonesia. Combinations of topics (23%) and themes (15%) were also often conducted in Indonesia, suggesting that WASH researchers started to recognize the need to analyze WASH problems holistically, i.e., from multiple perspectives. In addition, the distribution of WASH research was still dominated in the central part of Indonesia, whereas the WASH-related problems, i.e., poor WASH services, and behavior, often occur in this area. This study also offers some research gaps, both in terms of topics, themes, and regional distribution, that need to be considered for the design of future WASH research in Indonesia.

1. Introduction

Access to water, sanitation, and hygiene remains a global public health concern, as stated in the Sustainable Development Goals 6.1 and 6.2. Despite substantial increases in access to water, sanitation, and hygiene (WASH) services over the past thirty years, an estimated two billion people worldwide still lack access to safely managed drinking water, 3.6 billion people lack safe sanitation, and 2.3 billion people around the world lack basic hygiene services [ 1 ]. Poor WASH services can weaken health systems, threatens health security, and weigh on the economy. Therefore, appropriate WASH services improve the quality of life and fulfill human rights. WASH’s contribution is not only in the health sector, but also has implications for livelihoods, school attendance, and dignity and helps create resilient communities living in healthy environments [ 2 ]. This applies to developing countries, one of which is Indonesia, which is the fourth most populated country in the world and will get a demographic bonus in 2045 [ 3 ].

In 2011, the access for basic WASH services in Indonesia was around 55% and 56% for drinking water and sanitation services, respectively [ 4 ]. In 2020, the National Planning and Development Agency (“Bappenas” in Bahasa) adjusted standards for improving the quality of drinking water, settlements, and national sanitation according to the Sustainable Development Goals (SDGs) standards from “decent” to “safe” access [ 5 ]. With these efforts, in 2020, access to basic water, sanitation, and hygiene services increased to 92%, 86%, and 94%, respectively [ 1 ].

The WASH-related study is essential for supporting the acceleration of achieving SDG 6.1 and 6.2 in Indonesia. The study’s results can be used to critically review and monitor the current progress, develop evidence-based policy, or find causes of WASH-related phenomena [ 6 ]. Furthermore, WASH studies in Indonesia should cover all topics in WASH, including water, sanitation, and hygiene, or combinations of them, so there is adequate scientific support in achieving SDG 6.1 and 6.2 in Indonesia. The distribution of topics could also indicate the past and current research interests of WASH researchers in Indonesia. For example, despite its importance, few studies conducted in hygiene may indicate that this topic is underestimated or attracts little attention from WASH researchers in Indonesia.

Moreover, since there is a variation of WASH services, access, and also problems in different parts of Indonesia [ 7 ], it is important that WASH studies can be conducted locally to give an overview of the local situation, e.g., challenges or problems in a district or provincial levels, and then provide recommendations to solve those problems.

Therefore, it is essential to understand the past and current trends of WASH research in Indonesia. This can guide future WASH research in Indonesia. For example, by knowing the inequalities of the geographical location of WASH research in Indonesia, one can plan to conduct WASH research in a location with few or no studies or information about the WASH condition. WASH researchers can also indicate knowledge gaps in specific themes that should be explored, e.g., whether we need more research on financial or social themes related to hygiene topics. To the best of our knowledge, no study systematically reviews the past and current trends of WASH research in Indonesia. This study aims to fill that gap. The systematic review method was conducted to assess WASH research trends in Indonesia.

2. Materials and Methods

The systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines [ 8 ]. The literature review search strategy was to find all studies related to WASH in Indonesia published in Web of Science and Scopus until April 2021. The search keywords used were “water” OR “sanitation” OR “hygiene” OR “WASH” AND “Indonesia”.

The selected papers from each database were then inserted into Mendeley to exclude duplicate publications. Furthermore, the title of articles was checked manually and we excluded irrelevant topics. Articles included in the screening title are related to WASH keywords, e.g., drinking water, sanitary inspection, hand washing, latrine, water access, water quality, water supply, open defecation, water treatment, and fecal. We assumed that all articles are related to WASH are covered by those keywords. Hereupon, the abstract screening was carried out to identify articles that were included in SDGs 6.1 and 6.2. Afterward, articles that have met the inclusion criteria were included in the full-text review stage. The inclusion criteria included: (1) research main topic is related to WASH, especially SDGs 6.1 (water) and 6.2 (sanitation and hygiene); (2) access for the full paper to perform eligibility assessment; (3) full-text paper in English; and (4) research was conducted in Indonesia.

The following information was extracted from the included studies and recorded in Microsoft Excel: (1) WASH research topics, either water, sanitation, hygiene, or a combination. Combination here means that the article discusses more than one WASH topic, e.g., water and sanitation topics in one article; (2) Research theme categorized as Financial, Institution, environment, technical, social, or a combination. An article that covers more than one research theme was categorized into a combination theme; (3) Year of publication; (4) Keywords; and (5) Study location, i.e., province.

Descriptive analysis was carried out to specify information based on topic, themes, a trend of WASH research, and research region distribution. SPSS Statistic ver. 23 was used to analyze the association between research topics and research themes. Word cloud was also created to identify keywords that often appear in the title and abstract of the reviewed articles. The ArcGIS ver. 10.8 software was used to create the distribution of study locations in Indonesia.

3. Results and Discussion

3.1. search results.

The systematic literature review retrieved 8151 articles from Scopus and Web of Science that were published before April 2021. Some duplicates were removed and resulted in 7981 articles. The title screening resulted in 414 studies related to WASH. In the next stage of abstract screening, 136 articles were excluded since those studies were not closely related to SDGs 6.1 and 6.2. At the full-text review stage, 278 articles were included. Of these, six articles were also excluded because those studies were not written in English ( n = 2), were not located in Indonesia ( n = 3), or the paper could not be accessed ( n = 1). Thus, 272 studies were included in the final review process ( Figure 1 ). More information on those studies can be found in the Supplementary Materials , e.g., explanation of themes (FIETS), type of study, and study scale.

Diagram of the screening process and selected articles.

3.2. Characteristic WASH Research by Topics, Themes, and Year

The most discussed WASH topic in Indonesia was water (41%), followed by a combination topic (23%), and sanitation (22%) ( Figure 2 ). The results also showed that 39% of the studies discussed the social theme. It dominates themes in hygiene (66%), combination (63%), and sanitation (40%) ( Figure 3 ). The most common social research topic was the social-economic or behavioral determinants of the WASH access or behavior, e.g., [ 9 , 10 ]. This indicates that understanding the behavioral drivers of WASH practice is the core of WASH research in Indonesia.

( a ) Proportion of research topics and ( b ) Proportion of themes.

Percentage of themes in WASH topics.

Only 14% of the articles in the study discussed hygiene. The results show that hygiene has not been widely published in Indonesia, particularly during 1991–2004 ( Figure 4 ). On the other hand, the outbreak of COVID-19 has provided a new paradigm where personal hygiene is the key element in controlling the spread of the virus [ 11 ]. Therefore, this finding suggests the need to conduct more hygiene-related research to provide a better understanding of hygiene conditions in Indonesia.

Growth of WASH research amount in Indonesia from 1975 to 2021.

Another theme with the highest percentage was the technical theme (18%) ( Figure 2 ). However, this only applied to the water-related topic articles (29%) ( Figure 3 ). These articles mainly discussed water treatment, e.g., [ 12 ]. The percentage of institutional themes was 13–15% in water, sanitation, and combination articles, but only 5% in hygiene-related topic articles. Only two articles of the institutional themes were in the hygiene topic, which discussed low resource settings for clinicians contacted with patients without hand hygiene in rural hospitals [ 13 ] and the evaluation of the children under two years old program (“Baduta Program” in Bahasa) [ 14 ].

The financial theme had the smallest proportion in WASH research in Indonesia (6%). Several studies link poverty with access to WASH services, e.g., [ 15 ]. Most of the financial-related themes in the water topic were about water service tariff and willingness to pay (12% of all financial-related themes), e.g., [ 16 ]. Financial-related themes in sanitation (7%) were about selecting affordable sanitation systems for the community, e.g., [ 17 ] ( Figure 3 ). On the other hand, it was found that none of the hygiene articles addressed the financial theme. In a report published by GLAAS in 2019, Indonesia already has policies and plans to develop cost estimates for WASH plans covering aspects of drinking water and sanitation, but not hygiene aspects [ 18 ], whereas, there is a cost needed for hygiene facility, e.g., to buy soap or install handwashing facility in a public place. This suggests a knowledge gap in financial research on the topic of hygiene in Indonesia.

The first recorded publication of WASH research in Indonesia was in 1975, but then no article was published between 1981–1991. WASH research in Indonesia has been published regularly since 1991 until now, except in 1992, 1998, and 2003. Significantly, WASH research in Indonesia continues to grow in the 2015–2020 period. Five articles before 1990 were published on water topics. Moreover, the number of articles related to the water topics reached its peak in 2019, i.e., 24 articles. Water-related topics were dominant between 1975–1981, but then combination-related topics were dominant between 1990–2000 ( Figure 4 ).

In contrast to water topics, there were year gaps in sanitation and hygiene topics. The study on sanitation had not been published until 2010 and became the most discussed topic in 2010 compared to other topics. We suspect this is related to the determination of sanitation as one of the main targets in Indonesia’s 2010–2014 Medium Term Development Plan (“RPJMN” in Bahasa). The national policy has, previously, indirectly driven the sanitation research in Indonesia. Furthermore, despite there being hygiene research in 1991, there was a long wait until the second study on the hygiene topic in 2004. Hygiene research started to increase in 2016, which may have been driven by the SDGs implementation in Indonesia.

The title and abstracts of all articles were analyzed to identify the most frequent keywords in Indonesia’s WASH research. Drinking water, water supplies, stunting, diarrhea, and sustainability were the top 5 keywords ( Figure 5 ). Since 40% of the studies were on water topics ( Figure 1 ), terms related to water dominate the keyword identification results. Drinking water has become a widely discussed sub-topic, e.g., safe drinking water sources, treatments to ensure good water quality, and selection for piped and bottled water. The word cloud brings out some terms related to diseases, e.g., stunting and transmitted helminth. This indicates that WASH research in Indonesia began to be linked with the health issue.

The word cloud of WASH research in Indonesia.

3.3. Geographical Distribution of WASH Research in Indonesia

Identification of WASH research locations in Indonesia was categorized into four groups. The first group was multi-country research in which Indonesia was included as one of the study countries. This group primarily discusses sanitation and social topics as dominant themes, including financial and social, e.g., [ 17 ]. The second group was studies located in Indonesia, but which do not mention the exact province or location. The second group comprises 56 articles, which mainly discussed combination topics and social themes, e.g., [ 19 ]. The third group was studies conducted in several provinces. These studies were often related to sanitation topics and social themes with 10 articles, e.g., [ 20 ]. The last group was studies conducted only in one specific province, with 203 articles, e.g., [ 21 ] ( Figure 6 ), or equal to 74.5% of the total reviewed articles.

Provincial distribution of WASH research in Indonesia from 1975 to April 2021.

Moreover, if we look at the research location at the provincial level in Indonesia, the results showed that there is inequality in the WASH research conducted in Indonesia. Most of the research was conducted in the provinces located in Java Islands ( Figure 6 ). The province with the most frequent WASH research location in Indonesia was West Java with 29 articles, e.g., [ 22 ], Jakarta with 28 articles, e.g., [ 16 ], Central Java with 27 articles, e.g., [ 23 ], and East Java with 27 articles, e.g., [ 24 ]. All those provinces were located on the Java Island which has the best research facilities in Indonesia. Studies conducted in East Java mainly discussed sanitation topics, while water topics dominated studies conducted in Jakarta, Central Java, and West Java. For the theme of the articles, East Java and West Java were dominated by social themes, Jakarta with technical and social themes, and Central Java with combination themes.

On the other hand, in Central Indonesia, East Nusa Tenggara had the highest WASH research with 15 articles, and in Eastern Indonesia, Papua province had the highest WASH research, i.e., 7 articles. Provinces with a small number of WASH research in Indonesia were South Kalimantan, with three articles, e.g., [ 25 ], and West Kalimantan, i.e., 3 articles, e.g., [ 26 ], and Gorontalo, i.e., 2 articles, e.g., [ 27 ]. Provinces with only one article were Bangka Belitung [ 28 ], East Kalimantan [ 29 ], Riau [ 30 ], Riau Archipelago [ 31 ], Central Kalimantan [ 25 ], Southeast Sulawesi [ 32 ], North Sulawesi [ 33 ], and Maluku [ 34 ]. Lastly, there was no WASH research recorded in six provinces between 1975–April 2021, i.e., Jambi, Bengkulu, North Maluku, and West Papua.

