The Impact of Water, Sanitation and Hygiene On Key Health and Social Outcomes

THE IMPACT OF WATER, SANITATION AND HYGIENE
ON KEY HEALTH AND SOCIAL OUTCOMES:

REVIEW OF EVIDENCE
Joanna Esteves Mills & Oliver Cumming
JUNE 2016
Photo on front cover:
Women from Podumkhana village collect water from a pump designed by UNICEF
(India, 2009) | © UNICEF/UNI79307/Pietrasik
Acknowledgements
DFID Evidence Paper
Sanitation and Hygiene Applied Research for Equity (SHARE)

consortium reviewers: Alexandra Chitty, London School of
Hygiene & Tropical Medicine, Erin Flynn, London School of Hygiene
& Tropical Medicine
UNICEF advisors: Sue Cavill, Greg Keast, Cindy Kushner
External reviewers: Lenka Benova, London School of Hygiene &

Tropical Medicine, Sandy Cairncross, London School of Hygiene &
Tropical Medicine, Alan Dangour, London School of Hygiene & Tropical
Medicine, Robert Dreibelbis, University of Oklahoma, Jeroen Ensink,
London School of Hygiene & Tropical Medicine, Matthew Freeman,
Emory University, Andrew Prendergast, Queen Mary University of
London, Marni Sommer, Columbia University Mailman School of Public
Health, Dawn Taylor, Medecins Sans Frontierés, Belen Torondel,
London School of Hygiene & Tropical Medicine, Jane Wilbur, WaterAid
Editors: Vina Barahman, Phillip Poirier
Contributors
This material has been funded by UK aid

from the Department for International
Development (DFID). However, the view
expressed do not necessarily reflect the
Department’s official policies.
Contents
Acknowledgements 1
Acronyms 5
Executive summary 6
Introduction 9
Aims 9
Interpreting the evidence on WASH 11
Review methods 13
WASH and diarrhoea 15

The problem 15
How does WASH influence diarrhoeal diseases? 16
Recent updates in knowledge
What don’t we know? 22
Ongoing studies 23
Conclusion 24
WASH and undernutrition 25

The problem 25
How does WASH influence childhood undernutrition? 26
Ongoing studies 30
Conclusion 31
WASH and complementary food hygiene 32

The problem 32
How does WASH influence complementary food hygiene? 32
Ongoing studies 34
Conclusion 35
The Impact of WASH on Key Health & Social Outcomes • PAGE 2

EVIDENCE PAPER • The Impact of WASH on Key Health & Social Outcomes
WASH, violence against women and girls,

and female psychosocial stress 36
The problem 36
How does WASH influence violence and psychosocial stress? 37
Ongoing studies 42
Conclusion 42
WASH and maternal and newborn health 44

The problem 44
How does WASH influence maternal health? 46
Ongoing studies 50
Conclusion 50
WASH and menstrual hygiene management 52

The problem 52
How can WASH support safe MHM? 52
Ongoing studies 56
Conclusion 56
WASH and school attendance 58

The problem 58
How does WASH influence school attendance? 58
Ongoing studies 61
Conclusion 62

WASH and Oral Vaccine Performance 63

The problem 63
How might WASH influence vaccine performance? 63
Ongoing studies 64
Conclusion 65
WASH and neglected tropical diseases 67

The problem 67
How does WASH influence NTDs transmission? 68
Ongoing studies 72
Conclusion 73
WASH and disability 74

The problem 74
WASH and disabilities 75
Ongoing studies 80
Conclusion 80
References 82

Acronyms
CRPD Convention on the Rights of Persons with Disabilities
DALYs Disability-adjusted life years
DFID UK Department for International Development
DHS Demographic and Health Survey
EED Environmental Enteric Dysfunction
ETEC Enterotoxigenic Escherichia coli
GBV Gender-based violence
HP Hygiene promotion
HWWS Handwashing with soap
IASC Inter-Agency Standing Committee
MDA Mass drug administration
MDGs Millennium Development Goals
MHM Menstrual hygiene management
MHPSS Mental health and psychosocial support
MM Maternal mortality
NTDs Neglected tropical diseases
POU Point-of-use
PPSSP Programme de Promotion des Soins de Santé Primaires
RCT Randomized controlled trial
RV Rotavirus vaccine
SDGs Sustainable Development Goals
STH Soil-transmitted helminth
UNICEF United Nations Children’s Fund
VAWG Violence against women and girls
WASH Water, sanitation and hygiene
WHO World Health Organization
WinS WASH in schools
WT Water treatment

Executive summary
This evidence paper looks at 10 areas identified collaboratively
with the United Nations Children’s Fund (UNICEF) on which
WASH can plausibly have a strong impact: diarrhoea, nutrition,
complementary food hygiene, female psychosocial stress, violence,
maternal and newborn health, menstrual hygiene management,
school attendance, oral vaccine performance, and neglected
tropical diseases. Together, these areas cover the most significant
sector outcomes associated with the distinct life course phases1
that UNICEF seeks to help to address through its WASH activities.
UNICEF’s strategic vision on WASH is to achieve universal and
sustainable water and sanitation services and the promotion of
hygiene, with a focus on reducing inequalities especially for the
most vulnerable children, wherever they are; both in times of
stability and crisis.
The paper highlights a number of points where evidence-based
consensus has been established, or is emerging in these areas, and
these are summarized here:
1. D
espite discussion in recent years around the best approach
for estimating the proportion of the diarrhoeal disease burden
attributable to poor WASH, there is strong consensus that that
the majority of this disease burden is due to poor WASH;
2. W
ASH plausibly influences child growth in multiple ways.
While the magnitude of effect for WASH interventions on
undernutrition is less clear, there is a strong and growing
consensus, in both the WASH and nutrition sectors, that WASH is
an essential component of strategies to reduce undernutrition,
and that efforts should be concentrated on the first 1000 days—
from conception to a child’s second birthday;
3. Inadequate food hygiene practices can lead to high levels of
microbial contamination of food, and interventions focusing on
critical control points may reduce this contamination. While we
need to better understand how to change behaviour sustainably
through such interventions, and to assess their impacts on
child health, there is growing consensus on the importance
of integrating food hygiene components into both WASH and
nutrition programmes;
1 A
dolescence; Pregnancy; Delivery and 0.7 days newborn; Post-natal to one year; Childhood
(1-5 years); School age children.

4. A
lthough the evidence base remains largely qualitative in
nature, it is increasingly accepted that inadequate access to
WASH can expose vulnerable groups—particularly women and
girls—directly to violence. This may cause psychosocial stress
due to the perceived threat of such violence, adding to other
causes of psychosocial stress such as the perceived threat of
harassment, or the threat of being unable to meet basic needs;
5.WASH plausibly affects maternal and newborn health through
multiple direct and indirect mechanisms, and WASH coverage
in delivery settings in low and middle-income countries
is extremely low. There is a consensus that safe WASH in
health facilities—and in other delivery settings—is critical for
accelerated progress on maternal and newborn health;
6. F
urther rigorous research is needed on the impact of poor
MHM on social and health outcomes, but the challenges and
barriers associated with MHM among schoolgirls and women
are well documented through qualitative studies. Few would
contest that a girl or woman without access to water, soap,
and a toilet, whether at home, school, or work, will face great
difficulties in managing her menstrual hygiene effectively
and with dignity. Furthermore, there is consensus on what is
required to enable safe, dignified management of menstrual
hygiene: knowledge, materials and facilities;
7. In many countries, it has been reported that poor WASH
facilities act as a barrier to student attendance and enrolment.
This affects girls in particular, but especially girls post-
menarche, when their MHM needs may not be addressed. Until
recently, there was little robust evidence to support this but
there has now been a least one rigorous intervention study
supporting the positive effect of improved WASH on school
attendance—for both boys and girls—when services are well
designed and managed. In addition, there is a growing body of
evidence around successful approaches to increasing access to
WASH in schools;
8. W
hile the evidence for the impact of WASH on oral vaccine
performance is only suggestive and further research is needed
to demonstrate its effect, there is a recognition that routine
immunization campaigns may be a useful entry point for
promoting safe hygiene among caregivers;

9. While investments to address NTDs remain largely focused on

treatment measures such as mass drug administration (MDA)
campaigns, there is strong consensus, supported by good
evidence, that WASH plays an important role in preventing the
transmission of these diseases;
10. The distribution of WASH-related mortality and morbidity
is inequitable, and falls disproportionately on the poor, on
women and on children. There is a clear consensus that for
WASH policy and programmes to be effective, they must
address this inequality.
For each area, the most recent updates in knowledge are presented,
as well as persisting knowledge gaps and ongoing studies where
relevant, and the evidence is assessed and rated according to an
established methodology (articulated in sections 1.2 and 1.3). In
essence, the evidence reviewed in this paper has been graded as
‘good’, ‘suggestive’, or ‘weak’, as per the criteria below:
• Good evidence: several good quality studies showing a consistent
effect. For example, randomized trials with a low risk of bias,
or observational studies showing a large effect size with a low
potential for confounding;
• Suggestive evidence: some studies show an effect, but the
statistical support is weak due to insufficient study size. Or studies
show significant effects, but there is a risk of bias and confounding
due to study design;
• Weak evidence: no studies have been done, or where they have
been done, they have shown inconclusive results.
While the structure and content of this evidence paper has been
tailored to support the development of the new UNICEF’s Strategy
for WASH 2016-2030 - by providing a concise overview of the present
evidence base on the influence of WASH on number of key health
and social outcomes, it has broader relevance to the WASH sector as
a whole, and, in some cases, to other sectors.

