"The current water and sanitation situation in Zimbabwe faces many challenges around capacity, behaviours and the lack of investment in these sectors during and after the economic crisis of the last decade. Access to clean water is a basic right that is important for the survival of humanity yet it can be one of the hardest resources to attain." UNICEF.ORG
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- Written by: Nkeka P. Tseole ,Tafadzwa Mindu,Chester Kalinda,Moses J. Chimbari
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Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: A scoping review
Abstract
A healthy and a dignified life experience requires adequate water, sanitation, and hygiene (WaSH) coverage.
However, inadequate WaSH resources remain a significant public health challenge in many communities in Southern Africa. A systematic search of peer-reviewed journal articles from 2010 –May 2022 was undertaken on Medline, PubMed, EbscoHost and Google Scholar from 2010 to May 2022 was searched using combinations of predefined search terms with Boolean operators.
Eighteen peer-reviewed articles from Southern Africa satisfied the inclusion criteria for this review.
The general themes that emerged for both barriers and facilitators included:
- geographical inequalities;
- climate change{?}:
- investment in WaSH resources:
- low levels of knowledge on water borne-diseases and:
- ineffective local community engagement:
Key facilitators to improved WaSH practices included improved WaSH infrastructure
- effective local community engagement
- increased latrine ownership by individual households
- and the development of social capital
.Water and sanitation are critical to ensuring a healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities due to lack of WaSH infrastructure compared to urban settings. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in SDG 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments in WaSH infrastructure, inadequate knowledge on water-borne illnesses and lack of community engagement.
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- Written by: Duncan Mara,Jon Lane,Beth Scott,David Trouba
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Sanitation and Health
Citation: Mara D, Lane J, Scott B, Trouba D (2010) Sanitation and Health. PLoS Med 7(11): e1000363. https://doi.org/10.1371/journal.pmed.1000363
Published: November 16, 2010
Copyright: © 2010 Mara et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No funding sources were used to write this article.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: CLTS, community-led total sanitation; DALY, disability-adjusted life year; MDG, Millennium Development Goal
Provenance: Not commissioned; externally peer reviewed.
Summary Points
- 2.6 billion people in the world lack adequate sanitation—the safe disposal of human excreta. Lack of sanitation contributes to about 10% of the global disease burden, causing mainly diarrhoeal diseases.
- In the past, government agencies have typically built sanitation infrastructure, but sanitation professionals are now concentrating on helping people to improve their own sanitation and to change their behaviour.
- Improved sanitation has significant impacts not only on health, but on social and economic development, particularly in developing countries.
- The health sector has a strong role to play in improving sanitation in developing countries through policy development and the implementation of sanitation programmes.
This is one article in a four-part PLoS Medicine series on water and sanitation. Part 2 CLICK; Part 3 Click and Part 4 Click
Introduction and Definitions
Adequate sanitation, together with good hygiene and safe water, are fundamental to good health and to social and economic development. That is why, in 2008, the Prime Minister of India quoted Mahatma Gandhi who said in 1923, “sanitation is more important than independence” [1]. Improvements in one or more of these three components of good health can substantially reduce the rates of morbidity and the severity of various diseases and improve the quality of life of huge numbers of people, particularly children, in developing countries [2],[3]. Although linked, and often mutually supporting, these three components have different public health characteristics. This paper focuses on sanitation. It seeks to present the latest evidence on the provision of adequate sanitation, to analyse why more progress has not been made, and to suggest strategies to improve the impact of sanitation, highlighting the role of the health sector. It also seeks to show that sanitation work to improve health, once considered the exclusive domain of engineers, now requires the involvement of social scientists, behaviour change experts, health professionals, and, vitally, individual people.
Throughout this paper, we define sanitation as the safe disposal of human excreta [4]. The phrase “safe disposal” implies not only that people must excrete hygienically but also that their excreta must be contained or treated to avoid adversely affecting their health or that of other people.
Health Impacts of Sanitation
Lack of sanitation leads to disease, as was first noted scientifically in 1842 in Chadwick's seminal “Report on an inquiry into the sanitary condition of the labouring population of Great Britain” [5]. A less scientifically rigorous but nonetheless professionally significant indicator of the impact on health of poor sanitation was provided in 2007, when readers of the BMJ (British Medical Journal) voted sanitation the most important medical milestone since 1840 [6].
The diseases associated with poor sanitation are particularly correlated with poverty and infancy and alone account for about 10% of the global burden of disease [7]. At any given time close to half of the urban populations of Africa, Asia, and Latin America have a disease associated with poor sanitation, hygiene, and water [8].
Of human excreta, faeces are the most dangerous to health. One gram of fresh faeces from an infected person can contain around 106 viral pathogens, 106–108 bacterial pathogens, 104 protozoan cysts or oocysts, and 10–104 helminth eggs [9]. The major faeco-oral disease transmission pathways are demonstrated in the “F Diagram” (Figure 1) [10], which illustrates the importance of particular interventions, notably the safe disposal of faeces, in preventing disease transmission.