3.4. Recommendation for Future WASH Research in Indonesia

This systematic review provides some recommendations for future WASH research, in terms of topic, theme, and area. The hygiene-related research topic should be conducted more often in Indonesia. There are various contexts of hygiene that are potentially explored in Indonesia, e.g., hygiene in school, emergencies settings, healthcare facilities, menstrual hygiene, etc. These contexts can complement the current context in hygiene research in Indonesia, which focused mostly on personal and household hygiene. Furthermore, the COVID-19 pandemic has made hygiene an important discussion around the world and a daily necessity to prevent the spread of the COVID virus. We believe that this is a nice momentum to boost hygiene-related research in Indonesia. Another knowledge gap is that there is no hygiene research related to the financial theme. Future hygiene studies in Indonesia should address this topic, especially to escalate hygiene services, e.g., handwashing facilities, in vulnerable areas, e.g., emergency, school, and rural areas.

The social theme is common in the WASH research in Indonesia, which is dominated by finding the drivers or determinants of WASH practice. However, based on our review, there were only two scientific articles, e.g., [ 10 , 35 ] that discuss behavior change interventions in Indonesia, whereas it is important to learn the lessons on how to change community behavior in WASH. Furthermore, based on our observation, behavioral change intervention is one of the cores of activity of many WASH-related non-governmental organizations (NGOs) in Indonesia. However, it could be that the NGOs do not collaborate closely with academia in conducting their WASH project, which results in very few scientific articles on the behavioral change intervention in WASH coming from Indonesia. Therefore, we suggest a collaboration between WASH NGOs and academia in conducting implementation research in Indonesia, e.g., a baseline study, follow-up by the behavioral change intervention, and the project outcomes or evaluation are reported in a scientific journal. This is also to ensure that any WASH research does not merely end up in a scientific article but can be used to design relevant policy or intervention.

Financial theme research was rarely conducted in Indonesia. Financial-related studies are needed to develop strategies to enhance the practice of and access to WASH services, especially among the poor, e.g., assessing the willingness to pay or find cost-efficient technology that can be implemented in society at a low cost. For example, a recent study conducted in less developed and rural Indonesia shows that many households in such areas could not afford WASH technologies, e.g., the latrine [ 36 ], and a financial-related study is needed to find the solution for this.

An adequate number of the combination-related topics (23.4%), e.g., water and sanitation, and themes (15%), e.g., social and financial. Based on our experience, the result suggests several things. First, WASH researchers in Indonesia start to realize that all topics in WASH are correlated, e.g., access to water is correlated with the sanitation practice. Moreover, considering the F-diagram that exposure to a pathogen can be through multiple pathways [ 37 ], the analysis of the provision of safely managed water services should be accompanied. Second, the combination-related themes suggest that WASH researchers in Indonesia try to see the WASH problem from multiple perspectives, i.e., multi-disciplinary. Research themes are categorized as financial, institution, environment, technical, social, or combination (FIETS). Daniel et al [ 36 ] show how financial, institution, environmental, technology, and social (FIETS) are interrelated in the WASH sector. Neglecting one aspect will hinder us to understand fully the problem. Moreover, WASH experts and practitioners have recognized that the WASH problem is complex [ 38 , 39 ]. Future WASH studies in Indonesia should then address the complexity of WASH conditions in a specific area by analyzing multiple WASH topics, e.g., water, sanitation, and hygiene, and also multiple themes, e.g., FIETS.

While conducting multiple WASH topics and themes can give a holistic view of the WASH situation in a specific area, it has some potential challenges. First, the WASH researchers in Indonesia, which often come from the field of environmental science or engineering or public health, need to involve people from different disciplines, e.g., economic or psychology. Reducing this “discipline barrier” is still a challenge in conducting multidisciplinary research in Indonesia [ 40 ]. Second, the construction of knowledge in Indonesian education is largely formed within the boundaries of discipline, which is a challenge in multidisciplinary research [ 41 ]. Even though the understanding of concepts and objectives has been equalized, different scientific perspectives have resulted in differences in answering research problems, for example when conducting screening papers.

There is inequality in WASH research in Indonesia, in which areas outside Java tend to be under-researched. There were four provinces without any WASH research recorded, i.e., Jambi, Bengkulu, North Maluku, and West Papua. This could be due to the limitations of technical and human resources needed to conduct WASH research and also geographical conditions that are difficult to reach. The government could provide research grant opportunities to conduct WASH studies in these areas to tackle the technical resources problem. Moreover, universities located in Java Island, i.e., which often have better resources, can also consider these areas as their future study location to overcome the human resources issue. They can collaborate and help local universities to conduct WASH research. All these actions are needed to increase the number of WASH research outside Java, i.e., solve WASH problems and also monitor the progress of SDG 6.1 and 6.2 in all provinces in Indonesia.

Factors that influence the WASH conditions, behaviors, or services vary depending on contexts or settings and we could not simply extrapolate the research results, e.g., apply the same recommendations, in one context or setting to others [ 42 ]. Thus, the WASH intervention must be adapted to local circumstances, highlighting the need for local WASH research. Our systematic review found that three-fourths of the reviewed articles were located in one province only, suggesting that those studies try to find solutions for a local WASH problem. This also implies that there are many potential WASH studies that can be conducted in Indonesia, considering various WASH topics, themes, and locations.

The review also shows that there are knowledge gaps of WASH research among vulnerable communities, e.g., disabilities, indigenous, and remote communities. Thus group has the right to full and effective participation in all aspects of life. Its manifestation can be related to the fulfillment of accessibility both in the physical environment, transportation, information and communication, and access to other facilities and services that are open or provided to the public, both in urban and rural areas [ 43 ]. They are often neglected and have poor access to WASH services [ 44 ]. Future WASH research should target these communities to understand their problems and ensure that there are no communities or areas left behind in achieving SDG 6.1 and 6.2 in Indonesia.

Other potential WASH research in Indonesia is related to WASH services in school, emergency settings, and healthcare facilities. Universal access to WASH in SDGs 6.1 and 6.2 covers all settings, including households, schools, health facilities, workplaces, and public places [ 45 ]. A report indicates that the basic WASH services at schools in Indonesia in 2019 were 72.73% for water, 40.40% for sanitation, and 58.86% for hygiene. For health facilities in Indonesia, data shows that 80.17% have been covered by basic level WASH services [ 46 ]. Our review shows that there is only one WASH study in the school setting in Indonesia [ 47 ], and one study related to healthcare facilities, i.e., discussed the hygiene of health workers [ 13 ]. Additionally, there is only one study related to the emergency setting in Indonesia [ 27 ]. We think that more research is needed to understand how to enhance access to WASH services in these settings.

Menstrual hygiene is another knowledge gap that starts to gain interest among WASH researchers in Indonesia [ 48 ]. Menstrual hygiene management (MHM) is still limited in Indonesia, besides that in most primary schools, hygiene in sanitation facilities is still lacking [ 49 ]. Girls find it challenging to access WASH facilities that can be used and are suitable for menstruation, e.g., in school, whereas, one of the problems that often occur in school-age girls who have reached the age of puberty do not attend school during menstruation [ 50 ]. All these research areas attract the attention of the global WASH practitioners in the past years and are potentially conducted in future WASH research in Indonesia.

There are some limitations of this review. First, due to the wide scope of this study, the knowledge gap in this WASH research is also not very detailed, i.e., there are no specific and detailed knowledge gaps in each topic, theme, and region. A future review study may focus on a smaller scope so one can assess the knowledge gaps in more detail, e.g., the review can focus only on the water topic and discover knowledge gaps on this topic. Second, we do not assess the risk of bias or quality of the reviewed studies. Thus, the topic or theme may have been studied before but we do not the quality of the study. Therefore, if one wants to conduct a study on the same topic or theme, we suggest studying carefully the previous study and designing their study on top of the previous study, by considering also the risk of bias and quality of the previous study. More information about all reviewed studies in this article can be found in the Supplementary Materials . Finally, this study can be seen as a starting point by scholars, especially in Indonesia, to design more comprehensive WASH research in Indonesia.

4. Conclusions

This review study discusses 272 articles on WASH-related research in Indonesia published before April 2021. The result shows that the most frequent research topic was water, while the dominant research theme in Indonesia is the social theme. The technical theme, e.g., water supply and water treatment, was dominant in the water topic, while the social theme was dominant in the sanitation, hygiene, and combination topics. Almost half of the total studies were conducted in Java Island. There are few records of implementation research or behavioral change intervention in the WASH studies in Indonesia. This implies that past WASH research in Indonesia often stopped only at finding behavioral determinants. Future WASH research in Indonesia can consider hygiene and WASH-related to financial research topics, researching the indigenous and remote populations or areas, in school, emergency, and health-care facility settings, and also related to menstrual hygiene. Research on these topics can enrich our understanding of the current WASH situations in Indonesia.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph19031617/s1 , Table S1: Definition each theme in research; Table S2: Article used in The Analysis of WASH Research Trends in Indonesia; Table S3: PRISMA checklist.

Author Contributions

Methodology, validation, formal analysis (i.e., database searching, remove duplicate, abstract screening title screening, and full-text screening), visualization, data curation, writing—original draft: S.S.; validation, formal analysis (i.e., database searching, remove duplicate, abstract screening title screening, and full-text screening), writing—review, and editing, data curation: I.S.I.; conceptualization, writing—review and editing, supervision, project administration: D.D. All authors have read and agreed to the published version of the manuscript.

This first author receives funding from Indonesia Endowment Fund for Education (LPDP) for the master study at Universitas Gadjah Mada.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The author declares no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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56 Water, sanitation, and hygiene

• Published: January 2019
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This chapter on water, sanitation and hygiene (WASH) outlines the principles of safe water and sanitation as essential determinants of health, quality of life, and dignity. It provides the health worker with the necessary information to appropriately prioritize WASH, understand the process of primary prevention of WASH-related diseases, to identify best practices for different contexts, and to recognize when specialized assistance might be required.

Introduction to water, sanitation, and hygiene (WASH)

Safe water and sanitation, which enable proper hygiene, are essential determinants of health, quality of life, as well as human dignity. As the most essential element of life, water is protected by international law. The UN General Assembly explicitly recognized the right to water and sanitation, and acknowledged that clean drinking water and sanitation are essential to the realization of all human rights. Additionally, in situations of conflict, the Geneva Conventions stipulate that water supplies essential for the survival of the civilian population must be protected from attack.

However, a large part of the world’s population does not have access to these essential services. More than 780 million people today lack safe drinking water, and some 2.5 billion—>35% of the world’s population—lack improved sanitation. As a consequence, more than a million people, most of them children, die every year from diseases associated with the lack of access to safe drinking water, inadequate sanitation, and poor hygiene. In many contexts where humanitarian crises commonly occur, where water, sanitation, and hygiene (WASH) infrastructure vital for public health might have been under fire, where people are under constant threat and have experienced years of conflict and/or have had to flee their home, the risk of diseases or epidemics is even greater. Consequently, the need for WASH interventions to prevent and control such diseases is also greater.

This chapter aims to provide the health worker with the necessary information to appropriately prioritize WASH, understand the process of primary prevention of WASH-related diseases, identify best practices for different contexts, and recognize when specialized assistance might be required.

As the full complexity of WASH, particularly in low-resource settings, may be beyond the scope of this work, readers interested in further information are referred to the comprehensive field-oriented handbook ‘Public Health Engineering in Precarious Situations’. 1 This freely accessible manual provides detailed information on the subject, including narratives per technical domain and detailed guidance for implementation of basic WASH activities in the field.

WASH as public health intervention

Non-improved hygiene, inadequate sanitation, and insufficient and unsafe drinking water account for 7% of the total disease burden and 19% of child mortality worldwide. 2 WASH interventions are highly cost-effective, and are capable of preventing a large part of this devastating disease burden and are a cornerstone of primary prevention.

While perennially in the shadow of the ‘big three’ of the international public health community—HIV/AIDS, TB, and malaria—one disease alone kills more young children each year than all three combined—diarrhoea 3 —and the key to its control is WASH. Evidence suggests that adequate WASH interventions such as improved excreta disposal and/or a surge in handwashing with soap by the affected population and/or rehabilitation of improper water infrastructures may be capable of reducing the prevalence of diarrhoeal disease by 30% under operational conditions. A more pronounced impact (up to 63% reduction) may be associated with water piped to one or more taps on a property.

Universal access to safe drinking water, adequate sanitation, and improved hygiene is steadily increasing; and the level and quality of services continues to grow, but progress is painfully slow in many LIC. Despite having identified the cause, and having the technology and means to eliminate this cause, countless children in the world continue to die each year from easily preventable diseases. In industrialized countries, much of the early drive to provide WASH came from the medical community rather than falling under a variety of governmental departments. In LIC, the health sector could play a similar crucial and much more prominent role in providing universal access.