Introduction
Aims
This paper was commissioned by UNICEF and undertaken by the
DFID-funded Sanitation and Hygiene Applied Research for Equity
(SHARE) research programme consortium.
This evidence paper aims to provide evidence for specific elements
of UNICEF’s forthcoming WASH Strategy, 2016-2030. In particular, it
seeks to present the evidence on the importance of WASH to other
outcomes beyond child diarrhoea.
A key rationale for investing in WASH is the importance of WASH
to other Sustainable Development Goal (SDG) outcomes. The
essential inputs that the WASH sector provides, in the form of
services and hygiene promotion, have multiple impacts beyond
the WASH outcome itself, such as nutritional status, or education.
Furthermore, these far-reaching effects of WASH can be felt beyond
the immediate impact, can have a cumulative effect throughout the
life course of an individual, and can often also affect the lives of
their offspring (Ben-Shlomo & Kuh, 2002; Campbell et al., 2014).
This paper describes the contribution of WASH to outcomes in other
sectors and summarises the evidence for investment in these areas.
The paper considers the following outcomes to which UNICEF is
committed: diarrhoea, nutrition, complementary food hygiene,
violence and female psychosocial stress, maternal and newborn
health, MHM, school attendance, oral vaccine performance, NTDs,
and disability.
With this in mind, the objectives of this evidence paper are
specifically to:
• Review the best available evidence with regard to strategic
priorities of UNICEF;
• Provide an accessible guide to existing evidence on how WASH
can affect women and child health and well-being and other
development outcomes, with a particular focus on outcomes that
include but go beyond those traditionally measured by the WASH
sector (see below for topics);
• Present the available evidence on the benefits of WASH
interventions on health;
• Identify what we do and do not know, and assess the robustness
of the available evidence relating to the impact of WASH and the
effect of WASH interventions on these outcomes.

This evidence paper does not make specific recommendations on

what UNICEF should or should not do, but instead identifies key
points for consideration in defining and implementing UNICEF’s
Strategy for WASH 2016-2030 in the following areas:
1. Assessing the scale of the problem

2. Evidence of impact
3. Evidence of what works
4. Remaining knowledge gaps
To achieve this, each thematic chapter addressing a different

outcome will cover:
1. The problem: The extent to which this issue affects child
health and well-being;
2. Can WASH have an impact?: An assessment of the plausible
impact of WASH;
3. The effect of WASH interventions: A review of the evidence
specifically for the effects of WASH interventions.
© UNICEF/UNI47396/Pirozzi
Liberia, 2007. A girl carries a large pail of water, outside her school in the village of Selega in
the north-central Lofa County.

Interpreting the evidence on WASH

WASH brings together several interventions, which are frequently
implemented by multiple agencies, often delivered separately but
sometimes together. These interventions affect a wide range of
direct outcomes, beyond just health outcomes. As a result, the
evidence is complex and, therefore, difficult to classify.
Nonetheless, expectations on the quality of evidence needed to
justify interventions have increased in recent years, and consensus
has formed around rules of best practice for analysis, weighing and
combination of such evidence.
In many policy-making domains, the systematic review and the
Randomized Controlled Trial (RCT) have emerged as the gold
standard for quality of evidence as they are judged to reduce
systematic error – or bias – to the greatest extent possible (Jüni
et al., 2001). However, aside from RCTs and their meta-analysis,
there are a wide range of observational study designs, including
ecological, cohort, cross-sectional and case-control studies, some
of which do not have a specified intervention and/or control.
Increasingly in the WASH sector, various econometric methods are
also being employed to interrogate cross-sectional and longitudinal
data to address important questions (Spears, 2012).
Beyond this, there are of course a wide range of qualitative
approaches which can be employed in isolation or in combination
with quantitative methods, and which are essential to many
areas of research, in particular those which are highly sensitive.
For example, eliciting information from people about violence –
possibly of a sexual nature – experienced while tending to their
urinary, defecation or MHM needs, can be a difficult process,
provoking feelings of shame or inadequacy. Beyond these methods
and approaches, a very broad range of research disciplines is
actively engaged in WASH research; epidemiologists, economists,
microbiologists, geographers, anthropologists, statisticians,
and engineers, to name but a few. As a result of this, the WASH
literature may be unwieldy, but it is rich and voluminous, reflecting
the broad challenge of delivering interventions which require both
changes in infrastructure and in behaviour, and which influence
people’s lives in many different ways.
Assessing the quality of such a body of evidence is difficult to do
objectively. The GRADE approach uses algorithms for weighing and
combining evidence from these different levels (Guyatt et al.,
2008) to reduce the partiality of human judgement in an objective
manner. However, careful consideration is required to interpret the

outcome of GRADE when navigating questions with high biological

plausibility, but where very few intervention studies have been
conducted. Four specific challenges relating to the WASH literature
should be highlighted:
1. S
ubjective outcomes: There are ethical and logical arguments
against studies using the principal health outcome of interest:
death from diarrhoea. However, the alternative outcomes,
particularly self-reported diarrhoea morbidity, have proven
to be more subjective and subject to bias than was originally
believed. For example, the 2007 systematic review on point-
of-use (POU) water treatment by Clasen and colleagues drew
the conclusion from nearly 40 rigorous RCTs that drinking water
quality improvements were associated with reductions of nearly
50% in diarrhoea rates. However, when the handful of blinded
studies were isolated they showed no impact on diarrhoea –
suggesting that the overall impact may have resulted from a
placebo effect or courtesy bias (Schmidt & Cairncross, 2009).
This weakness in the evidence base is relevant to any behaviour
change intervention for which, by its very nature, allocation
cannot usually be blinded.
2. L
ogistical challenges of randomization: There are political,
ethical and practical complications associated with randomising
an intervention like water supply and sanitation, or even
allocating it by individual household. This is because of the
much appreciated non-health benefits of WASH—for example,
time saved on water collection (Churchill et al., 1987)—and
the impossibility of providing water and sanitation without the
knowledge of the studied population.
3. C
omplex exposure-outcome relationship: In addition to the
three basic dimensions of WASH, there are various levels of
service and a variety of combinations of the three. For example,
practically every intervention study of sanitation is in fact a
study of water and sanitation.
4. Importance of context: A standpipe isolated in the desert is a
different level of service from a standpipe in a village where half
the households already have household connections. Quite apart
from the variation in technology between different settings,
there are often important differences in programme design
and execution; hygiene promotion implemented effectively in
one setting may have been much less effective in another. An
epidemiological study in this sector is thus meaningless unless it
is seen in the context of the setting in which it was carried out.

There is clearly a tension that exists between achieving internal

and external validity that should be taken into account when
designing studies. If a study is to provide high-quality evidence
of health impact, it must be designed to exacting standards of
rigour, eliminating the potential for confounding and for bias due
to extraneous factors. However, often the more ‘rigorous’ the
study the more it achieves internal validity, potentially at the
cost of becoming less relevant to the wider context and existing
programmes and policy issues.
Box 1: Bradford Hill’s ‘viewpoints’ for assessing causality

1. Consistency – in a systematic review the 6. Coherence – (i.e. laboratory and epidemiology
impact was similar for the more rigorous results cohere) – more faecal bacteria in
studies (Curtis & Cairncross, 2003); drinking water is associated with more
frequent diarrhoea (Moe et al., 1991);
2. S
trength of association – in a study focused
on domestic transmission of a single pathogen, 7. Biological plausibility – given the number of
handwashing prevented 85% of secondary faecal pathogens present in a community’s
cases (Khan, 1982); waste, it is not surprising that excreta
disposal helps to prevent excreta-related
3. T
emporal sequence – handwashing by mothers disease (Feachem et al., 1983);
just before preparing the family’s food has a
greater impact than at other times (Luby et 8. Analogy – in particular, sanitation helps to
al., 2011); prevent intestinal worm infections; it can
therefore be expected to prevent transmission
4. D
ose response – one study found the impact of other faecal pathogens, such as those
of a sewer system construction project on causing diarrhoea;
diarrhoea in a neighbourhood increased with
the proportion of households connected to the 9. Experimental evidence – this refers to
sewers (Barreto et al., 2007); intervention studies, ideally randomized
trials, many of which have been carried out
5. Specificity – for example, water treatment for household water treatment.
affects diarrhoea, but not malaria;
Review methods
This evidence paper is not a systematic review. Our methods have been
heuristic, based on existing systematic reviews where possible and
exploratory reviews on a range of topics, and supplemented with more
recent studies. Wherever possible, we rely on published systematic
review-based meta-analyses to estimate the magnitude of effect for a
given WASH intervention on a given outcome.
This paper takes a broad perspective, allowing for a range of exposures
and outcomes, a variety of settings in which studies have been carried
out and the application of judgement based on an assessment of
the available evidence. In assessing causal evidence, our approach

was generally informed by the criteria or ‘viewpoints’ famously

proposed by Bradford Hill (1965). Box 1 broadly illustrates these,
with reference to WASH. For the purpose of this evidence paper,
we have used a pragmatic set of five applied viewpoints from which
to appraise the evidence base for WASH interventions. That is,
whereas Bradford Hill’s viewpoints are for assessing the evidence
for causality in an association, the following viewpoints are used in
this paper to appraise the strength of support for implementation
of each intervention. The first viewpoint is internal validity, which
assesses the rigour of the studies demonstrating cause and effect,
including randomization, blinding, etc. The second assesses the ease
of going to scale, which requires relevance to programme conditions
in the field. The third looks at the sustainability of the intervention,
assuming reasonable effort is devoted to maintaining it. The fourth
and fifth evaluate other substantial health benefits in addition to
impact on diarrhoea and significant non-health benefits respectively.
For this evidence paper, we have been asked to show which
relationships are supported by firm evidence and which by relatively
weak evidence. Throughout this paper, we consider the type of
evidence but also seek to grade the strength of the evidence
according to the following three categories:
•G
ood evidence: several good quality studies consistently show
an effect. For example, randomized trials with a low risk of bias,
or observational studies showing a large effect size with a low
potential for confounding;
•S
uggestive evidence: studies show an effect, but statistical
support is weak due to insufficient study size. Or studies show
significant effects, but there is a risk of bias and confounding;
• Weak evidence: no studies have been done, or where they been
done, they have shown inconclusive results.