Diarrhoeal Diseases
Diarrhoeal diseases are the most important of the faeco-oral diseases globally, causing around 1.6–2.5 million deaths annually, many of them among children under 5 years old living in developing countries [11],[12]. In 2008, for example, diarrhoea was the leading cause of death among children under 5 years in sub-Saharan Africa, resulting in 19% of all deaths in this age group [13].
Systematic reviews suggest that improved sanitation can reduce rates of diarrhoeal diseases by 32%–37% [14]–[16]. While many of the studies included in those reviews could not rigorously disaggregate the specific effects of sanitation from the overall effects of wider water, sanitation, and hygiene interventions, a longitudinal cohort study in Salvador, Brazil, found that an increase in sewerage coverage from 26% to 80% of the target population resulted in a 22% reduction of diarrhoea prevalence in children under 3 years of age; in those areas where the baseline diarrhoea prevalence had been highest and safe sanitation coverage lowest, the prevalence rate fell by 43% [17]. Similarly, a recent meta-analysis that explored the impact of the provision of sewerage on diarrhoea prevalence reported a pooled estimate of a 30% reduction in diarrhoea prevalence and up to 60% reduction in areas with especially poor baseline sanitation conditions [18]. Another longitudinal study in urban Brazil found that the major risk factors for diarrhoea in the first three years of life were low socioeconomic status, poor sanitation conditions, presence of intestinal parasites, and absence of prenatal examination. The study concluded that diarrhoeal disease rates could be substantially decreased by interventions designed to improve the sanitary and general living conditions of households [19].
Further, it is not just the provision and adult use of sanitation that is important. A meta-analysis of observational studies of infants' faeces disposal practices found that unsafe disposal increased the risk of diarrhoea by 23%, highlighting the importance of the safe management of both adults' and infants' faeces [20].
Neglected Tropical Diseases
Neglected tropical diseases, while resulting in little mortality, cause substantial disability-adjusted life year (DALY) losses in developing countries [21]. Many of these diseases have a faeco-oral transmission pathway. Thus, improved sanitation could contribute significantly to a sustained reduction in the prevalence of many of them, including trachoma, soil-transmitted helminthiases, and schistosomiasis. Unfortunately, the current policy focus in most parts of the world is on treatment by medication, which, unlike good sanitation, is not a preferred solution because, in part, it is much more expensive.
Trachoma is endemic in many of the world's poorest countries. It is caused by the bacterium Chlamydia trachomatis and is the world's leading cause of preventable blindness [22]. Trachoma control is predominantly antibiotic-based despite the existence of the SAFE control strategy (surgery, antibiotics, face-washing, and environmental measures, namely sanitation promotion) [23],[24]. However, a recent cluster-randomised control trial in Ghana found that the provision of toilets reduced appreciably the number of Musca sorbens flies (the vector for trachoma) caught on children's eyes and by 30% the prevalence of trachoma, thus confirming the long-suspected role that sanitation could play in the control of trachoma [25].
Soil-transmitted helminths such as the large human roundworm, the human whipworm, and the human hookworms cause many millions of infections every year and many individuals are infected with more than one of these geohelminths [26]. Helminthic infections negatively impact the nutritional status of infected individuals, with consequent growth faltering in young children, and anaemia, particularly in pregnant women [27],[28]. Adult helminths live in the human gastrointestinal tract where they reproduce sexually. Their eggs are discharged in the faeces of the infected host and thus, mainly via open defecation, to other people. Ending the practice of open defecation with good sanitation can cut this transmission path completely, but most current helminth-control programmes focus on medication, which must be repeated periodically in the absence of sanitation [28],[29].
Globally, some 190 million people are infected with schistosomiasis, which can result in chronic debilitation, haematuria, impaired growth, bladder and colorectal cancers, and essential organ malfunction [28]. Adult schistosomes live in the portal veins where they pass their eggs into the environment via the urine (Schistosoma haematobium) or faeces (the other human schistosomes). After passing part of their life cycle in aquatic snails where they multiply asexually, cercariae are discharged into the water where they come into contact with and infect their human hosts through their skin. Thus, sanitation (and water) interventions are essential to any long-term control and elimination of schistosomiaisis, whereas the current standard intervention is repeated medication [29].
Acute Respiratory Infections
With 4.2 million deaths each year (1.6 million among children under 5 years), acute respiratory infections are the leading cause of mortality in developing countries [30],[31]. Although sanitation is not directly linked to all acute respiratory infections, a recent study reported that 26% of acute lower respiratory infections among malnourished children in rural Ghana may have been due to recent episodes of diarrhoea [32]. Thus, sanitation could be a powerful intervention against acute respiratory infections.
Wider Benefits of Sanitation
In addition to its impact on health, improved sanitation generates both social and economic benefits. Householders understand these wider benefits [36] but scientists have only recently begun to study individuals' motivations for improving sanitation and changing sanitation behaviour.