Although involvement in WASH may seem like an added burden for an overtaxed, under-resourced health system, it actually represents a highly cost-effective strategy. It may represent an added upfront investment burden, but it reduces downstream costs, due to the decreased morbidity and mortality burden, as well as time saved.

Breaking the cycle of infectious disease transmission

Transmission of infectious diseases is not random, but results from a complex interaction between the environment, pathogen, and host. The reservoir of an infectious agent is the habitat or host in which the agent commonly lives and the most appropriate primary prevention strategy is reducing the environmental reservoir, and/or blocking the transmission routes to a new host. This blocking of transmission can be achieved by applying general WASH principles in a context-specific manner.

The F-diagram in Fig. 56.1 illustrates how appropriate primary prevention interventions can halt faecal–oral disease transmission, primarily by promoting the safe disposal of faeces, improving the quantity and quality of the water supply, and improving hygiene. The scope of WASH, however, goes far beyond prevention of faecal–oral transmission. Primary prevention interventions to break other transmission pathways have been developed for other diseases in a multitude of contexts. (See Table 56.1 for environmental classification of water- and excreta-related infections. 3 , 4 )

All diseases in categories A, C, and D, most helminthic diseases in E, and diseases labelled with

together comprise ‘excreted infections’.

Hardware and software components

WASH activities enable the promotion of hygiene practices that prevent and control infectious diseases. In all WASH activities, a distinction can be made between complementary ‘hardware’ and ‘software’ components:

‘Hardware’ generally refers to technical activities such as the supply, construction, or installation of specific equipment (with tangible outputs such as the construction of culturally appropriate latrines).

‘Software’ includes activities such as health promotion, education, and community involvement, which generally concern context-specific social and cultural factors aiming to achieve behavioural change (with tangible outputs such as the appropriate use of the aforementioned latrines).

Effective WASH-driven public health interventions in the field require complementary hardware and software components (e.g. an impregnated bed net only protects against malaria if used correctly). Considering that motivators to adopt primary prevention measures are not necessarily health related, the importance of providing appropriate/context-adapted ‘software’ (health promotion, training) must be emphasized.

WASH activities

The collection, treatment, and distribution of potable water, water source.

Identification of the best water resources should include all stakeholders, in collaboration with local, national, and international partners. Typically, the preferred choice is a protected ground water source, extracted via a pump-equipped borehole. However, other options can be considered as well (see Table 56.2 ). To ensure access to potable water, various parameters need to be considered:

The source needs to be self-contained, independent of the variations of climate or outside factors.

A physical, chemical, and microbiological analysis of the water should systematically be performed prior to the initial supply to the population.

Optimal sources are free of microbiological contamination and have a low turbidity (the amount of suspended particles in the water will have an impact on the chlorination efficacy).

Water sources should have a low concentration of toxic chemical products, which can be naturally occurring (e.g. arsenic, documented in Bangladesh, or fluoride causing dental or skeletal fluorosis in Niger), or the consequence of human activities (e.g. by mercury, a toxic heavy metal from gold mining; or nitrates/nitrites, from agriculture).

Although with a limited effect on health, factors such as salinity, colour, odour, and taste have a role in the acceptability by the consumers.

Accessibility of water, including distance, altitude differences, and queuing at the supply point, largely determine water utilization.

An aquifer <3 m deep has the characteristics of surface water.

Description of a hand-dug well.

Hand-dug well with telescoping principle

Wellhead (with lid/lifting mechanism)

Apron with protective kerb and anchorage

Intake with graded aggregate filter

Water table (static water level)

Impermeable concrete rings or sealed masonry lining

Reinforced concrete slab with anchorage

Foundation anchorage

Perforated/permeable concrete rings (or open-jointed masonry lining)

Graded aggregate filter (cleaned gravel)

Cutting ring

Backfilling (cleaned gravel)

Water intake

To be usable, water is collected from a source through an intake which transports the water from the source either to treatment and/or storage, or in some cases directly to the user. The water intake has to be:

well chosen (e.g. avoid rivers with a fluctuating water level and ensure the intake is set below the minimum water level of the river)

well designed, to avoid loss and further contamination of the water. Water moves through the intake either by gravity or by lifting (e.g. wells with a hand pump, or a deep well with a solar submersible pump)

well maintained, an unexpected challenge as demonstrated by the plethora of broken hand pumps around the world.

Atypical intakes have been developed in response to specific extenuating circumstances, such as in Libya, when the water supply was cut off and acute insecurity made movement outside the health structures impossible. In this case, condensation water was harvested from the multiple air conditioners working at full capacity with all the windows open. Another example was in Sudan, during an emergency situation, when a gigantic plastic sheet was spread out on the ground, leading rainwater to a ditch equipped with a pump that transferred the water to a storage reservoir.

Water treatment

Water treatment at household level reduces the risk of recontamination during transport and storage, but raises difficulties in the mass distribution of the products/material and teaching the population how to use them correctly.

Community-level water treatment, in rural settings, is easier for distribution and training as less people are involved, but might not be possible for small isolated pockets of people or for populations on the move.

Centralized water treatment is especially suited for big populations in cities (e.g. slums) and larger refugee camps.

See Table 56.3 for the various treatment methods for the elimination of microbiological pathogens. 1

Methods requiring low water turbidity—UV radiation and chlorine disinfection—require an initial step removing the suspended particles in the water, by assisted sedimentation and/or sand or membrane filtration.

When there is suspicion of salt intrusion (a major concern in coastal aquifers) or chemical pollution (e.g. quality decreases drastically in gold mining areas), it is in general advisable to change the water source. To ensure elimination of salt and chemical intoxicants, more elaborate methods are required to obtain potable water such as reversed osmosis or filtration on resins. These methods are expensive, high tech, and more difficult to operate and maintain in resource-poor settings.

Water distribution, transport, and storage

Transport, storage, and distribution of water can result in recontamination of the water prior to its consumption, so special attention should go to the following:

The internal cleanliness of pumps, pipes, water trucks, reservoirs, and tap stands. Consider that pressure in the distribution network can be intermittent and as a consequence, contaminated surface water can be sucked into the pipe in case of leaks in the network.

The cleanliness and appropriate use of household recipients of the collected water. In emergency contexts, quickly-deployed distribution of jerry cans or buckets can be important, in particular during outbreaks of infectious diseases (e.g. cholera in rural areas).

Jerry cans with a small opening reduce the risk of people putting their hands inside, but render their cleaning difficult.

Buckets with special lids having a small opening are ideal, as they allow safe taking of water for everyday use, and allow occasional internal cleaning.

Excreta disposal facilities

Management of excreta disposal is of paramount importance in keeping the environment, and thus the water sources, safe. This is particularly true in contexts with large population concentrations (e.g. refugee camps, urban slums), or where the usual sanitation infrastructures are destroyed (e.g. natural disasters). Though often overlooked as a priority during emergencies, it is essential to immediately provide and maintain simple temporary toilet facilities (e.g. trench latrines—Fig. 56.3 ). Over time, the temporary solution should be upgraded (e.g. improved trench latrines) and replaced progressively by more suitable structures as the situation develops into a chronic emergency (e.g. simple pit latrines—Fig. 56.4 ) and a stabilized situation (e.g. ventilated improved pit latrines).

Description of a trench latrine.

Fence (e.g. plastic sheeting)

Closed water container with tap/soap or ash

Infiltration system for wastewater (e.g. gravel pit)

Zigzag entrance

Trenches (0.3 m wide)

Soil for burying excreta

Band of plastic sheeting (optional)

Runoff drainage

Simple pit latrine.

Vertical cut of the simple pit latrine

Excavation for the concrete base

Detail of the base reinforcements

Pit (partly filled with excreta)

Defecation hole

Slab with footrests

Superstructure

Concrete base

Drainage channel (at the sides and back of the latrine)

Aquifer (water table)

Mortar layer (at least 10 mm thick)

Perforated corrugated iron sheets (pit reinforcement)

Example of a slab: concrete, plastic, (wood)

In these later phases, users should be consulted in order to better meet their needs. Small children might have problems using normal pit latrines because of the big size of the drop hole, the position of the foot rests, or fear of the closed structure of a normal pit latrine, and so a modified children’s pit latrine should be used (Fig. 56.5 ).

Children’s pit latrines.

Handle bar (for a child to hold on to when squatting)

Slab with adapted footrests

Defecation holes (adapted size for children) with lid

Open superstructure

Drainage channel

Toilet facilities should meet basic criteria, including the following:

Not posing a public health threat, such as attracting disease vectors.

Offering users a certain level of comfort, taking into account local beliefs and incorporating cultural requirements

Offering the frequently overlooked requirements for appropriate menstrual hygiene management in humanitarian emergencies.

Offering a minimum of privacy, with separated facilities for men and women.

Being safe in structure and location.

Adapted to specific users (e.g. disabled, children, elderly, women).

Have some form of functional handwashing stations.

In addition to the hygiene aspects, provision of safe sanitation can have significant social and security benefits. Some areas with high levels of poverty and a lack of law enforcement can make venturing out at night in search of a place to go to the toilet risky for all, particularly women who face the additional and documented threat of sexual violence. Further, for girls, the provision of school sanitation facilities means that they are less likely to miss school by staying at home during menstruation. The proximity to the dwelling results in time not spent queuing at shared sanitation facilities or walking.

Waste management

Wastewater drainage and disposal.

Stagnant water, originating from rainwater or wastewater, requires effective wastewater disposal systems to contain smells, proliferation of insect larval breeding sites, contamination of water sources, and spread of pathogens. Wastewater disposal can include:

rudimentary soak away pits (see Fig. 56.6 ) for infiltration of limited amounts of wastewater into permeable soil during an emergency intervention

more elaborate infiltration trenches (see Fig. 56.7 ), which serve as dispersal systems with infiltration pipes, typically installed in a later phase

evapo-transpiration areas, suitable in hot, windy, arid, or semi-arid climates.

Soak away pits.

Permeable soil

Incoming pipe (min. diameter 100 mm)

Compacted earth

Cleared space at the end of the pipe

Geo-textile or perforated plastic sheeting

Clean stones (boulders)

Flat stone or concrete slab

Water table

Wastewater infiltrating in the soil

Infiltration trenches.

Longitudinal section

Bird’s view of the multiple trench system

Cross section

Clean gravel

Incoming pipe

Plug at the end of the drain pipe

Distribution box

Manhole (optional)

Union pipes with elbow

Measurements are indicated in metres.

Once collected and before wastewater infiltrates into the ground, the solid faecal matter coming from toilets should be removed by a septic tank. The solid materials, grease and fat coming from kitchens/showers/sinks, should be separated from the wastewater by a grease trap in order to avoid very quick clogging of an infiltration system.

Dead body management

It is a common misconception that dead bodies that are not cared for immediately will lead to outbreaks of infectious diseases. In general, the management of human remains is more a matter of respect and of providing a culturally appropriate response.

However, for some highly contagious infectious diseases, the correct management of human remains is an important component of the outbreak response. In contexts of haemorrhagic fevers (e.g. Ebola, Marburg, Lassa fever) or of faecal–oral epidemics (e.g. cholera), culturally appropriate adaptations need to be made during the management of the human remains to avoid contact with infectious bodily fluids. In the context of louse-borne (e.g. relapsing fever, typhus) or flea borne (e.g. plague) infections, the transfer of infected insects to non-infected individuals needs to be avoided with timely and context-specific effective vector control measures.

Vector control

Vector control aims at reducing the morbidity and mortality due to vector-transmitted diseases, and strategies are generally tailored to the vectors’ context-specific behaviour. The vector control response is an integral part of the WASH responsibility and measures include:

preventive actions (drainage of stagnant water, waste collection, etc.)

distribution of personal protection methods (e.g. repellents, insecticide-treated mosquito nets, etc.)

chemical control (e.g. insecticide residual and space spraying, insecticidal dusting, use of larvicides in water bodies, rodenticide application, etc.)

other innovative vector control methods (e.g. sterile insect technology).

Hygiene/health promotion

People’s motivation to change their hygiene behavior not always relates to health but can depend as well on other drivers of human behavior like convenience and self-respect. To have any impact, it’s important to have a better understanding of the target population as well as their preferred communication ways in a given context. Simple education/information sharing might be sufficient during acute emergencies as people might be receptive to the hygiene/health messages because they might be afraid to get ill of a specific outbreak, whereas for chronic emergencies and stabilized situations other reasons might have to be highlighted (e.g. promote ownership of a latrine as a status symbol). Some people will prefer face-to-face communication (e.g. participatory exercises) which is normally limited to rather small groups but has the advantage that potential questions can be addressed immediately. Mini-media (e.g. theatre, puppet show, video) offers the advantage to reach already a bigger audience, whilst their immediate feedback is still possible. Mass-media (e.g. newspapers, radio, television) is more suited for spreading relevant information to big numbers of people, but goes mainly in one direction, thus additional monitoring for correct comprehension is required.