WASH and diarrhoea

The problem
Diarrhoea is defined as the passage of three or more loose or
liquid stools per day (World Health Organization [WHO], 2013). But
globally, diarrhoeal diseases are caused by infectious agents such as
bacteria (e.g. E. coli, salmonella, shigella, campylobacter), viruses
(e.g. rotaviruses, noroviruses and adenoviruses), and protozoa (e.g.
cryptosporidium, amoeba and giardia). However, the aetiology of
diarrhoeal diseases varies from region to region. Rotavirus is the
main cause of severe and moderate diarrhoea (Lozano et al., 2013;
Kotloff et al., 2014). Only a small proportion of diarrhoea cases
result from non-infectious conditions (such as intoxication or non-
infectious inflammatory diseases) (WHO).
Most diarrhoeal deaths are among children under the age of five
(Prüss-Üstün et al., 2014), and within low-income countries, the
very poor suffer much more from diarrhoea than others (Howling &
Kunst, 2010). In both low and middle-income countries, diarrhoeal
disease is the second leading cause of morbidity and mortality
among children under the age of five (Lim et al., 2012; Walker et
al., 2013; Murray et al., 2015), and the leading cause of death in
sub-Saharan Africa (Prüss-Üstün et al., 2014). Approximately 1.5
million children under the age of five died of diarrhoeal disease in
2012 (Prüss-Üstün et al., 2014).
Diarrhoeal disease can also affect a child’s nutritional status, with
the associated health and socio-economic consequences (discussed
in the following section). One multiple country study found that
25% of stunting in children under the age of two could be due to
five or more diarrhoeal episodes (Checkley et al., 2008). Long-
term exposure to faecal pathogens may also partially explain
environmental enteric dysfunction (EDD) (Humphrey, 2009).
While most diarrhoeal diseases associated with poor WASH tend to
be endemic, some are epidemic in nature – notably, cholera and
typhoid fever. Cholera is an acute diarrhoeal disease that can kill
within hours if left untreated, and it is a continual public health
problem in many parts of the world. Researchers have estimated
that every year there are roughly 1.4 million to 4.3 million cases,
and 28,000 to 142,000 deaths per year worldwide (Ali et al., 2012).
The majority of reported cholera cases and deaths occur in Africa
(Gaffga et al., 2007). Furthermore, the continent suffers from
explosive outbreaks that result in high levels of both morbidity and
mortality.

How does WASH influence diarrhoeal

diseases? Recent updates in knowledge
1. Can WASH affect diarrhoeal disease?
Diarrhoeal diseases are characteristically transmitted via the faecal-
oral route. Poor WASH increases an individual’s exposure to faecal
pathogens through multiple pathways, as demonstrated in the
‘F-diagram’ below.
Figure 1: The ‘F-diagram’
Water
(fluids)
Flies
HOST Food SUSCEPTIBLE
Soil
(fields)
Hands
(fingers)
SOURCE: Cumming & Cairncross (2016); adapted from Wagner & Lanoix (1958)
and Kawata (1978)
It has been estimated that in 2012 a total of 842,000 diarrhoea

deaths were caused by inadequate WASH (502,000 from water,
280,000 from sanitation and 297,000 from hand hygiene). This
represents over half of diarrhoeal diseases, or an estimated 1.5%
of the total disease burden (Prüss-Üstün et al., 2014). Given what
we know about disease transmission routes and possible barriers to
these, the most recent estimate suggests that adequate WASH could
prevent the deaths of 361,000 children under the age of five, or 5.5%
of deaths in that age group (Prüss-Üstün et al., 2014). A different
estimate, which includes WASH in addition to other interventions
such as oral rehydration treatment and exclusive breastfeeding,
suggests that 95% of diarrhoeal deaths in children under the age of
five could be prevented by 2025, as a result of targeted scale-up of
such proven interventions (Bhutta et al., 2013).

As diarrhoeagenic pathogens spread by many different interacting

pathways, the different components of WASH interventions need to
be well coordinated to be effective—although evidence is lacking
on how best to combine different approaches. There is little doubt,
however, that improving access to adequate amounts of water from
an adequately distanced source, hygienic sanitation facilities and
promotion of handwashing with soap should be the cornerstones of
integrated WASH campaigns (Cairncross et al., 2010).
Sanitation and hygiene promotion are still the two most effective
interventions for controlling endemic diarrhoea (Laxminarayan et
al., 2006). An additional potentially critical intervention would be to
improve food hygiene, which may prevent many diarrhoea deaths,
especially in hot climates where food hygiene is difficult to maintain
(Curtis et al., 2011). For more information read this paper’s section
on Complementary Food Hygiene.
© UNICEF/UNI85770/Holtz
Niger, 2009. A child near traditional clay water containers in his family’s courtyard in the
village of Foura Guirké, in the southern Maradi Region.
With regard to cholera, although it is largely perceived to be a

waterborne disease, person-to-person transmission, limited access
to sanitation, an inadequate water supply and poor hygienic
practices may contribute to the rapid progression of an epidemic.
The WHO promotes safe drinking water, sanitation, personal
hygiene, health education and food safety as specific control
measures. However, this approach is not always implemented or
indeed feasible in low-income settings, particularly in the context
of an outbreak.

2.The effect of WASH interventions on

diarrhoeal disease
The effect of interest here is the reduction in diarrhoeal disease as
a result of improvements in WASH.
It is not necessarily helpful to separate out the three WASH
interventions, as they act upon interlinked transmission pathways,
and often cannot be provided in isolation from each other.
Appropriate sanitation and hygiene behaviours both require
adequate water supply. However, the literature on each intervention
contains important lessons. Therefore, this section discusses water,
sanitation and hygiene interventions individually.
Water: The global, Millennium Development Goal (MDG) era
definition for an ‘improved’ drinking-water source is one that, by
the nature of its construction and when properly used, adequately
protects the source from outside contamination, particularly faecal
matter (WHO/UNICEF, 2015). Improved sources include piped water
to the plot or household, public taps or standpipes, tube wells or
boreholes, protected dug wells, protected springs, or rainwater.
However, these provide varying degrees of safety, according to
their differentiated ability to protect from outside contamination.
For example, systematically managed piped water from an
improved point source of water reduces diarrhoeal disease risk by
an estimated 73%, while that same water source is likely only to
provide a 28% reduction if treated at point of use and stored in the
household (WHO, 2014a).
The evidence suggests that improving water quality at the point of
consumption can protect children from diarrhoeal diseases. A review
by Wolf and colleagues in 2014, which included 61 studies for meta-
analysis, suggests that water interventions could reduce diarrhoea
by 34% (Wolf et al., 2014).
The effect on diarrhoea can vary according to different water
interventions. Wolf and colleagues found a significantly higher
effect from household-level interventions versus community-level
interventions. These conclusions are consistent with the findings
of previous systematic reviews (Fewtrell et al., 2005; Clasen
et al., 2007; Waddington et al., 2009; Cairncross et al., 2010).
Furthermore, specific improvements, such as the use of water filters
and provision of high-quality piped water were associated with
greater reductions in diarrhoea compared with other interventions
(Wolf et al., 2014).

A subsequent prospective longitudinal cohort study, which examined

the association between water quality and subsequent diarrhoea in
children of the same household, found that each 10-fold increase
in E.coli contamination in drinking water was associated with a 16%
increase in diarrhoea (Luby et al., 2015).
As was pointed out by Cairncross and colleagues in their 2010
review, the bias associated with trials measuring the effect on
diarrhoeal disease of water quality interventions is estimated
to be high. While the relatively smaller effect of water quality
interventions at the source could be due to subsequent
contamination of the water on its way to the household or during
storage, the bigger effect of POU household water treatment could
also be due to bias in reporting. Indeed, the four blinded trials
included in their analysis suggested only a 7% reduction in diarrhoeal
disease. Issues of bias with the potential to affect the evidence base
for water quality interventions have also been articulated elsewhere
(Clasen et al., 2007; Schmidt et al., 2009). The more recent
review, by Wolf and colleagues, addresses this issue using statistical
methods based on empirical evidence (Wolf et al., 2014).
Sanitation: The global definition of an ‘improved’ sanitation facility
is one that hygienically separates human excreta from human
contact (WHO/UNICEF, 2015). A number of sanitation solutions fall
within this category: the flush toilet, piped sewer system, septic
tank, flush/pour flush to pit latrine, ventilated improved pit latrine,
pit latrine with slab and a composting toilet. However, similar to the
definitions for water, these are safe to varying degrees; the WHO
has recently estimated that effective sewer connections provide
an estimated 69% reduction in diarrhoeal disease compared to an
estimated 16% reduction from improved sanitation without sewer
connections – although this is based on limited evidence and should
therefore be considered preliminary (WHO, 2014a).
A recent systematic review by Wolf and colleagues, which
included 11 studies of a randomized, quasi-randomized, case-
control or observational design, and addressed bias through
statistical methodologies, found that improved sanitation can
decrease diarrhoeal disease by 28%, and also that there are
notable differences in illness reduction according to the type of
improved water and sanitation implemented (Wolf et al., 2014).
Sewer connections were associated with greater reductions in
diarrhoea compared to other onsite or non-reticulated sanitation
interventions. The underlying evidence for this is limited to a
small number of studies and the extent to which any technology is
appropriate, and to which the costs are justified, will depend on
the setting.

These findings are broadly in accordance with the findings of

previous systematic reviews in this area. Three recent systematic
reviews of the impact of sanitation on diarrhoea estimated a mean
decrease of 32–36% (Fewtrell et al., 2005; Waddington et al., 2009;
Cairncross et al., 2010) consistent with earlier estimates by Esrey
(1991). A Cochrane Review was conducted in 2010 but no pooled
analysis was conducted due to the heterogeneity of included studies
(Clasen et al., 2010).
Hygiene: According to a number of systematic reviews,
handwashing with soap (HWWS) has a significant effect on health
and reduced diarrhoea. A Cochrane Review carried out by Ejemot
and colleagues, which pooled data from five RCTs of community-
based interventions in low or middle-income countries found a
reduction of 32% in diarrhoea episodes among children (Ejemot et
al., 2008). A number of other systematic reviews, many of which
take into account trials beyond RCTs, have found a higher reduction
in diarrhoea, of up to 48% (Esrey et al., 1997; Huttly et al., 1997;
Curtis et al., 2003; Fewtrell et al., 2005; Waddington et al., 2009;
Cairncross et al., 2010).
Although further evidence is required to assess the sustainability
of HWWS behaviour change interventions (Brown et al., 2013), one
study in India by Cairncross and colleagues shows that persistent
change in behaviour may be possible following an effective
intervention. In this study several methods were used to study
the sustainability of changed hygiene behaviour at various periods
up to nine years after the conclusion of a multi-pronged hygiene
promotion intervention in Kerala, India. Good handwashing practice
was reported by over half of the adults in intervention areas, versus
less than 10% of adults in a control area (Cairncross et al., 2005).
© UNICEF/UNI154811/Maitem
Philippines, 2013. Children stand outside portable toilets, in the Astrodome evacuation centre
in Tacloban City — among the areas worst affected by Typhoon Haiyan.