Context-related WASH

In health structures.

Nosocomial or healthcare-associated infections are a global burden and represent a safety concern for patients, visitors, healthcare professionals, and nearby communities alike. Healthcare-associated infections are very diverse and include diarrhoeal diseases, hepatitis B and C, HIV/AIDS, wound infections, urinary tract infections, and chest infections. The prevalence varies considerably from hospital to hospital, with an incidence range in HIC reported between 5% and 15%, with a broader range of 5.7–45.8% reported in sub-Saharan Africa where little is known about the overall epidemiology. 5

The reality in many LIC is one of insufficient personal washing or hand hygiene implementation, improper cleaning and/or sterilization of medical and surgical apparatus and equipment, insufficient drinking water and washing water safety, poor provision of sanitation, poor medical practices (such as unsafe injections), lack of vector control measures, as well as risky medical waste and wastewater disposal. Many of these issues are integrated within the standard precautions, and the provision of WASH elements to any healthcare system is an essential requirement. In particular, in the context of highly contagious diseases, context-specific WASH interventions play a crucial role.

In populations

An elder in South Sudan, when asked about the health needs of his community said: ‘Why are you giving me medicine to cure my diarrhoea—that I must swallow with the same water that made me ill?’

WASH activities are essential at all phases of health provision, from acute emergencies to more stable environments. In acute or chronic emergencies and post-conflict situations, or in the aftermath of a natural disaster, WASH services in LIC are often dysfunctional or non-existent. To prevent excess morbidity and mortality in the affected population, services need to be (re-)established as soon as possible.

Rather than a ‘one-size-fits-all’ approach which tracks universal coverage indicators, giving priority to ‘transmission’ hotspots amenable by adequate WASH interventions is often preferable as a strategy in, e.g. large-scale cholera or malaria outbreaks. The type, size, extension, and focus of WASH activities should be adapted to the contexts, and medical goals set in the multidisciplinary evolution of the public health problem. The response should be geared towards tools for fast deployment in the acute phase, and foreseeing transition to more sustainable, less resource-heavy technology in the post-emergency phase.

A relevant WASH intervention in natural catastrophes such as floods is the massive cleaning and disinfection of all flooded water points such as wells and boreholes, which needs to be conducted once the waters retreat.

Future and innovation in the WASH sector

Interestingly, while WASH interventions are among the most crucial in public health, the evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is sparse, and numerous methodological limitations undermine the ability to determine associative, let alone causal, relationships. The challenging contexts where the WASH sector operates, often characterized by life-or-death situations, overwhelming constraints, and competing priorities, tend to be a fertile environment for the development of innovative strategies and tools that greatly benefit the populations in need and strengthen the WASH sector’s expertise. However, despite this continuous innovation, rigorous documentation and publication of both innovative and long-standing empirical WASH interventions remain sparse, and generation of evidence through, e.g. operational research, continues to lag behind.

The further translation of WASH innovations into policy adaptation and wider implementation in the field thus remains an important area for improvement. The interface and communication between the WASH sector and global policymakers needs to be strengthened, in order to assure that it is accorded at least the same importance as other activities in humanitarian interventions and in the research sphere—the absence of an industrial lobby behind WASH should not mean that it is absent from the operational decision-making table.

1.   Van Den Noortgate J , Maes P.   Public Health Engineering in Precarious Situations. Paris: Médecins Sans Frontières; 2010   http://refbooks.msf.org/msf_docs/en/public_health/public_health_en.pdf .

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2.   Prüs-Üstün A , Bos R , Gore F , Bartram J.   Safer Water, Better Health: Cost, Benefits and Sustainability of Interventions to Protect and Promote Health. Geneva: World Health Organization; 2008 .

3.   Bartram J , Cairncross S.   Hygiene, sanitation, and water: forgotten foundations of health.   PLoS Med   2010 ;7:e1000367. 10.1371/journal.pmed.1000367

4.   Mara DD.   Unitary environmental classification of water and excreta-related diseases.   J Environ Engineering   1999 ;125(4):335. 10.1061/(ASCE)0733-9372(1999)125:4(334)

5.   Bagheri Nejad S , Allegranzi B , Syed SB , Ellis B , Pittet D.   Health-care-associated infection in Africa: a systematic review.   Bull World Health Organ   2011 ;89:757–65. 10.2471/BLT.11.088179

Web of Science

Further reading

Cairncross S , Feachem R.   Environmental Health Engineering in the Tropics. Chichester: Wiley; 1993 .

Cook GC.   Thomas Southwood Smith FRCP (1788–1861): leading exponent of diseases of poverty, and pioneer of sanitary reform in the mid-nineteenth century.   J Med Biog   2002 ;10:194–205. 10.1177/096777200201000403

Davis J , Lambert R.   Engineering in Emergencies: A Practical Guide for Relief Workers Intermediate Technology. 2nd rev ed. London: ITDG Publishing; 2002

Ferron S , Morgan J , O’Reilly M.   Hygiene Promotion. A Practical Manual for Relief and Development. 2nd ed. Rugby: Practical Action Publishing; 2007 . 10.3362/9781780441184

PAHO/WHO/IFRC/ICRC. Management of Dead Bodies after Disasters: A Field Manual for First Responders. Washington, DC: PAHO; 2006 .

Porter D.   Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times. London: Routledge; 1999 .

Rozendaal J.   Vector Control: Methods for Use by Individuals and Communities. Geneva: World Health Organization; 1997 .

The Lancet . Keeping sanitation in the international spotlight. Lancet 2008 ;371:1045. 10.1016/S0140-6736(08)60459-6

Thomson M.   Disease Prevention through Vector Control: Guidelines for Relief Organisations. Oxford: Oxfam Publication; 1995 . 10.3362/9780855987077

Wagner EG , Lanoix JN.   Excreta Disposal in Rural Areas and Small Communities. Geneva: World Health Organization; 1958 .

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Tapping the Benefits of Clean Water, Sanitation, and Hygiene

By Guest Blogger on July 6, 2017

By Katie Dahlstrom, Nestlé Corporate Communications Manager and Helen Medina, Nestlé Senior Public Affairs Manager, Government and Multilateral Relations

Clean water is one of the few things in life that never fails to live up to expectations.

It is difficult to overstate the importance of having it. In fact, it’s probably impossible. Clean water changes almost everything. This is also why access to and management of clean water, sanitation, and hygiene are included in the Sustainable Development Goals (SDGs), specifically, SDG 6, which Nestlé is contributing directly through our partnership with the International Federation of Red Cross and Red Crescent Societies (IFRC). But how are we doing this?

Tapping the benefits

Having clean water and sanitation means being able to avoid exposure to countless diseases.

Every year, millions of people die from diseases caused by inadequate water supply, sanitation, and hygiene. Other than pneumonia, diarrhea is the  main cause of death  in children under age 5.

Poor sanitation and unsafe water  cause nearly 20% of workplace deaths . It costs around  $260 billion  in lost productivity every year.

But the benefits of having a source of clean water in a community are much wider. When women and girls no longer have to walk miles to fetch water each day, they have more time to learn. Literacy rates rise. And when schools build proper toilet facilities,  girls spend more time in school and less time at home.  

The  United  N ations  estimates that every Swiss franc invested in water and sanitation leads to four francs in economic returns – which is why investing in this area is such an effective way of creating stronger, more resilient communities.

Connecting communities

In Côte d’Ivoire,  63% of the population lacks access to proper sanitation . People must often walk miles to collect water, which may not even be safe to drink, as well as use open air, unhygienic shared toilets.  

The IFRC is working across Côte d’Ivoire to extend access to clean water, sanitation, and hygiene.

As the IFRC’s longest-standing corporate partner, Nestlé has helped to deliver clean water and sanitation to almost 110,000 people in Côte d’Ivoire’s cocoa-growing communities for the past 10 years.  

A total of 181 water pumps and 93 blocks of school toilets have been built or renovated as well as more than 7,000 family latrines.  

Education has been an essential part of the effort too. More than 200 community water and sanitation committees and 93 school hygiene clubs have been established since 2007.  

Their members promote hygiene in their local area. They teach people how to store water safely and build safe sanitation facilities, and children how to wash their hands well. Sometimes it is the simplest measures that have the biggest effect.  

“Our grandchildren will not suffer…”

Adjoua is a 55-year-old widow from the village of Ndri Koffikro in the south of Côte d’Ivoire. She recalls that ever since she was young, her community’s biggest wish has been to have access to safe drinking water. Traditionally, residents relied on ponds and a river nestled in a forest two kilometers away for their water.

Before the IFRC committed to building a water point in the village, it made sure a viable management system could be set up with community members. A management committee, which consists of six women and two men from the village, oversees the operation and maintenance of the water point and handles the accounts related to the income generated from selling water.

It ensures that the investment made in the water point will live on for generations.  

“Now, I and my community members will have more time and energy to take care of our family as well as our farming activities,” says Adjoua. “Our grandchildren will not suffer all the pains we went through.”

Safe water and better hygiene reduce the burden of ill health on families and allow women more time to earn their own income. An end to open defecation means people are safer – particularly at night – and the land is cleaner and the crops healthier.  

Meaningful progress

Education programs teach school children good hygiene habits. Some  768 million people still do not have access to an improved source of drinking water ; 40% of them in sub-Saharan Africa. There is still a long way to go, but progress is being made.

With the program up and running successfully in Côte d’Ivoire, the next phase of the project has already begun in Ghana, where wells are now being constructed. Over 76,000 people in cocoa producing communities that Nestlé works with will have better access to clean water and sanitation by April 2018.  

By bringing basic hygiene knowledge alongside clean water, the IFRC program ensures that the health benefits of its work endure.  

[Photo: Copyright Nestlé S.A. and by Remo Naegli]         

This post is part of the “SDG Solutions” series hosted by the United Nations Foundation, Global Daily, and +SocialGood to raise awareness of ways the international community can advance, and is advancing, progress on the Sustainable Development Goals. As the international community prepares to gather at the UN for the High-Level Political Forum on Sustainable Development from July 10-19, this series will share ideas and examples of action. Previous posts in the series can be found here .

Nestlé   is a part of the Every Woman Every Child movement, launched in 2010 and led by the UN Secretary-General, to intensify commitment and action by governments, the UN, multilaterals, the private sector, and civil society to keep women’s, children’s and adolescents’ health and wellbeing at the heart of development. As a multi-stakeholder platform to operationalize the Every Woman Every Child Global Strategy for Women’s, Children’s and Adolescents’ Health, the movement mobilizes partnerships and coordinated efforts across sectors to ensure that all women, children and adolescents not only survive, but also thrive to help transform the world. Learn more : http://www.everywomaneverychild.org/

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• Biology Article
• Need For Hygiene And Sanitation

Need for Hygiene and Sanitation

What is hygiene.

Hygiene is a set of personal practices that contribute to good health. This includes washing hands, cutting hair/nails periodically, bathing, etc.

What is Sanitation?

Sanitation refers to public health conditions such as drinking clean water, sewage treatment, etc. All the effective tools and actions that help in keeping the environment clean come under sanitation.

Also Read:  Health and Hygiene

Read on to explore the importance of hygiene and sanitation.

Importance of Hygiene and Sanitation

Maintaining personal hygiene and sanitation is important for several reasons such as personal, social, psychological, health, etc. Proper hygiene and sanitation prevent the spread of diseases and infections. If every individual on the planet maintains good hygiene for himself and the things around him, diseases will eradicate to a great level.

Importance of Hygiene

Hygiene, as defined by the WHO refers to “ the conditions and practices that help maintain health and prevent the spread of diseases. ”

This means more than just keeping ourselves clean. This means shunning all practices that lead to bad health. Throwing garbage on the road, defecating in the open, and many more. By adopting such a practice, we not only make ourselves healthier but also improve the quality of our lives.

Personal hygiene means keeping the body clean, consumption of clean drinking water, washing fruits and vegetables before eating, washing one’s hand, etc. Public hygiene refers to discarding waste and excreta properly, that means, waste segregation and recycling, regular disinfection and maintenance of the city’s water reservoir. Quality of hygiene in the kitchens is extremely important to prevent diseases.

Diseases spread through vectors. Say the vector is contaminated water as in the case of typhoid, cholera, and amoebiasis (food poisoning). By drinking clean water, we can completely eliminate the chances of getting diseases.

Some diseases are caused by pathogens carried by insects and animals. For eg., plague is carried by rats, malaria, filarial, roundworms by flies and mosquitoes, etc.

Mosquitoes thrive in stagnant water and rats in garbage dumps and the food that is dumped out in the open. By spraying stagnant water bodies with kerosene or other chemicals, we can completely eliminate mosquitoes from our neighbourhood. If that is unfeasible, we can all use mosquito nets prevents us from mosquitoes while we’re asleep. This poses a physical barrier for the mosquito.

Rats thrive on unsystematic waste disposal. By segregating the waste we can ensure that we don’t leave food lying around for rats to eat. Close contact with sick people is also another way of contracting diseases .

A country has to strive to educate more doctors so that medical need of every citizen is taken care of. The importance of cleanliness should be inculcated in every citizen and this will in turn show in the cleanliness of the places we live in.

Importance of Sanitation

Sanitation is another very important aspect. Many of the common diseases mentioned earlier such as roundworms spread through the faeces of infected people. By ensuring that people do not defecate in the open, we can completely eliminate such diseases and even more severe ones such as the one caused by E. Coli. The advancement in biology has given us answers to many questions, we are now able to identify the pathogen and treat an ailment accordingly.

Also Read:  Health and Diseases

For more detailed information about what is hygiene, what is sanitation, the Importance of Hygiene and Sanitation, keep visiting BYJU’S website or download BYJU’S app for further reference.

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VERY GOOD ARTICLE TO GAIN KNOWLEDGE

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Thanks a lot Byju’s for the knowledge u r transferring to the young generation

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• Published: 26 April 2024

A cluster-randomized trial of water, sanitation, handwashing and nutritional interventions on stress and epigenetic programming

• Audrie Lin   ORCID: orcid.org/0000-0002-3877-3469 1 ,
• Andrew N. Mertens   ORCID: orcid.org/0000-0002-1050-6721 2 ,
• Md. Ziaur Rahman 3 ,
• Sophia T. Tan 4 ,
• Dora Il’yasova 5 ,
• Ivan Spasojevic   ORCID: orcid.org/0000-0001-9890-6246 5 , 6 ,
• Shahjahan Ali   ORCID: orcid.org/0000-0003-3883-1208 3 ,
• Christine P. Stewart   ORCID: orcid.org/0000-0003-4575-8571 7 ,
• Lia C. H. Fernald 2 ,
• Lisa Kim 2 ,
• Liying Yan 8 ,
• Ann Meyer 8 ,
• Md. Rabiul Karim 3 ,
• Sunny Shahriar 3 ,
• Gabrielle Shuman 2 ,
• Benjamin F. Arnold   ORCID: orcid.org/0000-0001-6105-7295 9 ,
• Alan E. Hubbard   ORCID: orcid.org/0000-0002-3769-0127 2 ,
• Syeda L. Famida 3 ,
• Salma Akther 3 ,
• Md. Saheen Hossen 3 ,
• Palash Mutsuddi 3 ,
• Abul K. Shoab 3 ,
• Idan Shalev 10 ,
• Mahbubur Rahman   ORCID: orcid.org/0000-0003-0520-2683 3 ,
• Leanne Unicomb 3 ,
• Christopher D. Heaney 11 ,
• Patricia Kariger 2 ,
• John M. Colford Jr. 2 ,
• Stephen P. Luby   ORCID: orcid.org/0000-0001-5385-899X 4   na1 &
• Douglas A. Granger 12 , 13   na1  

Nature Communications volume  15 , Article number:  3572 ( 2024 ) Cite this article

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• Developing world
• Endocrine system and metabolic diseases
• Public health
• Stress and resilience

A regulated stress response is essential for healthy child growth and development trajectories. We conducted a cluster-randomized trial in rural Bangladesh (funded by the Bill & Melinda Gates Foundation, ClinicalTrials.gov NCT01590095) to assess the effects of an integrated nutritional, water, sanitation, and handwashing intervention on child health. We previously reported on the primary outcomes of the trial, linear growth and caregiver-reported diarrhea. Here, we assessed additional prespecified outcomes: physiological stress response, oxidative stress, and DNA methylation ( N  = 759, ages 1–2 years). Eight neighboring pregnant women were grouped into a study cluster. Eight geographically adjacent clusters were block-randomized into the control or the combined nutrition, water, sanitation, and handwashing (N + WSH) intervention group (receiving nutritional counseling and lipid-based nutrient supplements, chlorinated drinking water, upgraded sanitation, and handwashing with soap). Participants and data collectors were not masked, but analyses were masked. There were 358 children (68 clusters) in the control group and 401 children (63 clusters) in the intervention group. We measured four F2-isoprostanes isomers (iPF(2α)-III; 2,3-dinor-iPF(2α)-III; iPF(2α)-VI; 8,12-iso-iPF(2α)-VI), salivary alpha-amylase and cortisol, and methylation of the glucocorticoid receptor ( NR3C1 ) exon 1F promoter including the NGFI-A binding site. Compared with control, the N + WSH group had lower concentrations of F2-isoprostanes isomers (differences ranging from −0.16 to −0.19 log ng/mg of creatinine, P  < 0.01), elevated post-stressor cortisol (0.24 log µg/dl; P  < 0.01), higher cortisol residualized gain scores (0.06 µg/dl; P  = 0.023), and decreased methylation of the NGFI-A binding site (−0.04; P  = 0.037). The N + WSH intervention enhanced adaptive responses of the physiological stress system in early childhood.

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Introduction.

Children living in low-income settings often experience recurrent infections and undernutrition due to inadequate water, sanitation, and hygiene infrastructure and food insecurity that may have lasting impacts on their stress response system critical for healthy growth and development. Although several studies have evaluated the effects of psychosocial interventions on the physiological stress system 1 , a major gap is the lack of experimental studies assessing the effects of physical health interventions on the hypothalamic-pituitary-adrenocortical (HPA) and sympathetic adrenomedullary (SAM) systems and epigenetic programming in early childhood.

Chronic stress, in the form of undernutrition, infection, and psychosocial adversity, may cause irreversible harm if it occurs during the early years of life (under age 2 years), a period of rapid growth and development 2 . During this period of heightened plasticity, the neuroendocrine-immune network develops and adapts in response to exposure to environmental stimuli 3 . Stressful stimuli shape the set point, reactivity, and regulation of the two primary neuroendocrine axes—the SAM and the HPA systems—and these axes, in turn, regulate the immune system 3 . Activation of the SAM system leads to increased blood pressure and heart rate and changes in the levels of salivary alpha-amylase, a biomarker of the SAM system 4 , 5 .

The HPA axis modulates the SAM system through the production of glucocorticoids. Cortisol, a key glucocorticoid, regulates the immune system, growth factors, and neurodevelopment 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 . Cortisol production follows a circadian rhythm that is developed during the first year of life 14 . Chronic stress disrupts the tight regulation of this circadian rhythm 15 . An HPA or SAM challenge, such as an acute physical stressor (e.g., vaccination), is typically used to induce and measure cortisol or salivary alpha-amylase reactivity in children 16 . This artificial induction of reactivity reflects the magnitude of an individual’s HPA or SAM response to a stressor in a naturalistic setting 17 , 18 . Exposure to chronic stress may alter a child’s cortisol response to an acute physical stressor, which could indicate HPA axis dysregulation. Glucocorticoids also regulate genes involved in oxidative stress pathways 19 , 20 . Oxidative stress results from an imbalance between generation of reactive oxygen species and elimination of them through the antioxidant defense system 21 . F2-isoprostanes reflect systemic oxidative damage 22 , 23 and are associated with infections and neurological damage 24 , 25 .

Cortisol binds to the glucocorticoid receptor, encoded by the NR3C1 gene 6 . Studies suggest associations between stress and epigenetic modulation of the NR3C1 gene 6 . During early childhood, the epigenome undergoes dramatic changes. Environmental factors significantly affect these epigenetic processes, which involve the regulation of gene expression through methylation and chromatin modification. Recent studies are beginning to elucidate the degree to which environmental factors during infancy affect developmental programming at the DNA level to determine health outcomes in adulthood. Within the NR3C1  gene, increased methylation of CpG sites of a noncanonical nerve growth factor-inducible protein A (NGFI-A) binding site downregulates the expression of the NR3C1 gene 26 . Differential methylation of NR3C1 or the NGFI-A binding site is associated with childhood maltreatment 27 .

Previously, the WASH Benefits trial reported that children receiving a combined nutrition, water, sanitation, and handwashing intervention experienced better growth (primary outcome), reduced diarrhea prevalence (primary outcome), and improved neurodevelopment (secondary outcome) compared to children in the control group 28 , 29 . Here, we evaluated the effects of the intervention on additional prespecified outcomes: physiological stress response, oxidative stress levels, and DNA methylation of the NR3C1 gene among young children.

The overall trial assessed 13279 pregnant women for eligibility. 5551 women were enrolled between 31 May 2012 and 7 July 2013. A total of 90 blocks were defined, and each block was made up of 8 clusters randomly allocated to one of the intervention or control groups (720 clusters randomized) (Fig.  1 ). The target enrollment for the stress substudy was 996 children after one year of intervention and 1021 children after two years of intervention (Fig.  1 ). The substudy included 70 blocks (135 clusters). Stress outcomes were assessed in 688 children (51% female) at age 14.3 (IQR, 12.7–15.6) months, and 759 children (52% female) at age 28.2 (IQR, 27.0–29.6) months (Fig.  1 ). At enrollment, household characteristics were similar across intervention and control arms (Table  1 ) and comparable to the overall trial (Supplementary Table  1 ).

Source data are provided as a Source Data file.

Oxidative stress

Compared to children in the control group, after one year of combined N + WSH intervention (median age 14 months), children in the intervention arm exhibited lower levels of all four F2-isoprostanes isomers measured: IPF(2α)-III (−0.16 log ng/mg of creatinine; CI −0.27 to −0.06, P  < 0.01), 2,3-dinor-iPF(2α)-III (−0.16 log ng/mg of creatinine; CI −0.23 to −0.09, P  < 0.001), iPF(2α)-VI (−0.17 log ng/mg of creatinine; CI −0.25 to −0.1, P  < 0.001), and 8,12-iso-iPF(2α)-VI (−0.19 log ng/mg creatinine; CI −0.29 to −0.1, P  < 0.001) (Table  2 ; Supplementary Fig.  1 ; Supplementary Table 2 ).

HPA and SAM axes

For the cortisol and salivary alpha-amylase measurements, the acute stressor was a venipuncture and physical separation of the child from the caregiver. In terms of cortisol reactivity, 69% of the children were classified as responders to the acute stressor (exhibited an increase in pre- to post-stressor cortisol levels), 13% of the children were classified as non-responders to the acute stressor (exhibited a decrease in pre- to post-stressor cortisol levels), and 18% experienced no change in cortisol levels (Supplementary Fig.  2 ). After two years of intervention (median age 28 months), children in the combined N + WSH intervention group had elevated post-stressor salivary cortisol levels (0.24 log µg/dl; CI 0.07 to 0.4, P  < 0.01), higher cortisol slope scores (0.002 µg/dl/min; CI 0 to 0.003, P  = 0.035), and higher residualized gain scores for cortisol (0.06 µg/dl; CI 0.01 to 0.12, P  = 0.023; Table  3 ; Supplementary Fig.  1 ; Supplementary Table  3 ). There was no difference in the overall methylation levels of the NR3C1 between the control and the combined N + WSH intervention groups. Logit-transformed methylation of the NGFI-A transcription factor binding site was lower in the combined N + WSH intervention group compared to the control group (−0.04, CI −0.08 to 0, P  = 0.037; Table  3 ; Supplementary Fig.  1 ; Supplementary Table 3 ). Unadjusted, adjusted, and inverse probability of censoring weighted (IPCW) analyses produced similar estimates (Supplementary Tables  2 and 3 ), indicating balance in measured confounders across arms and no differential loss to follow-up.

Subgroup analyses

A prespecified subgroup analysis revealed that sex was not an effect modifier for F2-isoprostanes at year one (Supplementary Table  4 ). After two years, there was some evidence of effect measure modification with child sex: among males, the combined N + WSH intervention group had a lower resting heart rate compared to the control group (−3.53 bpm, CI −6.62 to −0.44; P  = 0.025), and there was no effect among females (sex by treatment interaction P  = 0.027; Supplementary Table  5 ). Among females, the combined N + WSH intervention group had higher pre-stressor cortisol levels compared to the control group (0.16 log µg/dl, CI 0.01 to 0.32; P  = 0.038), and there was no intervention effect on pre-stressor cortisol levels among males (sex by treatment interaction P  = 0.035).

The trial found that a combined nutrition, water, sanitation, and handwashing intervention reduced oxidative stress, enhanced HPA axis functioning, and reduced methylation levels of the NGFI-A binding site in the NR3C1 exon 1F promoter in young children. The magnitude of the effects of this environmental and nutritional intervention on cortisol production is within the range of intervention effects of psychosocial interventions reported in early childhood 30 . The N + WSH intervention effects on F2-isoprostanes are also comparable to the effects of dietary interventions in adult populations 31 .