WASH for cholera control: While a range of WASH interventions

are frequently employed to control cholera outbreaks, a
recent systematic review found that evidence regarding their
effectiveness, and in particular those interventions with a focus
beyond water quality, is often missing (Taylor et al., 2015). Given
the insufficiency of studies measuring cholera as a health outcome,
the review focused on studies evaluating the intermediary outcomes
associated with implementing WASH interventions in cholera
settings. Eighteen studies were reviewed, most of which were of
poor quality. The majority of these studies collected information
on water quality and POU treatment, and they predominantly
evaluated interventions carried out by emergency organizations,
rather than experimental interventions.
The review did not find well chlorination to be an effective
cholera outbreak response. The available evidence suggests that
this measure is poorly executed at scale, and that mainstream
approaches to source water treatment are, on the whole,
ineffective due to lack of coverage and monitoring of water
quality (Taylor et al., 2015). POU water treatment, in particular
chlorination products, was found to be the most popular
intervention in cholera outbreaks, but with large inconsistencies in
product use (Taylor et al., 2015). The four studies that evaluated
the effect of a hygiene promotion intervention on community
knowledge and cholera awareness found that increased knowledge
did not correlate with better hygiene practices. This suggests a
need for better, more evidence-based design of behaviour change
interventions. The most popular communication channel used in
these studies was mass media (Taylor et al., 2015). No study was
found that evaluated a sanitation intervention alone.
The review highlighted a lack of evidence on the effect of water
quantity on cholera. Since the review, findings from a study in the
Democratic Republic of Congo (DRC), led by the London School
of Hygiene & Tropical Medicine, suggest a detrimental effect of
water supply interruptions on cholera and other diarrhoeal diseases
(Jeandron et al., 2015). Through a time-series regression looking at
the pattern of water supply and suspected cholera admissions over
a five-year period, the study found that in the ten days following
a day with no tap water supply to the town of Uvira (South Kivu,
Eastern DRC), the suspected cholera incidence more than doubled.
Tap water is not available citywide in Uvira, and the observed effect
was higher in neighbourhoods that are generally better supplied by
tap water.

WASH in humanitarian emergencies: WASH provision is an

effective intervention within emergency settings, as well as in
longer-term development (Brown et al., 2012), but emergency
situations often present more challenging environments for WASH
implementation (ibid.). However, a systematic review of the
evidence on the effectiveness of WASH interventions on health
outcomes in humanitarian crises, published in 2015, found an
extremely limited evidence base. It found that over the past 33
years, only six published studies evaluated WASH interventions
in relation to public health outcomes in humanitarian settings,
and all of these evaluated water-related interventions, with only
one study measuring hygiene as well and none providing evidence
on the impact of sanitation interventions (Ramesh et al., 2015).
Numerous methodological limitations precluded the possibility of a
meta-analysis and constrained the ability to determine associative
relationships (Ramesh et al., 2015). Among water-related
interventions, two high-quality studies, one of which was blinded
(Doocy et al., 2006), indicated that POU interventions at the
household level are effective at controlling diarrhoea, statistically
reducing either prevalence or incidence (Doocy et al., 2006; Moll et
al., 2007).
What don’t we know?

Although there is significant evidence highlighting the role of WASH
in decreasing the incidence of diarrheal diseases, a number of areas
remain under researched. These include:
•D
ominant transmission pathways: Rigorous research is required
to provide a greater understanding of what the dominant
transmission pathways are in particular contexts and how they
influence the selection of intervention strategies;
•T
he role of ‘WASH+’: A greater understanding is needed of the
impact of non-traditional/new WASH interventions, such as safe
disposal of child faeces, complementary feeding, hygienic play
areas, and others;
•Integration with broader diarrhoeal disease control: Studies that
look at how WASH efforts are integrated with broader diarrhoeal
disease control strategies, notably existing (retrovirus) rotavirus
and future (Enterotoxigenic Escherichia coli (ETEC) and Shigella)
vaccines, are needed;
•G
ender: A greater understanding is needed of the effect of gender
roles and power dynamics on the prevalence of diarrhoeal disease
in children;

•C
holera control interventions: Further investigation is required
to identify the most appropriate interventions in different
contexts, including emergencies settings, in order to ensure
effective cholera control and the best use of limited resources
(Taylor et al., 2015);
•T
he effect of water quantity on cholera control: While the
above study in DRC (Jeandron et al., 2015) highlights the effect
of water availability and reliability on cholera, further research
is required to investigate whether the reduction in water supply
causes reduced hygiene behaviours, or a reduction in water
quality. This would have significant implications for intervention
design;
• Diarrhoeal disease control in humanitarian emergencies:
Further research is needed to address critical unknowns about
how to effectively deliver sanitation and water in both urban
and rural emergency settings (Brown et al., 2012). In addition,
more research is needed on whether new technologies, new
approaches or new behaviour change interventions may play a
role in providing sustained access to safe water at the point of
consumption through effective POU water treatment solutions
(Brown et al., 2012).
Ongoing studies
The Global Enteric Multicentre (GEMS) three-year case-control
study, coordinated by the University of Maryland School of
Medicine’s Centre for Vaccine Development, is the largest study
ever conducted on diarrhoeal diseases in developing countries,
enrolling over 20,000 children from seven sites across Asia and
Africa. Important results have already been published with regard to
the prevailing causes of severe and moderate diarrhoea (Kotloff et
al., 2013), but the trial is ongoing. The WASH Benefits study aims to
generate rigorous evidence about the impacts of sanitation, water
quality, handwashing, and nutrition interventions on child health
and development in the first years of life. The study is designed as
two highly comparable cluster randomized trials in rural Bangladesh
and Kenya. In each country, the study has six treatment arms
and one control arm. In particular, the study seeks to determine
whether there are larger reductions in diarrhoea when providing a
combined water, sanitation and handwashing intervention compared
to each component alone (Arnold et al., 2013). MAL-ED, a five-
year, multi-site project led by the Foundation for the National
Institutes of Health, studies specific enteric infections, looks at
their relationship to malnutrition and intestinal infections, and

explores the consequences of these conditions on various aspects of

child development. MAPSAN, a controlled, before-and-after study,
will estimate the health impacts of an urban sanitation intervention
in informal neighbourhoods of Maputo, Mozambique, including an
assessment of whether exposures and health outcomes vary by
localized population density (Brown et al., 2015).
Conclusion
There is good evidence that poor WASH contributes to the majority
of the burden of diarrhoea and related adverse health effects, and
strong consensus around this point. There is suggestive evidence that
hygiene (i.e. handwashing) substantially reduces diarrhoeal diseases
in the community. There is suggestive evidence that sanitation
and household water treatment can reduce diarrhoea. There is
suggestive evidence that increasing water quantity directly reduces
the risk of diarrhoea and other WASH-related diseases. However,
while biological plausibility is high, there is currently only weak
epidemiological evidence that WASH interventions reduce mortality.
Few studies have looked at the effect of WASH interventions on
mortality – and those that have, have not been good quality.
There are significant challenges associated with experimentally
assessing the impact of sanitation interventions on diarrhoeal
disease, as discussed in the introduction (Section 1.2). However,
despite heterogeneity across settings and a continued lack of clarity
on the magnitude of the effect with regard to different types of
intervention, few would contest the idea that drinking water that
is safe from contamination, the safe containment of excreta, and
hygiene practices that reduce transmission (including through food),
can reduce diarrhoeal disease. Sustained behaviour change is key to
these reductions – as illustrated clearly by the frequent relapse of
certified defecation-free communities – and must therefore be a key
focus in the design of effective WASH interventions.
A clean environment, by ensuring access to water, sanitation and
hygiene, has historically been a key to improving health and survival
in countries now regarded as developed. There is little evidence
to suggest that equally impressive improvements in health and
longevity cannot be achieved in low-income settings today through
effective and sustainable WASH interventions.

WASH and undernutrition

The problem
Undernutrition is defined as “the outcome of insufficient food intake
and repeated infectious diseases. It includes being underweight
for one’s age, too short for one’s age (stunting), dangerously thin
for one’s height (wasting) and deficient in vitamins and minerals
(micronutrient malnutrition)” (UNICEF, 2006)
In 2014 at least 159 million children worldwide were stunted and
at least 16 million children were severely wasted (WHO, 2015c).
Undernutrition increases the risk of death from infectious diseases
in childhood (Pelletier et al., 1995; Caulfield et al., 2004; Black
et al., 2013; Olofin et al., 2013). It is responsible for an estimated
3.1 million deaths of children under the age of five annually and
accounted for 45% of the global burden of child mortality in 2011
(Black et al., 2013). Evidence also suggests a negative impact of
undernutrition on motor and cognitive development in children
(Grantham-McGregor et al., 2007; Aburto et al., 2009; Walker et al.,
2011; Walker et al., 2012; Black et al., 2013).
Significant progress has been made in the last three decades; the
prevalence of stunting, wasting and underweight has decreased by
35%, 11% and 36% respectively worldwide since 1990 (Black et al.,
2013). However, while this progress is close to the rate required
to meet the 2015 MDG target, improvements have been unevenly
distributed between and within different regions (WHO, 2015).
Furthermore, at current rates improvements will fall well short
of expectations defining the post-MDG agenda. For example, SDG
target 2.2 pledges to “by 2030, end all forms of malnutrition,
including achieving, by 2025, the internationally agreed targets
on stunting and wasting in children under five years of age”. Yet
current progress will not come close to achieving these agreed
targets, which are embodied in the 13-year Comprehensive
Implementation Plan (2012-25) on Maternal, Infant and Young Child
Nutrition. This plan calls for a 40% reduction in the prevalence of
stunting among children under the age of five by 2025, compared
to the 2010 baseline (WHO, 2012a). The 56 countries participating
in the Scaling Up Nutrition (SUN) movement have established or
are establishing national goals geared towards meeting these
global targets. However, at the current rate, the best that can be
hoped for is a 20% reduction (Black et al., 2013). Fast demographic
changes pose additional challenges in certain regions. For example,
in Africa, with the current rate of population increase, stunting
prevalence is actually going up (Black et al., 2013).

The necessary step-change in global efforts to reduce undernutrition

will require a more comprehensive and ambitious approach,
including the scale-up of high-impact interventions. For example,
much more focus should be placed on the first two years of life.
Studies suggest that the process of stunting is concentrated in
the first 1000 days of a child’s life, from conception to 2 years
old (Kuklina et al., 2006; Martorell et al., 2010; Victora, 2010;
Adair et al., 2013). Furthermore, studies looking at the impact of
interventions targeted towards this age group strongly suggest that
the first two years of a child’s life present a “window of opportunity
for preventing undernutrition” (Victora et al., 2010) and that
nutrition interventions are most effective during this period.
Nutrition-specific interventions2 cannot alone adequately address
the current deficit in nutritional outcomes. A recent study has
found that even if coverage of key evidence-based nutrition specific
interventions were scaled up to 90% in the 34 countries with the
highest burden of child undernutrition, there would still only be a
20% reduction in stunting (Bhutta et al., 2013). Nutrition-sensitive3
interventions, for which WASH is an integral part, are a key part of
the solution.
How does WASH influence childhood

undernutrition? Recent updates in
knowledge
1. Can WASH affect childhood undernutrition?
Achieving the goal of global food security – that, “all people at all
times have access to sufficient, safe, nutritious food to maintain
a healthy and active life” (as defined by the World Food Summit
of 1996)—requires a set of complex and often cross-cutting
interventions and programmes (see Figure 2 below). While WASH
interventions constitute only part of this broader picture, an
appreciation of their influence on nutritional outcomes is of vital
importance for the development of comprehensive solutions to this
important issue for child health.
It has been estimated that environmental factors, including no access
to water and sanitation and poor hygiene practices, may account
for half of all undernutrition (Blossner & de Onis, 2005; Prüss-Üstün
& Corvalan, 2006; Victora & Fall, 2008; World Bank, 2008). Further,
one study has estimated that approximately 860,000 child deaths
attributable to undernutrition could be prevented with improved
WASH (Prüss-Üstün et al., 2008).
2 Nutrition-sensitive interventions: Interventions or programs that address the underlying

determinants of malnutrition and incorporate specific nutrition goals and actions (Black et
al., 2013)
3 Nutrition-specific interventions: Interventions or programmes that address the immediate
causes of suboptimum growth and development (Black et al., 2013)

Figure 2: Interventions and programmes required to tackle child undernutrition
Benefits during the life course

Morbidity and Cognitive, motor, School performance and Adult Stature Work Capacity
mortality in childhood socioemotional learning capacity and productivity
development Obesity and NCDs
Nutrition specific Nutrition sensitive

interventions and programmes and approaches
programmes Optimum fetal and child nutrition and development • Agriculture and food security
•Adolescent health and • Social safety nets
preconception nutrition • Early child development
•Maternal dietary • Maternal mental health
supplementation •Breastfeeding, nutrient- •Feeding and caregiving •Low burden of
• Women’s empowerment
•Micronutrient rich foods, and eating practices, parenting, infectious diseases
supplementation routine stimulation • Child protection
or fortification • Classroom education
•Breastfeeding and • Water and sanitation
complimentary feeding • Health and family
•Dietary planning services
supplementation •Food security, including •Feeding and care-giving •Access and use of
for children availability, economic resources (maternal, health services,
•Dietary diversification access, and use of food household, and a safe and hygenic
•Feeding behaviours and community levels) environment
Building an enabling environment
stimulation
• Rigorous evaluations
•Treatment of severe
acute malnutrition • Advocacy strategies
•Disease prevention and • Horizontal and vertical coordination
management • Accountability, incentives
•Nutrition interventions regulation, legislation
in emergencies • Leadership programmes
Knowledge and evidence
• Capacity investments
Politics and governance
• Domestic resource
Leadership, capacity, and financial resources mobilization
Social, economic, political, and environmental context
(national and global)
SOURCE: Adapted from the Lancet Series on Maternal and Child Undernutrition and
Overweight (Black et al., 2013), building on the UNICEF framework used in the 2008 series.

Figure 3: How WASH can affect childhood undernutrition
Inadequate water, sanitation and hygiene

(WASH)
Exposure to enteric pathogens
Soil- Environmental
transmitted Diarrhoeal
Enteric
helminth Diseases
Dysfunction
infections
Poor nutritional status
SOURCE: Adapted from Cumming et al., 2015
WASH could potentially affect childhood nutrition via at least three

pathways: intestinal worms, EED and repeated bouts of diarrhoea
(Dangour et al., 2013). All three of these pathways are mediated by
enteric pathogen exposure that can be prevented with WASH.
Repeated bouts of diarrhoea: Diarrhoea, the leading cause of
which is inadequate WASH (Prüss-Üstün et al., 2014), causes
undernutrition (Checkley et al., 2008), which in turn reduces a
child’s resistance to subsequent infections (Lima et al., 2000;
Checkley et al., 2008), creating a vicious circle (Brown et al., 2003).
An estimated 25% of stunting is attributable to five or more episodes
of diarrhoea before 24 months of age (confidence interval [CI].
8-38%) (Checkley et al., 2008).
Parasitic worm infections: These infections, which are associated
with inadequate water and sanitation, may limit growth and
cognitive development (O’Lorcain & Holland 2000; De Silva et al.,
2003; Bethony et al., 2006; Prüss-Üstün & Corvalan, 2006; Hall et
al., 2008; Ziegelbauer et al., 2012). Hookworm and roundworm can
also cause maternal anaemia and low birthweight (Brooker et al.,
2008; Noronha et al., 2012).

Environmental Enteric Dysfunction: EED is a largely asymptomatic

syndrome leading to chronic inflammation, reduced nutrient
absorption of the intestine, and weakened barrier function of the
small intestine. There are observational studies that suggest that
this condition is associated with poor WASH and undernutrition
(Haghighi et al., 1997; Humphrey, 2009; Keusch et al., 2014; Crane
et al., 2015).
There are also several indirect social and economic pathways that
may be as important as biological mechanisms in understanding the
plausible impact of WASH on undernutrition. These include the time
taken to collect and the cost of buying water, which may divert
scarce resources from food and time spent feeding infants, and the
chemical contamination of water (Cumming & Cairncross, 2015).
2.The effect of WASH interventions

on undernutrition
The effect of interest here is the reduction in undernutrition as a
result of improvements in WASH.
A number of observational studies have shown a robust association
between WASH and childhood undernutrition (Spears, 2013; Spears
et al., 2013; Liu et al., 2015; Rah et al., 2015). One study reported
a strong association after adjustment between open defecation and
stunting in 112 districts of India (Spears et al., 2013). However, the
evidence on the effects of interventions to improve WASH on the
nutritional status of children is less well established. A Cochrane
Review on this topic, published in 2013 (Dangour et al.) ranked most
available studies as poor quality, and the five cluster RCTs amenable
to meta-analysis were mostly POU water treatment interventions,
with none evaluating sanitation or water supply. Nonetheless, the
review found suggestive evidence of a small benefit for children
under the age of five, in terms of reducing stunting or wasting (a
mean difference [MD] in Height-for-Age Z-score [HAZ] of 0.08, 95%
CI[0.0-0.16]). A pre-specified individual participant data analysis
found a larger effect for children under the age of 24 months (an
MD of 0.25, 95% CI [0.14-0.35]).
Since 2013, five RCTs for the effect of sanitation on undernutrition
have been published. Of these, two found a large effect on
childhood stunting (Hammer & Spears, 2013; Pickering et al.,
2015), while the remainder found no effect (Cameron et al., 2013;
Clasen et al., 2014; Patil et al., 2014). It should be noted that the
interventions for the trials reporting no effect also reported low
levels of uptake and compliance, which may explain the absence of

an effect. By contrast, Pickering and colleagues report that access

to sanitation was substantially increased, and open defecation
reduced, as a result of the intervention evaluated in Mali, West
Africa (Pickering et al., 2015), while the intervention evaluated
by Hammer and Spears in India achieved more modest increases in
sanitation access (Hammer & Spears, 2013). This epidemiological
literature confirms what is well known by many WASH implementers:
that the requisite changes in behaviour are hard to initiate and even
harder to sustain over time.

Over the last five years there has been markedly more attention
dedicated to the influence of WASH on undernutrition, and the
evidence base has developed. Nonetheless, evidence gaps remain.
Going forward priority should be given to:
•U
nderstanding the benefits of integrated approaches:
Synergistic effects of WASH interventions delivered alongside
nutrition interventions;
•Q
uantifying the effect of targeted interventions: In particular,
the effect that WASH interventions targeting in-utero and early
life nutrition have on early childhood development and growth;
•D
emonstrating the effect of WASH interventions on EED and
specific enteric infections, and undernutrition;
•U
nderstanding the intervention needs of informal urban
settings: Effect of onsite sanitation on child health in high
density/informal urban settings;
•U
nderstanding different gender roles: A greater understanding is
needed of the effect of gender roles and power dynamics on the
ability of WASH interventions to reduce child undernutrition, in
particular given the role of women as caregivers in the household.
Ongoing studies
Three large new WASH intervention studies currently ongoing in
Zimbabwe, Bangladesh, Kenya and Mozambique will go at least some
way towards addressing the above evidence gaps. The SHINE trial,
a cluster RCT, will evaluate the independent and combined effects
of improved water, sanitation and hygiene, and improved infant
diet on child health and anaemia between birth and 18 months
of age (Humphrey, 2013). The WASH Benefits study, described on
p.15-16, will measure the health and developmental benefits of

water, sanitation, handwashing and nutritional interventions among

newborn infants in rural Bangladesh and Kenya (Arnold et al., 2013).
The MapSan trial, described on p.16, will collect anthropometric
measures to assess the effect on child growth as a specific outcome
(Brown et al., 2015).
All of the trials will enable an assessment of whether WASH
improvements can decrease EED, as well as an understanding of
whether the impact of poor WASH on stunting is mediated by EED.
The SHINE trial and WASH Benefits study will allow for both the
independent effect of WASH interventions on stunting as well as the
combined effect of WASH and nutrition interventions together to be
assessed.
Conclusion
There is good evidence to suggest that interventions that focus
solely on nutrition-specific strategies are insufficient for reducing
undernutrition, and that WASH may have impacts on undernutrition
via multiple biological and social mechanisms. There is also good
evidence that strategies to tackle undernutrition must focus on the
first 1000 days, from conception to a child’s second birthday, after
which the damage is largely irreversible.
While the evidence is less clear on the magnitude of the effect
and on what interventions are the most efficacious for tackling this
issue, the current evidence is sufficient to justify the inclusion of
WASH interventions in strategies aimed at reducing undernutrition.
For WASH interventions to contribute more effectively to reducing
undernutrition, modification may be required around targeting
children under the age of two, understanding how this group is
specifically exposed to enteric pathogens, and prioritising actions
that target these age-specific exposure pathways.