Oxidative stress, the accumulation of unstable free radicals that damage DNA and cellular structures, has been implicated in the pathophysiology of several pediatric disorders including asthma, protein-energy malnutrition, and diarrheal diseases 32 . Augmented oxidative stress in children with severe forms of malnutrition, including kwashiorkor and marasmus, may be the consequence of increased production of reactive oxygen species or impaired antioxidant defenses 33 , 34 . Micronutrients serve key roles in the body’s antioxidant defense system, either directly as antioxidants (e.g., vitamins C, A, and E) or indirectly as co-factors of antioxidant enzymes (e.g., manganese, copper, or zinc) 35 . The combined N + WSH intervention reduced diarrhea, anemia, iron deficiency, and ultimately improved child growth 28 , 36 . The lipid nutrient supplement containing ≥100% of the recommended daily allowance for 12 vitamins, including antioxidants such as vitamins C, A, and E and 9 minerals including manganese, copper, zinc, and selenium (full list available in Stewart et al. 36 ) may have strengthened the antioxidant defenses of children in the intervention group compared to children in the control group. With enhanced antioxidant defenses, the bodies of children who received the intervention may have more efficiently scavenged free radicals, prevented their formation, and disrupted free-radical reactions.

As part of the innate immune response against pathogen invasion, phagocytic cells release reactive oxygen and nitrogen species that target proteins, DNA, and lipids 37 . Innate immunity is tightly regulated because reactive oxygen and nitrogen species target pathogens and host cells alike. After one year, children in the intervention arm experienced less diarrhea and less enteric viral infections 28 , 38 . It is plausible that the water, sanitation, and handwashing interventions interrupted pathogen transmission, leading to lower non-specific innate immune activity, less generation of reactive oxygen species, and reductions in downstream lipid peroxidation as measured by F2-isoprostanes. Together, less immune-activated production of reactive oxygen species and reinforced antioxidant defenses may have contributed to the lower levels of oxidative stress observed in children receiving the combined N + WSH interventions compared to children in the control group. These biological mechanisms could underpin the subsequent improvements in child development that we observed at age two years in the intervention group 29 .

The effects of the intervention were remarkably consistent across upstream and downstream levels of the HPA axis. Compared to the control group, the combined N + WSH intervention group had hypomethylated NGFI-A transcription factor binding site, which leads to elevated glucocorticoid receptor gene expression 39 . The higher post-stressor cortisol levels and cortisol reactivity exhibited in the intervention group are also indicative of increased activation of the glucocorticoid receptor. The mechanisms by which nutrition modulates the HPA axis have not been fully elucidated but could be mediated through the immune triad 15 or epigenetic programming 40 .

In settings with inadequate water, sanitation, and hygiene infrastructure, infections are acquired early and frequently in childhood. Infections affect the transcriptional activation of the glucocorticoid receptor 41 . In the WASH Benefits trial, children in arms receiving the WSH intervention had reduced Giardia and hookworm infections and lower acute respiratory illness at age two years compared with children in the control group 42 , 43 , 44 . The hypomethylation of the NGFI-A transcription factor binding site and the robust cortisol response observed in the intervention group may have strengthened resistance to infections, as glucocorticoids are immunomodulatory hormones 45 . Sex assigned at birth was an effect modifier: among females, the intervention group experienced an elevation in pre-stressor cortisol levels. Identifying mediators of these sex-based differences in stress response will guide the future design of targeted early childhood interventions. During early childhood, a period of increased physiological plasticity and epigenetic programming, the combined nutrition, water, sanitation, and handwashing intervention enhanced children’s HPA axis regulatory capabilities, which in turn may have cascading effects on growth and development.

In the parent trial, improved child linear growth was only observed in the arms receiving the nutrition intervention (the nutrition alone arm and the combined N + WSH arm) 28 , and child neurodevelopment was improved in all intervention arms 29 . Although the combined N + WSH intervention may have directly impacted the physiological stress system through improved nutritional status and infection reduction, the intervention may also have had indirect impacts through reductions in caregiver depression and enhanced caregiver social support. In the WASH Benefits parent trial, community health promoters visited households in the intervention arm to promote intervention-related behaviors (e.g., treating water, using latrines), but they did not visit households in the control arm. The trial reported lower levels of depressive symptoms among women in the intervention arm compared with the control arm 29 . Maternal depression is associated with blunted cortisol reactivity in infants, mediated by increased family conflict and less responsive parenting 46 . Hence, the intervention-associated reductions in maternal depressive symptoms and increased caregiver support may have led to the higher cortisol reactivity observed among children in the intervention arm compared with the children in the control arm. Forthcoming studies will aim to elucidate the complex interplay between nutrition, infection, psychosocial factors, and the physiological stress response.

This study has limitations. One limitation of the study is that we only analyzed cortisol and salivary alpha-amylase reactivity, which prevented us from characterizing the full cortisol and salivary alpha-amylase awakening response, a common measure of HPA axis and autonomic nervous system functioning. Here, we report the effects of the combined intervention on stress response, because we did not also analyze samples from children who received only the nutrition and only the WSH intervention; thus, we cannot determine whether the effects were primarily driven by the nutrition intervention, the WSH intervention, or the combination of both. There was also loss-to-follow-up among children targeted for enrollment in this study and between measurement rounds (Fig.  1 ). Though loss-to-follow-up may have reduced the study’s power, randomization was maintained, as evidenced by the balance between household characteristics across intervention and control arms (both between children with outcome data (Table  1 ) and between those lost to follow-up (Supplementary Table  1 )), suggesting that selection bias from differential loss-to-follow-up was unlikely. Additionally, an inverse probability of censoring-weighted analysis, which re-weights the measured outcomes so the observed population reflects the characteristics of the full study population 47 , 48 , produced similar estimates (Supplementary Tables  2 and 3 ), which further suggests that differential loss-to-follow-up likely did not lead to systematic bias in effect estimates. Because the study included a candidate gene methylation study of NR3C1 , the chance of observing false positives and false negatives is high. The randomized experimental design minimizes the risk of spurious results in the study. To further minimize the risk of erroneous findings, future studies should consider using a combination of linkage mapping and a candidate gene approach.

In a low-resource setting, we found that an intensive combined nutrition, drinking water, sanitation, and handwashing intervention in early childhood reduced oxidative stress, enhanced the cortisol response, and reduced methylation levels of the glucocorticoid receptor gene. These findings support the future design and optimization of targeted nutritional and environmental therapeutic approaches that leverage physiologic plasticity to improve children’s health outcomes through the life course.

Study design and randomization

The WASH Benefits trial was conducted in rural villages in the Gazipur, Mymensingh, Tangail, and Kishoreganj districts of Bangladesh 28 . The traditional household structure in rural Bangladesh is the compound, where patrilineal families live together and share a common courtyard, and additionally sometimes other resources such as a pond, water source, and latrine. Eight pregnant women who lived near each other were grouped into a study cluster, the unit of randomization, to make it easy for a single community health promoter to walk to each compound. A one km buffer zone around each cluster was enforced in order to prevent spillover from nearby clusters. Eight geographically adjacent clusters formed a block. Using a random number generator, an investigator at UC Berkeley (B.F.A.) block randomized each of the eight geographically adjacent clusters to the double-sized control arm or to one of the six intervention arms in the parent trial: water; sanitation; handwashing; combined water, sanitation, and handwashing (WSH); nutrition, or combined nutrition, water, sanitation, and handwashing (N + WSH). This study only assessed physiological stress, oxidative stress, and DNA methylation in the control and the N + WSH arm of the trial.

Since each intervention delivered had visible physical components (lipid-based nutrient supplement sachets, chlorine tablets and storage vessels, potties, latrines, sani-scoop hoes, and handwashing stations), participants and outcome assessors were not masked. However, laboratory investigators were masked to group assignments and four researchers (A.L., A.N.M., S.T.T., and L.K.), following the pre-registered analysis plan, conducted independent masked statistical analyses. Analyses were replicated once. Results were only unmasked after replication of masked analyses.

Sample size and power calculations

Because the sample size calculations were based on the original environmental enteric dysfunction study 49 , we assumed that this sample size would be sufficient to assess the stress response and DNA methylation outcomes of this substudy. To estimate the minimum detectable effect of nutrition and WSH interventions on sAA, cortisol, oxidative stress, blood pressure, heart rate, and NR3C1 methylation in the trial, we assumed 135 clusters (average of 5 children per cluster) would be enrolled in this substudy and used the standard deviations in Table  4 .

With a range of cluster-level intra-class correlations for repeated measures (0.01 to 0.20), the trial would have 90% power to detect the differences between each intervention arm and the control arm outlined in Table  5 .

Study protocols were approved by human subjects committees at icddr,b (PR-11063 and PR-14108), the University of California, Berkeley (2011-09-3652 and 2014-07-6561) and Stanford University (25863 and 35583). icddr,b organized a data safety monitoring committee that oversaw the trial. The study protocol is available as a  Supplementary Note . Participants provided written informed consent. Because compensation for research participation can be perceived as coercive in low-income settings, instead, families received health information (e.g., blood group testing results) as a token of appreciation.

Participants

Pregnant women in their first or second trimesters and their children were enrolled in the study between 31 May 2012 and 7 July 2013 28 . The trial enrolled pregnant women in the first two trimesters to increase the number of available participants in the study area and to address the inaccuracies of gestational age estimation using self-reported last menstrual period dates. Households that had plans to move in the following year or did not own their own home were excluded in order to minimize loss to follow-up. Households that utilized a water source with high iron were excluded to optimize the effectiveness of the chlorine-based water treatment intervention. The selected study area had low levels of groundwater iron and arsenic, as determined by data from the Department of Public Health Engineering, the British Geological Survey, the Department for International Development National Hydrochemical Survey, and a survey conducted before the study began 36 . Study staff also conducted surveys where respondents self-reported if there was iron taste in their drinking water or iron staining of their water storage vessels. If the respondent was uncertain about the iron content of their drinking water, study staff used Aquatabs and a digital Hach Pocket Colorimeter II to test the water’s chlorine demand. Households with residual chlorine levels below 0.2 mg/L after 30 min were excluded.

The control group did not receive intervention-related household visits. The intervention group received a combination of interventions including a nutrition intervention, a drinking water intervention, a sanitation intervention, and a handwashing intervention; hereafter, this combined intervention group will be referred to as the N + WSH group. Details of the combined intervention in the parent trial were previously described 28 . Briefly, the nutrition component of the combined intervention consisted of the provision of lipid-based nutrient supplements (LNS; Nutriset, France) that included ≥100% of the recommended daily allowance of 12 vitamins and 9 minerals with 9.6 g of fat and 2.6 g of protein daily for children 6–24 months old and age-appropriate maternal and infant World Health Organization (WHO)/Food and Agriculture Organization (FAO) nutrition recommendations (pregnancy–24 months) 36 . The drinking water component of the combined intervention included chlorine tablets (Aquatabs; Medentech, Ireland) and safe storage vessels for drinking water. The sanitation component of the combined intervention included child potties, sani-scoop hoes to remove feces, and a double pit latrine for all households. The handwashing component of the combined intervention included handwashing stations with soapy water bottles and detergent soap placed near the latrine and kitchen. To promote behaviors such as treating water, using latrines, and handwashing, local community health promoters visited clusters at least once per week during the first 6 months, and subsequently, at least once every 2 weeks.

One year after intervention, urine samples for oxidative stress analysis were collected in Briggs Pediatric Sterile U-Bags and preserved with 0.1% thimerosal 49 .

Two years after intervention, we collected saliva specimens. All study activities took place in the children’s homes. In our stress response protocol for cortisol and salivary alpha-amylase measurements, the acute stressor was a venipuncture and caregiver physical separation from the child. Children refrained from ingesting caffeinated products and medicine at least one hour before the venipuncture stress protocol. One hour before the venipuncture, the study team obtained consent and interviewed the caregiver about their child’s medical history. Thirty minutes before the venipuncture, the study team measured maternal and child blood pressure and heart rate. The child’s mouth was rinsed with drinking water 15–20 min prior to the venipuncture. During the period leading up to the venipuncture, the children typically played or slept. Using SalivaBio Children’s Swabs (Salimetrics), three saliva samples were collected during the stress response protocol (5–8 min before stressor onset, 5 min after stressor onset, and 20 min after stressor onset). The stressor was administered at a median time of 10:15 am (IQR: 9:20 am – 11:48 am). For each child, the stressor (the venipuncture and the physical separation of the child from the caregiver) lasted a median of 7.5 min (IQR: 7.5, 7.5). Cortisol was measured at two time points: pre-stressor and 20 min post-stressor. Salivary alpha-amylase was also measured at two time points: pre-stressor and 5 min post-stressor. Additional saliva samples for epigenetic analysis were collected in Oragene kits (OGR-575) and shipped at ambient temperature to EpigenDx (Hopkinton, MA) for DNA methylation analysis of the NR3C1 gene.