WASH and complementary

food hygiene
The problem
The period during which other foods or liquids are provided along
with breast milk is considered the period of complementary feeding.
Any nutrient-containing foods or liquids other than breast milk given
to young children during the period of complementary feeding are
defined as complementary foods (Brown et al., 1998).
It is important to an infant’s development that the caregiver
supplements breast milk with appropriate solid foods from six
months. However, inadequate complementary food hygiene, as
well as use of unsafe drinking water in food preparation, could
account for a significant proportion of diarrhoeal diseases among
infants and young children in low-income countries (Motarjemi et
al., 1993; Islam et al., 2013). The incidence of diarrhoeal disease is
higher in children after complementary food is introduced (Barrel et
al., 1997) and peaks during the second half-year of infancy, as the
intake of complementary food increases (Martinez et al., 1992). In
low-income settings, the level of contamination in complementary
foods can be higher than in drinking water (Esrey & Feachem, 1989;
Lanata, 2003), though this varies between environmental settings
(Toure et al., 2011; Islam et al., 2013). Keeping food free from
faecal contamination is essential to inhibiting faecal-oral disease
transmission (Curtis et al., 2011). Adequate food hygiene practices
have been found to reduce the risk of diarrhoea by 33% (Sheth et
al., 2006).
How does WASH influence

complementary food hygiene?
1.C
an WASH affect complementary food
hygiene?
While many factors influence food-borne contamination, including:
hot climate (Lanata et al., 2003), poor storage practices and
insufficient cooking time (Motarjemi et al., 1993; Lanata et al.,
2003), WASH plays a crucial role (Curtis et al., 2011), in particular
through environmental contamination due to lack of sanitation, use

of contaminated water to wash serving utensils, and not washing

hands prior to cooking and feeding. Figure 1 on page 16 shows the
pathways of faecal-oral transmission of pathogens and infers the
plausible influence of WASH on these.
2. The effect of WASH interventions on

complementary food contamination and
associated improvements in child health
outcomes
The effect of interest here is the reduction in the contamination of
complementary foods as a result of improvements in WASH.
Over the last 15 years a body of evidence around the impact of
WASH interventions in reducing complementary food contamination
has developed. The principles of Hazard Analysis and Critical Control
Points (HACCP) (Motarjemi et al., 1999) have been successfully
used to identify the pathways for contamination of complementary
food and the associated critical points where controls could
be applied to prevent, reduce or eliminate this contamination
(Michanie et al., 1987; Sheth et al., 2000; Ehiri et al., 2001). A
number of experimental studies in the last few years have tested
this approach. Findings suggest that using the HACCP approach
to identify points of contamination in the preparation, storage
and reheating of complementary food, alongside evidence-based,
innovative, behaviour change interventions can substantially reduce
contamination of food given to young children.
One small-scale hygiene experiment using the HACCP model in
peri-urban Bamako, Mali, proved to be effective in reducing the
contamination of complementary foods (Toure et al., 2012). Using
a similar approach, a small intervention study in Bangladesh was
effective in reducing complementary food contamination in a
different context (Islam et al., 2013). A further study in rural Nepal
designed, delivered and evaluated an intervention designed using
emotional drivers such as nurture rather than cognitive appeals
to change the food hygiene behaviours of mothers (Gautam et
al., 2015). A significant proportion (43%) of mothers were able
to maintain all five key behaviours for several months and the
intervention was successful in significantly improving the microbial
contamination in children’s food.


A number of studies have identified contamination of complimentary
food as an important transmission route of diarrhoeal diseases in
young children. Despite this a number of evidence gaps remain,
especially around identifying effective and scalable behaviour-
change interventions. Going forward research should prioritize:
• Identifying effective behaviour change interventions:
Successfully changing behaviours associated with routine hygiene
and food preparation and cooking practices remains a challenge.
More models of successful behaviour change, resulting from
experimentation, optimization and adaptation grounded in
context-specific formative work, as well as how to translate these
into effective design of hygiene promotion programmes, are
needed to secure sustainable food hygiene behaviour change;
•U
nderstanding the role of gender: A greater understanding is
needed of the effect of gender roles and power dynamics on the
ability of interventions to alter target behaviours successfully;
•U
nderstanding the transmission pathways of key enteric
pathogens: A fuller understanding is required of which major
enteric pathogens are transmitted via food, and what the
associated disease risk is versus other pathways;
•Q
uantifying the effect on child health: Greater clarity is needed
on the short and long-term health impact of contaminated
complementary food during the critical developmental window
of early childhood. This includes understanding the contribution
of foodborne transmission to enteric infection and longer term
conditions that develop as a consequence of growth faltering and
how this relates to Early Childhood Development;
• Identifying scalable interventions: Further development and
testing of strategies for scaling up complementary food hygiene
interventions are required to demonstrate that these interventions
can be cost-effective at scale.
Ongoing studies
Two studies that started earlier this year (2016) are further exploring
the questions of effective behavior change and scale up. A food
hygiene cluster RCT intervention in rural Gambia, led by University of
Birmingham, aims to substantiate the findings of the complementary
food hygiene behaviour intervention study in Nepal, through
adaptation to a different context. It seeks to provide an intervention
that can be scaled up, this time in low-income settings in Africa.

Meanwhile the community-based WASH and food hygiene RCT in

Malawi, led by Malawi Epidemiology and Intervention Research Unit
(MEIRU), is seeking to determine the effectiveness of combining WASH
and food hygiene interventions on the incidence of diarrhoeal disease
in children under the age of five. The study will entail developing,
implementing and evaluating an integrated, community-based WASH
and food hygiene intervention in Chikwawa District.
Conclusion
There is good evidence to suggest that inadequate food hygiene
practices can lead to high levels of microbial contamination of
food, and this is particularly concerning for the complementary
food of children under the age of two. There is also good evidence
that interventions focusing on certain critical control points may
improve the levels of contamination of such foods. However, the
extent to which behaviours can be sustainably changed through
such interventions has yet to be further explored. In addition, more
needs to be learnt as to the impacts on child health of food hygiene
interventions.
While further research is needed, the current evidence base
provides a clear case for integrating food-hygiene-specific
components to both WASH and nutrition programmes to ensure that
this important and often-neglected transmission pathway is given
more attention.
© UNICEF/UNI191744/Gilbertson VII Photo
Niger, 2015. A family standing next to large plastic containers bearing a combined total of 60
liters of water, the amount the family uses daily for drinking and cooking.

WASH, violence against

women and girls, and
female psychosocial stress
The problem
Poor access to safe water and sanitation can have profound impacts
for women and girls, including but not limited to adverse pregnancy
outcomes, maternal mortality, violence and psychosocial stress. The
latter is one of the less studied associated outcomes to date.
Violence against women and girls (VAWG) is a violation of
fundamental human rights, and a growing public health concern.
Gender-based violence (GBV) occurs as a result of the differences
in power between males and females. A large proportion of GBV
is aimed at women and girls, due to the discrimination that they
face in most societies and their lack of power relative to men and
boys. However, the gender roles assumed by men and boys, and
people with other gender and sexual identities, can also make them
vulnerable to violence (House et al., 2014; Sommer et al., 2014).
Other focuses include violence against those from specific social
groups, particularly those who may be in vulnerable, marginalised
or special circumstances; and violence that may occur between
people of the same gender, such as between women or between
men, or between men and boys (House et al., 2014). Beyond the
physical impacts – rape, assault, molestation, beating or fighting
can often lead to serious injury and even death – different types of
violence can also have long-term psychological impacts (Sahoo et
al., 2015), associated with harassment, bullying, discrimination or
marginalization, and psychosocial impacts, associated with the fear
of these acts of violence.
Psychosocial stress can be said to occur when a perceived threat
(real or imagined) or a given outcome outweighs the individual’s
perceived ability to overcome the challenges associated with
that outcome. While perhaps the most obvious relationship is
that between the experience and/or threat of violence and the
fear of that violence, it is not possible to fully understand women
and girls’ psychosocial stress in isolation from other gendered
health-outcomes. For example, psychosocial stress is but one of
a range of impacts associated with a woman or girl’s inability to
effectively manage her menstrual hygiene (see pages 34-36). It is
also associated with maternal health (see pages 29-32, or with the
stress involved in collecting water. Psychosocial stress contributes

directly to overall mental health. Broadly, mental and substance

abuse disorders account for approximately 8% of the global burden
of disease, with depressive disorders alone being the fifth leading
cause of disability-adjusted life years (DALYs) in 2013 (Institute for
Health Metrics and Evaluation, 2015).
This chapter aims to display the current evidence on violence and
psychosocial stress, as two interlinked and often neglected diverse
outcomes associated with WASH.
How does WASH influence violence and

psychosocial stress? Recent updates in
knowledge
1. Can WASH affect the levels of VAWG and
their psychosocial stress?
While there is currently insufficient rigorous evidence to
substantiate this claim there is reason to believe that the lack
of any or adequate WASH facilities is likely to increase the
vulnerability to violence in a given setting.
The Violence, Gender and WASH Practitioner’s Toolkit, a
collaborative piece published in 2014, offers an invaluable summary
of the available case studies on this topic (House et al., 2014).
These have been classified into the following forms of violence:
sexual violence, psychological violence, physical violence and socio-
cultural violence (House et al., 2014). To highlight a few examples,
the case studies suggest that poor access to WASH services can lead
to vulnerability, rape and assaults, and that fear of such assaults can
prevent women and children from using sanitary facilities outside of
the home at night. Children can be vulnerable to sexual violence in
school or when left at home while the mother is out to undertake
WASH-related tasks (House et al., 2014). A 2013 cross-sectional
study by WaterAid India of 10,000 Dalit households across five states
sought to identify and quantify the various forms of violence faced
by Dalit women when collecting water or defecating in the open
(WaterAid & the National Confederation of Dalit Organizations).
More recently, in 2015, using data from the 2008/2009 Kenya
Demographic and Health Survey, Winter and Barchi (2015) explored
the quantitative relationship between access to sanitation and
experiences of violence. Among all respondents, women that did
not have a sanitation facility had 38% greater odds of experiencing
non-partner violence within the last 12 months compared to

women that reported using a sanitation facility (after controlling

for marital status, residence, age, and experience of intimate
partner violence). This relationship was modified by neighbourhood
social disorganization – a measure based on neighbourhood
poverty, residential stability, and ethnic divert. Among women
in highly disorganized neighbourhoods, the odds of experiencing
non-partner violence in the last 12 twelve months were 13 times
greater for women practicing open defecation compared to women
who reported using a sanitation facility. Conversely, there was no
significant change in the odds of violence associated with sanitation
facilities in neighbourhoods with higher cohesion.
The experiences that women and girls have accessing water and
sanitation – including vulnerability to violence – can put them at risk
for negative psychosocial outcomes. These experiences are shaped
by socially constructed gender roles and behaviours that they
are expected to perform (Sommer & Caruso, 2015). The negative
outcomes can be further aggravated when the lack of appropriate
and hygienic sanitation facilities, at home or in public places, forces
women and girls to adopt a range of coping strategies. The risks are
multiple and cumulative, occurring across the duration of a woman’s
life and with far-reaching implications for social justice and social
equity.
A series of cross-sectional studies have offered insights into the
negative impact of WASH on the psychosocial stress levels of
women and girls (Wutich et al., 2008; Stevenson et al., 2012; Hirve
et al., 2015; Sahoo et al., 2015; Kulkarni et al.). One study into
the relationship between water insecurity and emotional distress
in Bolivia found a strong association, after adjusting for various
confounding factors, between female gender and water-related
© UNICEF/UNI131998/Sokol
South Sudan, 2012. Women cross a road that has been inundated with water after seasonal
flooding, in the town of Bunj, Upper Nile State.

emotional distress. The authors conclude that water-related

emotional distress results from people’s struggles to negotiate
access to water in the absence of regulation or established water
rights, rather than as a result of water scarcity per se (Wutich et
al., 2008).
A further study in Ethiopia, which tested the association between
women’s reported water insecurity and an established measure
of psychosocial distress – the Falk Self-Reporting Questionnaire –
found a significant association between women’s water insecurity
scores and psychosocial distress (Stevenson et al., 2012). A more
recent study in rural India drew on this methodology with a focus on
sanitation. This study found that sanitation practices encompassed
more than defecation and urination, to include water carrying for
use in personal hygiene, washing, bathing and MHM. Furthermore,
during the course of these activities women encountered three
broad types of stressors – environmental, social and sexual – the
intensity of which were modified by the woman’s life stage,
living environment and access to sanitation facilities (Sahoo et
al., 2015). A follow-up study developed a theoretically-grounded
tool to quantify sanitation-related psychosocial stress, and found
that inadequate access to a sanitation facility was an important
determinant of sanitation-related stress, but, crucially, that
improvements in quality of life due to sanitation infrastructure were
indirect and mediated through the experience of access and using
the facilities in question (Hulland et al., 2015).
Among slum dwellers in Dhaka, Gruebner and colleagues found
in 2012 that a composite variable related to access to sanitation
and garbage disposal had a statistically significant association with
WHO-5 scores, a widely used measure of quality of life and mental
health (Gruebner et al., 2012). Conversely, access to basic services
– including water services – did not have a significant relationship
with self-reported quality of life. Only job satisfaction, gender, and
self-reported disease status had a stronger association with self-
reported quality of life. Critically, the study did not provide gender-
disaggregated data, however it establishes that access to basic
sanitation facilities does impact overall quality of life.
Although biological markers of stress have been used in the wider
psychosocial stress literature, only one WASH study was identified
that had done this. In 2014, Henley and colleagues considered risk
factors for elevated cortisol concentrations in hair, and found an
association with feeling unsafe collecting water or using sanitation
facilities within the groups studied (Henley et al., 2014).

The 2015 Inter-Agency Standing Committee (IASC) Guidelines for

Integrating Gender-Based Violence Interventions in Humanitarian
Action draws qualitative evidence to provide a number of examples
of how humanitarian / acute emergency settings are likely to
place women and children, and girls in particular, at greater risk of
violence, including sexual violence. For example, girls and women
in emergencies have few choices over where and how to access
resources or facilities for drinking water, hygiene and sanitation.
In the absence of appropriate emergency WASH facilities, girls and
women, who are already at increased risk to violence for a range of
reasons particular to emergency settings, face further increased risk
to sexual violence when negotiating where and how to meet WASH
needs. Furthermore, both female and male survivors may require
exceptional access to WASH facilities as a result of urethral, genital
and/and or rectal traumas that render basic washing and hygiene
activities difficult and time consuming.
2.The effect of WASH interventions on

violence and psychosocial stress
The effect of interest here is the reduction in VAWG and women and
girls’ psychosocial stress as a result of improvements in WASH.
At the time of writing the authors were not aware of any
studies seeking to evaluate and/or quantify the effect of WASH
interventions on violence or psychosocial stress. However one 2010
study, which designed a matched cohort study to assess the impact
and sustainability of a non-randomized, pre-existing sanitation
mobilization, water supply, and hygiene intervention in rural India,
found that it had a positive effect on feelings of privacy and safety
for women and girls (Arnold et al., 2010). It found that private
toilet owners were 28 percentage points more likely to report that
women and girls feel safe while defecating during the day or night
compared with households without private toilets (81% vs. 53%).
Overall, the intervention increased the perception of privacy and
safety for women and girls during defecation by 13 percentage
points compared with controls (72% vs. 59%).
In the absence of rigorous, large-scale research findings, the
Violence, Gender and WASH Practitioner’s Toolkit brought together
in 2014 a range of examples of promising good practice from the
field that have the potential to reduce vulnerabilities associated
with WASH programmes and services. These include participatory
tools to assess and discuss safety and services, guidelines for siting,
design and management of facilities, opportunities for the WASH
sector to transform communities to reduce GBV, and many others

(House et al., 2014). For example, one programme undertaken in

the Democratic Republic of Congo by Tearfund partner Programme
de Promotion des Soins de Santé Primaires (PPSSP) adopted an
integrated community-based approach that included health, WASH
and protection, with separate but linked-in WASH and protection
committees established. Highlights of the successes associated
with the project include: almost two-thirds of women said that
they could express their views and actively participate in decision-
making in the community; community mechanisms were put in place
to discourage early marriage; and domestic violence reportedly
decreased. The programme was initially implemented as a pilot but
following its success, the integration of the WASH, protection and
other elements are now also being implemented into all projects
supported by PPSSP (PPSSP & Tearfund, 2011).
During a humanitarian emergency, well-designed WASH programmes
and facilities can help survivors deal with their injuries, as well as
minimize the likelihood of stigmatization. The IASC Guidelines for
Integrating Gender-Based Violence Interventions in Humanitarian
Action provide standards and best practice of applying gender-based
violence perspectives in the delivery of WASH knowledge, resources
and facilities in emergencies (IASC, 2015).

There is growing attention being given at a policy level to the
psychosocial stress burden associated with poor WASH, especially
among women and girls. There is a growing literature on this
topic, with a number of papers recently published, and new
studies underway, but there remains insufficient evidence as to the
magnitude of this problem and which interventions and approaches
are most effective in addressing it. While existing studies have
helped to characterize the problem, and made significant strides in
quantifying this outcome, more research is needed to:
•G
ain greater understanding of the various mechanisms: What
are the interaction between WASH and violence? Do these vary
across different countries and contexts?;
•Q
uantifying the magnitude of the effect: Do adequate WASH
facilities impact on the incidences of violence;
•U
nderstand the impact on sanitation practices: greater
exploration of the role that the association between VAWG and
sanitation may play in women’s sanitation practices;

•U
nderstand the psychosocial stress burden: And what is its
association with different deficits in WASH access in different
settings such as distant water sources in rural settings or shared
sanitation facilities in high-density informal urban settlements;
•U
nderstand which WASH interventions are the most effective:
In particular, which WASH provisions are most effective in reducing
violence and psychosocial stress ;
•Q
uantify the effect of WASH on stress: There is a need to assess
the effect of WASH interventions on measured stress, particularly
among women and girls.
Ongoing studies
Researchers from the University of Oklahoma, the London School
of Hygiene and Tropical Medicine, Texas A&M University, and
SOPPECOM have partnered on a quasi-experimental, mixed methods
study assessing changes in sanitation-related psychosocial stress,
generalized psychosocial stress (Perceived Stress Scale), and quality
of life (WHO-5) among 600 women aged 14 to 60 in villages receiving
the Global Sanitation Fund’s (GSF) sanitation intervention in 2016 –
matched with 600 women in villages receiving the same intervention
in 2017 or later. Additional outcome measures for this study include
self-reported urogenital infections and perceived privacy and safety.
Conclusion
There is suggestive evidence that inadequate WASH can affect
VAWG and on the psychosocial stress levels of women and girls.
Evidence as to the effect of WASH interventions on violence or on
psychosocial stress is currently weak.
While additional research is required to consider the precise
nature of the interactions between poor WASH and violence and
psychosocial stress, their magnitude, and how best to measure
them, the wealth of case studies and other anecdotal evidence
available leave little room to question that well-implemented WASH
interventions can reduce vulnerabilities – and the perceived threat
of vulnerability. The negative impact on women and girls of limited
availability of water and sanitation resources, and the physical
and social challenges associated with accessing those resources,
are beginning to receive greater attention by the WASH sector, but
there is a need for improved monitoring of these dimensions.