At two years, the resting heart rate of participants was measured with a finger pulse oximeter (Nonin 9590 Onyx Vantage) in triplicate, and systolic and diastolic blood pressure were measured with a blood pressure monitor (Omron HBP-1300) in triplicate.

Prespecified outcomes

Analyses were intention-to-treat. We compared the N + WSH arm versus the control arm separately at one year after intervention (median age 14 months) and two years after intervention (median age 28 months). Outcomes included the concentrations of four isomers of F2-isoprostanes [iPF(2α)-III; 2,3-dinor-iPF(2α)-III; iPF(2α)-VI; 8,12-iso-iPF(2α)-VI] measured at one year after intervention. Pre-stressor and post-stressor concentrations of salivary alpha-amylase and salivary cortisol were measured at two years after intervention (median age 28 months). The overall methylation level of the glucocorticoid receptor ( NR3C1 ) exon 1F promoter and the difference in percentage methylation at NGFI-A transcription factor binding site (CpG site 12) in DNA samples were measured at two years. Systolic and diastolic blood pressure and resting heart rate were measured at two years.

Oxidative stress biomarker measurements

F2-isoprostane isomers—iPF(2α)‐III, 2,3‐dinor‐iPF(2α)‐III, iPF(2α)‐VI, and 8,12‐iso‐iPF(2α)‐VI— were quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS) at Duke University as previously described and optimized for the present study 23 , 50 . Urine creatinine (CR) concentration was measured to determine sample volume used for F2-isoprostane analysis. A larger urine volume (300 μL) was used in case of low CR (CR < 0.6 mg/mL; highly diluted urine) to ensure assay sensitivity, a medium volume of urine (200 μL) was used when 0.6 mg/mL <CR < 1 mg/mL, whereas a lower volume (100 μL) was used when CR was high (CR > 1 mg/mL) to decrease the matrix suppression effect on F2-isoprostane signals. To the appropriate volume of urine sample, 20 μL of 1 M HCl, 20 μL of 100 ng/mL internal standard mix [iPF(2α)‐III‐d4, 8,12‐iso‐iPF(2α)‐VI‐d11, iPF(2α)‐VI‐d4], and 1 mL of methyl tert-butyl ether (MTBE) was added and vigorously mixed in FastPrep (Thermo) for 3 × 45 seconds at speed 4. After centrifugation, 800 μL of ether layer was evaporated (nitrogen stream), reconstituted in 50 μL methanol and 70 μL mobile phase A (see below) and 50 μL injected into Shimadzu 20 A series / Applied Biosystems API 4000 QTrap LC/MS/MS instrument. Two C18 columns (Agilent Eclipse Plus, 150 × 4.6 mm and 50 × 4.6 mm, 1.8 µm) in series were used with 0.1% acetic acid as mobile phase A and methanol as mobile phase B delivered as 40–75% B gradient elution over 26 minutes. The mass spectrometer was operated in negative mode with the following MS/MS transitions (m/z): 353/193 [iPF(2α)‐III], 357/197 [iPF(2α)‐III‐d4], 325/237 [2,3‐dinor‐iPF(2α)‐III], 353/115 [iPF(2α)‐VI and 8,12‐iso‐iPF(2α)‐VI], 364/115 [iPF(2α)‐VI‐d11], and 357/115 [8,12‐iso‐iPF(2α)‐VI‐d4]. Lower limits of quantification (LLOQ > 80% accuracy) were 0.063, 0.31, 0.63, and 0.63 mg/mL for iPF(2α)‐III, 2,3‐dinor‐iPF(2α)‐III, iPF(2α)‐VI, and 8,12‐iso‐iPF(2α)‐VI, respectively. The concentration of F2‐isoprostanes was adjusted for urinary creatinine (CR) to account for urine diluteness. Creatinine (CR) was measured after 1/1000 dilution of urine by deionized water, centrifugation, and direct injection into the LC/MS/MS system. Agilent Eclipse Plus 50 × 4.6 mm, 1.8 μm column was used for separation. CR and CR-d3 (internal standard) were measured at m/z = 114/44 and m/z = 117/47, respectively.

Physiological stress and methylation measurements

Pre-stressor and post-stressor salivary alpha-amylase and cortisol were measured following ELISA kit protocols at icddr,b (Salimetrics, Carlsbad, CA). The initial cortisol sample was undiluted, and the initial dilution was 1:200 for salivary alpha-amylase. Out-of-range specimens were rerun at higher or lower dilutions. The coefficient of variation for salivary alpha-amylase and cortisol outcomes was <10%.

Saliva samples that were to be used for the analysis of DNA methylation were collected in Oragene kits (OGR-575) and analyzed by EpigenDx (Hopkinton, MA). EpigenDx performed salivary DNA extraction from Oragene samples, sample bisulfite treatment, PCR amplification, and pyrosequencing and determined percent methylation 51 . Methylation levels were assessed across the entire glucocorticoid receptor ( NR3C1 ) exon 1F promoter (consisting of 39 assayed CpG sites) 52 .

First, DNA was extracted from 200 µL saliva using DNAdvance (Beckman Coulter) with the Biomek FXP liquid handler (Beckman Coulter) at EpigenDx (Hopkinton, MA). The NanoDrop 2000 (Thermo Fisher Scientific) was used to quantify the extracted DNA by OD 260/280.

Next, EpigenDx carried out pyrosequencing of bisulfite-treated DNA. Briefly, 500 ng of extracted genomic DNA was bisulfite treated using the EZ DNA Methylation kit (Zymo Research, Inc., CA). The kit protocol was followed for purification and elution of the bisulfite treated DNA (final elution volume of 46 µL). PCR amplification was achieved using 1 µL of bisulfite treated DNA and 0.2 µM of each primer. To purify the final PCR product using sepharose beads, one primer was biotin-labeled and purified by high performance liquid chromatography.

After being bound to Streptavidin Sepharose HP (GE Healthcare Life Sciences), the immobilized PCR products were purified, washed, denatured with a 0.2 µM NaOH solution, and rewashed using the Pyrosequencing Vacuum Prep Tool (Pyrosequencing, Qiagen), according to the manufacturer’s instructions. The NR3C1 pyrosequencing methylation assay target region is listed in Table  6 .

Purified single stranded PCR products were annealed to 0.5 µM of sequencing primer. Following the manufacturer’s protocol, 10 µL of the PCR products were pyrosequenced on the PSQ96 HS System (Pyrosequencing, Qiagen). QCpG software (Pyrosequencing, Qiagen) was used to analyze the methylation status of each locus (CpG site) individually as an artificial C/T SNP. To calculate the methylation level at each CpG site, the following formula was used: the percentage of methylated alleles divided by the sum of all methylated and unmethylated alleles. To obtain the mean methylation level, the methylation levels of all measured CpG sites within the targeted region of the gene were used. To ensure detection of incomplete bisulfite conversion of the DNA, each experiment used non-CpG cytosines as internal controls. Other controls in each PCR included unmethylated and methylated DNA. To test for bias, unmethylated control DNA was combined with in vitro methylated DNA at several ratios (0%, 5%, 10%, 25%, 50%, 75%, and 100%), the mixed products were bisulfite-modified and underwent PCR, followed by pyrosequencing analysis.

Statistical analysis

The analysis protocol was pre-registered on Open Science Framework on 14 August 2019. The pre-registered analysis protocol and replication files for the substudy are available ( https://osf.io/9573v/ ). For data management, we used STATA version 14.2. Analyses were conducted using R statistical software version 3.6.1. All biomarker distributions were right-skewed and thus log-transformed. Percentages of methylation were also skewed and therefore logit-transformed.

An individual was classified as a responder to the acute stressor if the difference between pre- and post-stressor cortisol concentrations was a positive change of at least two times the lower limit of sensitivity of the assay (0.014 μg/dL) and a change of at least two times the average coefficient of variation between duplicate tests of the same sample (20%). An individual was classified as a non-responder to the acute stressor if the difference between pre- and post-stressor cortisol concentrations was a negative change with the same thresholds outlined above. An individual was classified as no change if the difference between pre- and post-stressor cortisol concentrations was between these two thresholds, where the difference was not larger than the inherent error in the assay.

We used targeted maximum likelihood estimation with influence curve-based standard errors accounting for clustered observations from the trial’s geographic block-randomized design 53 .

The randomization of assignment to trial arm resulted in balance in the observed covariates across arms so the primary analysis was unadjusted. For each comparison between arms, we also conducted two secondary adjusted analyses: adjusting for child age and sex assigned at birth only and adjusting for child, age, sex, and covariates found to be significantly related to each outcome (likelihood ratio test P  < 0.2). Time of sampling was included as a covariate for salivary alpha-amylase and cortisol analyses only. The full list of covariates is included in the footnotes of the tables.

We conducted a prespecified analysis estimating interactions between child sex and the intervention since biological differences, differential care practices, or other behavioral practices may influence the effect of the N + WSH interventions.

To determine whether missing specimen rates were random, we compared rates of missing specimens across arms and compared characteristics of participants with missing specimens and those with full sets. To account for imbalances in missing outcomes across arms and potential bias due to informative censoring, we repeated the adjusted analysis using inverse probability of censoring weighting, using covariates to predict missing outcomes 47 , 48 .

The trial was registered at ClinicalTrials.gov (NCT01590095).

Reporting summary

Further information on research design is available in the  Nature Portfolio Reporting Summary linked to this article.

Data availability

The prespecified, registered statistical analysis plan and deidentified individual participant data generated in this study have been deposited in Open Science Framework ( https://osf.io/9573v/ ). Source data are provided with this paper. The raw DNA sequencing data discussed in this publication have been deposited in NCBI’s Gene Expression Omnibus and are accessible through GEO Series accession number GSE261098 . The raw liquid chromatography-tandem mass spectroscopy data have been deposited in the re3data repository and are accessible ( https://doi.org/10.7924//r49311p2m ). The consort checklist for the study is included in the Supplementary Information.  Source data are provided with this paper.

Code availability

The code and replication files for the study are publicly available on Open Science Framework ( https://osf.io/9573v/ ) and GitHub ( https://github.com/washb-eed-substudies/wash-stress ).

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Acknowledgements

We greatly appreciate the families who participated in the study and the dedication of the icddr,b staff who delivered the interventions and collected the data and specimens. This study was funded by Global Development grant OPPGD759 from the Bill & Melinda Gates Foundation to the University of California, Berkeley [J.M.C.] and by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health [grant number K01AI136885 to A.L.]. icddr,b is grateful to the Governments of Bangladesh, Canada, Sweden, and the United Kingdom for providing core/unrestricted support. National Institute of Health (NIH) / National Cancer Institute (NCI) Comprehensive Cancer Center Grant [grant number P30-CA014236-47 to I.S.] provided support for the Duke Cancer Institute PK/PD Core Laboratory. The funders approved the study design, but were not involved in data collection, analysis, interpretation, or any decisions related to publication. The corresponding author had full access to all study data and final responsibility for the decision to submit for publication.

Author information

These authors contributed equally: Stephen P. Luby, Douglas A. Granger.

Authors and Affiliations

Department of Microbiology and Environmental Toxicology, University of California, Santa Cruz, Santa Cruz, CA, USA

School of Public Health, University of California, Berkeley, Berkeley, CA, USA

Andrew N. Mertens, Lia C. H. Fernald, Lisa Kim, Gabrielle Shuman, Alan E. Hubbard, Patricia Kariger & John M. Colford Jr.

Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh

Md. Ziaur Rahman, Shahjahan Ali, Md. Rabiul Karim, Sunny Shahriar, Syeda L. Famida, Salma Akther, Md. Saheen Hossen, Palash Mutsuddi, Abul K. Shoab, Mahbubur Rahman & Leanne Unicomb

Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA

Sophia T. Tan & Stephen P. Luby

Department of Medicine, Duke University, Durham, NC, USA

Dora Il’yasova & Ivan Spasojevic

PK/PD Core Laboratory, Duke Cancer Institute, Durham, NC, USA

Ivan Spasojevic

Institute for Global Nutrition, University of California Davis, Davis, CA, USA

Christine P. Stewart

EpigenDx Inc., Hopkinton, MA, USA

Liying Yan & Ann Meyer

Francis I. Proctor Foundation, University of California, San Francisco, CA, USA

Benjamin F. Arnold

Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA

Idan Shalev

Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA

Christopher D. Heaney

Institute for Interdisciplinary Salivary Bioscience Research, University of California, Irvine, Irvine, CA, USA

Douglas A. Granger

Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA

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Contributions

A.L. drafted the research protocol and manuscript with input from all listed co-authors; she coordinated input from the study team throughout the project. A.L., A.N.M., M.Z.R., C.P.S., L.C.H., B.F.A., M.R., L.U., A.E.H., I.S., P.K., J.M.C., S.P.L. and D.A.G. developed the interventions and guided interpretation of the results. M.Z.R., D.I., I.S., L.Y., A.M., M.R.K., S.S. and G.S. performed the laboratory analyses. A.L., S.A., C.P.S., L.C.H., B.F.A., A.E.H., S.L.F., S.A., M.S.H., P.M., A.K.S., M.R., L.U., C.D.H., P.K., J.M.C. and S.P.L oversaw study implementation and responded to threats to validity. A.L., A.N.M., S.T.T., D.I., I.S., C.P.S., L.C.H., L.K., L.Y., A.M., B.F.A., A.E.H., I.S., P.K., J.M.C., S.P.L. and D.A.G. developed the analytical approach, conducted statistical analyses, constructed tables and figures, and interpreted results. All authors have read, contributed to, and approved the final version of the manuscript.

Corresponding author

Correspondence to Audrie Lin .

Ethics declarations

Competing interests.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. In the interest of full disclosure, Douglas Granger is the founder and chief scientific and strategy advisor at Salimetrics LLC and SalivaBio LLC and these relationships are managed by the policies of the committees on conflict of interest at the Johns Hopkins University School of Medicine and the University of California at Irvine. Liying Yan is the president of EpigenDx, Inc. Ann Meyer is the Associate Director of Operations at EpigenDx, Inc. The remaining authors declare no competing interests.

Ethics & Inclusion statement

The study complied with all relevant ethical regulations. The research included local researchers and stakeholders throughout the research process. The research is locally relevant as determined in collaboration with local partners at icddr,b. Roles and responsibilities as outlined in the author contributions section were agreed amongst collaborators ahead of the research. Capacity-building was included in all aspects of the research including intervention implementation, data collection, data analyses, laboratory analyses, and manuscript development. The parent trial included plans for local partners to lead and publish manuscripts and to disseminate study findings at conferences and other forums. Study protocols were approved by human subjects committees at the International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b) (PR-11063 and PR-14108), the University of California, Berkeley (2011-09-3652 and 2014-07-6561) and Stanford University (25863 and 35583). icddr,b organized a data safety monitoring committee that oversaw the trial. All researchers on the project have access to all biological materials stored in Bangladesh and the United States. We have taken local and regional research relevant to our study into account in the citations.

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Lin, A., Mertens, A.N., Rahman, M.Z. et al. A cluster-randomized trial of water, sanitation, handwashing and nutritional interventions on stress and epigenetic programming. Nat Commun 15 , 3572 (2024). https://doi.org/10.1038/s41467-024-47896-z

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Published : 26 April 2024

DOI : https://doi.org/10.1038/s41467-024-47896-z

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Water, sanitation and hygiene, we work with government and partners to ensure that every child in india has access to clean water and safe sanitation facilities, and practices good hygiene behaviors.

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Strengthening sustainable WASH programming

India has made rapid progress in ending open defecation across the country, which significantly impacts improving water, sanitation and hygiene (WASH). 

In 2015, nearly half of India’s population of around 568 million people suffered the indignity of defecating in fields, forests, bodies of water, or other public spaces due to a lack of access to toilets. India alone accounted for 90 per cent of the people in South Asia and half of the 1.2 billion people in the world that defecated in the open. 

UNICEF extended the objective of eradicating open defecation to effective solid and liquid waste management in all cities and villages. By 2019, according to the latest estimates, the number of people without access to toilets has reduced significantly by an estimated 450 million people. 

A tremendous achievement, only possible because of the Government’s flagship programme, the Swachh Bharat Mission (SBM) (Clean India Campaign), led by the Prime Minister himself. UNICEF has been a proud partner of the Swachh Bharat Mission , which is now in phase two of its implementation.  

India has made rapid progress in ending open defecation across the country. The number of people defecating in the open in India has reduced significantly by an estimated 450 million people. However, we all need to ensure sustained use of toilets and hygiene practices at all times.  Open defecation has historically been most prevalent among the poorest citizens in the cities or the countryside. 

The risk of spreading diarrheal and waterborne diseases gets compounded by the lack of regular handwashing and microbial contamination of water in their homes and communities. This practice amounted to tonnes of faeces introduced daily into the environment, regularly exposing India’s children to excrement through direct contact. The situation contributed to nearly 100,000 diarrhoeal deaths of children under five years in India. 

Poor sanitation can also have a ripple effect when it hinders national development because workers are suffering from illnesses and living shorter lives, producing and earning less, and unable to afford education and stable futures for their children. Inadequate water, sanitation and hygiene (WASH) services in India’s health facilities contributes to the high neonatal mortality rate, which is currently 24 deaths per 1000 live births. Sepsis – mainly spread in health facilities – contributes to 15 per cent of the overall neonatal mortality and 11 per cent of maternal deaths. Moreover, the risks do not end there when they are brought home to a community that lacks toilets.  (Source: Lancet report 2014)    In India’s schools, reports show that 22 per cent did not have appropriate toilets for girls, 58 per cent of preschools had no toilet at all, and 56 per cent of preschools had no water on the premises.  (Source: Rapid survey on children 2013-14) 

Chemical contamination of water, mainly through fluoride and arsenic, is present in 1.96 million dwellings. Meanwhile, less than 50 per cent of the population has access to safely managed drinking water (located on-premises, available when needed and free of contamination). Moreover, two-thirds of India’s 718 districts are affected by extreme water depletion, and the current lack of water safety and security planning is a significant concern. 

The solution

Collaboration and convergence are a vital feature of the UNICEF Country Programme in India, where WASH is positioned as cross-cutting support contributing towards results in all aspects of a child’s survival, growth and development. 

The WASH programme is also positioned to prevent malnutrition and preventable diseases, reduce neonatal mortality, and improve education outcomes.    UNICEF supports the Government of India’s flagship programmes, including the Swachh Bharat Mission, the Jal Jeevan Mission and WASH in Schools (including preschools called ‘anganwadis’). 

UNICEF also supports WASH in health care facilities and district-wide WASH interventions, supporting planning and implementation and incorporating behaviour change into state and national guidelines and costed plans. 

To support lagging states and districts, UNICEF works in 16 states and 192 districts, technically supports the Government, assists in alternative service delivery approaches, and mobilizes public institutions and partners, including the private sector, around WASH services. 

UNICEF has expanded its programme from rural to urban areas, where the urban poor are often left out of the sanitation equation. 

Monitoring and evaluation for WASH 

WASH programming is grounded in empirical data, rigorous research and thoughtful analysis. To ensure community participation, gender mainstreaming, and efficient programming, all water, sanitation and hygiene (WASH) interventions get supported by social and behaviour change communication (SBCC. 

The interventions are also supported by monitoring and evaluation (M&E) and knowledge management (KM) frameworks.  

India has accelerated its efforts over the past five years to assure its citizens, especially children, the right to WASH services. The monitoring process for the India Country Office includes internal monitoring based on the five-year country programme. 

The process includes external monitoring, primarily for donors and external partners, and system monitoring, referring to the support extended to government partners for setting up monitoring systems such as management information systems, online applications, and dashboards. 

Menstrual hygiene management in schools in South Asia

This report gives a country snapshot of MHM in India.

Report on environmental impact of Swachh Bharat Mission

UNICEF and the Ministry of Drinking Water and Sanitation, with support from Shri Ram Institute, conducted an assessment.

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मुझे उम्मीद है कि मेरी कहानी युवा लड़कियों को अलग सोचने के लिए प्रेरित करेगी

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HEALTHY BABIES, HAPPY PARENTS, ENERGISED HEALTH WORKERS

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UNICEF partners with Maharashtra government to deliver routine immunization to the most vulnerable children of nomadic communities

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India’s Water and Sanitation 3.0: A Blueprint for Sustainable Development

Photo: Amarjeet Kumar Singh/Anadolu/Getty Images

Commentary by Bhawna Prakash

Published April 25, 2024

This summer, 969 million Indians will vote for their national government. From increasing access to portable water to widescale implementation of hygiene promotion programs, Prime Minister Modi’s government has made commendable efforts since 2014. However, the new government will face the challenge of establishing robust water and sanitation delivery mechanisms amid escalating climate crises and water shortages . These systems must ensure universal, equitable, affordable, sustainable, and safely managed services, as envisioned under the United Nations’ Sustainable Development Goal 6 . To address this challenge, the government should implement a revamped water, sanitation, and hygiene (WASH) program focusing on three strategic priorities: performance enhancement and system reforms, a thriving WASH market for the private sector, and integrated planning and management.

The Journey So Far

In the last decade, India made strategic WASH investments through national missions. The first iteration, “WASH 1.0” (2014–19), prioritized basic sanitation to address the dignity of millions and launched the Swachh Bharat Mission (SBM) across urban and rural areas. Notably, SBM Rural built over 100 million household toilets and 230,000 community and public toilets between 2014 and 2019.

“WASH 2.0” (2019–24) introduced water as a strategic focus. The budget for SBM Urban increased from $7.6 billion for 2014–19 to $17.3 billion for 2021–26. The Jal Jeevan Mission achieved significant progress in portable water access. Additionally, the Atal Mission for Rejuvenation and Urban Transformation (AMRUT) focused on basic urban infrastructure, including WASH for cities with populations exceeding 100,000.

India requires further enhancements in solid waste processing. Embracing circularity across value chains and wastewater treatment are necessary. Additionally, as India elects the new government, the focus must be on WASH systems and markets.

The Road Ahead: WASH 3.0

The incoming government should double down on its efforts, broaden their scope, and execute three strategic imperatives as part of a “WASH 3.0” program:

Prioritize performance enhancement and system reforms . Most water, wastewater, and waste services are provided by government bodies. Inadequate data and reporting limits their assessment. These agencies should be required to regularly publish detailed operational, financial, and management data. The sustainability of these services hinges on their ability to recover costs, whether partially or in full, and to demonstrate operational excellence. Accountability for financial performance is crucial.

The government must prioritize service charge recovery to prevent waste of valuable resources. Pricing decisions tend to be influenced by political economy. While ensuring equitable WASH for all, the government can selectively implement recovery mechanisms in progressive cities, balancing value recognition with public goods. Addressing the issue of “non-revenue water”—water that remains unbilled—would significantly enhance the sector’s financial health.

Responsible governance, accountability, and transparency are vital in the sector, further necessitating an evaluation of an economic regulator for WASH.

Create a thriving WASH market for the private sector . Water and sanitation are not only public responsibilities but also economic opportunities. By fostering a vibrant WASH market, India can unlock innovation, efficiency, and accountability. While public funds have driven water and sanitation initiatives, limited private sector involvement exists through corporate social responsibility and some public-private partnerships. The government should strengthen private sector participation by leveraging the recent surge of start-ups in the sector and companies committed to environmental, social, and governance (ESG) investments. Energy, transport, consumer goods, cement, construction, infrastructure, and technology companies can play a critical role by emphasizing resource efficiency, developing a circular economy, and optimizing supply chains.

WASH 3.0 should adopt a market-based approach, incentivizing micro, small, and medium enterprises (MSMEs) and community-based initiatives. Forming innovative financing partnerships with development financial institutions (DFIs) and philanthropic organizations, in addition to leveraging civic and IT innovations, will be crucial. The government should primarily play an enabling role, setting policy and enforcing it.

The future of the sector hangs in the balance. Is India ready for privatization of WASH utilities and services? As the government evaluates this question, it must confront the challenges of delayed payments, regulatory approvals, contractual risks, working capital gaps, inadequacy of trained resources, and safety concerns.

Integrate planning and management . A unified approach is needed to break silos to forge a resilient and interconnected system of water, sanitation, wastewater, and waste. The water shortages in Bangalore and Chennai are glaring examples of WASH emergencies exacerbated by climate change and the inefficacy of erstwhile water management approaches.

Integrated water planning often gets lost amid the complexity of multiple government schemes, departments, and silos. To address this, the government should envision an integrated water-security management platform for cities and states to bridge gaps between agencies, fostering collaboration and improving planning. Through this new platform, states should prioritize water security, ensuring safe water and sanitation services across regions while breaking down operational barriers.

A digitized view encompassing water sources, deployment, usage, infrastructure, costs, and charges is urgently needed. For instance, in water-scarce Rajasthan, responsibilities are divided: the Public Health and Engineering Department handles infrastructure, the Water Resource Department oversees canals and dams, and the Panchayati Raj Department manages rural sanitation and wastewater. An integrated approach to optimize planning and ensure safe water supply for newly constructed taps is essential.

For WASH 3.0, the challenges lie in effective resource management. While water remains a public good that is critical for India’s growth, performance enhancement and private sector participation can alleviate sectoral pressures. To achieve India’s $5 trillion economy vision, valuing water—both fresh and wastewater—is paramount. Initiating progressive discussions on planning, resourcing, and management is imperative for a sustainable future.

Bhawna Prakash is a non-resident fellow with the Chair in U.S.-India Policy Studies at the Center for Strategic and International Studies in Washington, DC.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2024 by the Center for Strategic and International Studies. All rights reserved.

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