Thorough analysis of the context-specific needs and roles of those

at risk of GBV related to WASH is crucial for the effective design
of any WASH intervention, whether in an emergency or longer-
term development setting. Furthermore, it is critical to engage
women, girls and other at-risk groups in the design and delivery
of WASH programming – as both employees in the WASH sector and
as community-based advisers. This engagement not only helps to
ensure effective response to life saving needs, but also contributes
to long-term gains in gender equality and the reduction of GBV.
Actions taken by the WASH sector to prevent and mitigate the risk
of GBV should be implemented in coordination with GBV specialists
and actors working in other humanitarian sectors. WASH actors
should also coordinate with partners addressing issues of gender,
mental health and psychosocial support (MHPSS) in emergencies,
HIV, age, disability and environment (GBV 2015 Guidelines, WASH
Thematic Guide, p.40).
© UNICEF/UNI179359/Lynch
Burkina Faso, 2011. A sixth grade student at a Public primary school leaves the latrine
carrying water.

Wash and maternal

and newborn health
The problem
Maternal mortality (MM) is defined as “the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective
of the duration and site of the pregnancy, from any cause related
to or aggravated by the pregnancy or its management but not from
accidental or incidental causes”. In addition, many more women
become unwell with illnesses or conditions related to pregnancy and
childbirth than actually die. Maternal morbidity is defined as “any
health condition attributed to and/or aggravated by pregnancy and
childbirth that has a negative impact on the woman’s well-being”
(WHO, 2013).
The negative consequences of childbirth can go beyond the burden
of mortality and morbidity experienced by the mother and newborn,
affecting also the health of infants, children and other members of
the family (Anderson et al., 2007). Progress towards attaining MDG
5 – reducing MM by three quarters between 1990 and 2015 – was
slow and geographically and socioeconomically uneven (UNICEF
et al., 2014). With an estimated 303,000 maternal deaths still
occurring in 2015 across the globe (Alkema et al., 2015), it is clear
that traditional maternal health interventions alone have not been
sufficient to address this issue adequately.
© UNICEF/UNI182593/Pirozzi
Malaysia, 2014. A baby from the indigenous Kadazandusun ethnic group sleeps in a traditional
cloth cradle in child-care centre in Penampang district, Sabah State.

Figure 4: Dimensions, components and examples of health effects in conceptual

framework linking WASH with maternal and reproductive health.
1. In the water 2. Behaviours related to hygiene

Ingestion, inhalation or contact Availability/location of water and sanitation, logistics of handling them
or stigma of biological processes
E. Water-washed F. Water- G. distant H. water/ I. Perception of

A. Water-borne inorganic B. Water- C. Water- insufficient water for related water sanitation water and sanitation
D. Water- personal/domestic/ insect sources
chemical compounds ingested system based borne in risky or availability; stigma
or in contact with skin related infections institutional hygiene; vector- or lack of isolated or fear around use of
infections Poor hygiene and borne water when
infections locations sanitation facilities
faeces disposal infections needed
Via Other
Via Via enteric infections Via Real/
aquatic bacterial, infections, insects Pests
(eye, ear, Physical (insects perceived
Delib- vector parasitic, for example skin, lice- near
Natural erate Via example and viral diarrhoea water burden risk, stigma,
contamin- Industrial aerosols borne, and
additive fish and oral- and gastro of carting damage to Real or
ants contamin- from respira- snakes
ants example tape- faecal enteritis, example water, time self-esteem, perceived
example poorly tory) bites)
example fluorine, worm, infections spread by black flies or disgust availability
arsenic, chlorine managed and financial and
lead, shellfish example fingers, Example and of water or
salt, or its by- cooling food, onchocer costs, perverts surrounding
nitrates and flukes, cholera, trachoma sanitation
flouride products systems snails and listeria, fomites, chiasis drudgery defecation,
scabies (harass-
schisto- hepatitis field flies and ment and urination or
lassa
somes E crops, fever trypano- violence) menstruation
fluids, somes
or flies
Sponta-
Spontan- Legion- Mental Lack of use
Arsenic- neous
eous Schisto Hepatitis Hook- Uterine
Blue baby ellosis somiasis E Influenza Malaria Rape distress of health
osis abortion worm prolapse
services
SOURCE: Adapted from Campbell et al., 2014

How does WASH influence maternal

health? Recent updates in knowledge
1. Can WASH affect maternal health?
There is a strong association between MM and WASH (Benova
et al., 2014b), and the causal link between birth attendant
handwashing and maternal infection has long been established,
thanks to the work of Gordon, Holmes and Semmelweis (Gordon,
1795; Semmelweis, 1861; Gould, 2010;). Figure 4 (previous page)
shows the multiple direct and indirect mechanisms depicted in
a conceptual framework created by Campbell and colleagues in
2014. This framework identified 77 plausible chemical, biological
and behavioural mechanisms linking WASH to adverse maternal and
reproductive health. These are multiple and overlapping and may be
distant in time from the immediate health outcome.
Poor sanitation increases the risk of soil-transmitted helminth (STH)
infections (Bethony et al., 2006; Brooker et al., 2008; Noronha et
al., 2012, Strunz et al., 2014), which can cause anaemia, listeria
(Southwick et al., 1996), and increase the risk of maternal death.
STH infections are also associated with spontaneous abortion
and pre-term birth (Heymann, 2008; Semedo-Leite et al., 2012).
Schistosomiasis, another risk posed by poor WASH (Grimes et
al., 2014), is associated with ectopic pregnancy, anaemia and
undernutrition (King et al., 2005; Swai et al., 2006; Abelgadir et
al., 2012). Furthermore, there is evidence to suggest that repeated
early childhood infections of this sort, or of diarrhoeal diseases,
can cause stunting (Checkley et al., 2008; Guerrant et al., 2013) -
which in turn can lead to an increased risk of obstructed labour and
maternal mortality in later life (Konje et al., 2000; Neilson et al.,
2003; Toh-adam et al., 2012; Tsvieli et al., 2012). Indirect effects
of poor sanitation on maternal health include the increased risk of
pre-eclampsia and anaemia, which can be caused by urinary tract
infections arising from harmful coping mechanisms such as delayed
urination or reduced water or food intake associated with lack of
safe access to facilities (Schieve et al., 1994; Lennon et al., 2011;
Massey et al., 2011; Minassian et al., 2013).
Unsafe water management can encourage the breeding of
mosquitoes and associated transmission of malaria and dengue,
which pose high risks to pregnant women (Heymann, 2008; Mota
et al., 2012). Water collection can cause spinal injuries, hernias,
genital prolapse, and an increased risk of spontaneous abortion
(Florack et al., 1993; Jorgensen et al., 1994). It can also present
substantial caloric expenditure and thus hinder weight gain. Distant

water sources, and the resulting reduced water consumption (Howard

et al., 2003), can affect personal hygiene and increase risk of urinary
and reproductive tract infections associated with pre-eclampsia and
anaemia (Schieve et al., 1994; Minassian et al., 2013), as well as risk
of infection during delivery and post-partum. Drinking unsafe water
has been linked to higher rates of spontaneous abortion and stillbirth
(Milton et al., 2005; Ekong et al., 2006; Cherry et al., 2008; Caserta
et al., 2011; Khan et al., 2011).
Since the publication of Campbell and colleagues’ conceptual
framework, a systematic review has explored the effect of cholera
on pregnancy outcomes (Tran et al., 2015). While the results are
limited, findings suggest that maternal cholera, which is linked
to poor WASH, is associated with adverse pregnancy outcomes,
particularly foetal death.
2. WASH coverage and quality at delivery

Delivery represents a critical moment for potential infection of
both mother and baby through poor WASH, and yet studies have
found insufficient coverage and inadequate quality of WASH in birth
settings. A 2014 study concluded using existing data sources that
less than one-third of all births in Tanzania (home and facility) took
place in a water- and sanitation-safe environment (Benova et al.,
2014a). The 2015 UNICEF and WHO multi-country review of WASH
services in health care facilities, drew on data from 54 low and
middle-income countries and concluded that over one-third lacked
access to even basic levels of water and did not have handwashing
facilities, while just under a fifth lacked sanitation (WHO & UNICEF,
2015). A number of additional needs assessments in Bangladesh,
India (Afsana et al., 2014; Steinmann et al., 2015) and Zanzibar
(Fakih et al., 2016) also found WASH conditions to be sub-optimal
in health facilities. Common findings include contaminated delivery
beds, inadequate access to WASH facilities and poor WASH facility
conditions of upkeep and cleanliness.
3. The effect of WASH interventions on

maternal mortality and morbidity
The effect of interest here is the reduction in maternal mortality
and morbidity as a result of improvements in WASH.
A systematic review (Benova et al., 2014b) considered available
evidence on the links between WASH and MM but did not identify
any interventional studies. A meta-analysis of adjusted estimates
from four observational individual-level studies showed that

women living in households with poor sanitation were three times

more likely to die from maternal causes than those with adequate
sanitation access. Additionally, four of five ecological studies
identified in this review showed that at a country-level, poor
sanitation was associated with higher MM.
The only individual-level study that looked at the adjusted effect of
water showed a significant association between poor water access
and increased MM. Four of six ecological studies assessing water
environment found that poor water environment was associated
with higher MM on country level. There was only one facility-based
study, which found an association between a combined measure
of water and sanitation environment and a high risk of in-hospital
mortality (Galadanci et al., 2011).
A study in Afghanistan found that women in households with
unimproved water access had 1.91 higher odds of pregnancy-
related mortality, compared to women in households with improved
water access, and found an association between unimproved toilet
facilities and higher pregnancy-related mortality, although this
association was not statistically significant (Gon et al., 2014).
In 2015, an assessment of the association between poor sanitation
during pregnancy and adverse pregnancy outcomes found that
poor sanitation in general, and open defecation in particular,
were strongly associated with each of the four composite adverse
pregnancy outcomes studied, after adjusting for a broad range
of biological and socio-economic factors. This is the first rigorous
epidemiological study to demonstrate this relationship (Padhi et al.,
2015).
4. How does WASH influence the newborn?

Mortality among newborns (up to 28 days after birth) has been
reduced but did not declined at a pace sufficient to meet MDGs or
pace matching progress seen in child health. There were 2.8 million
deaths annually in this age group in 2013 (Oza et al., 2015).
Infections such as sepsis, tetanus, pneumonia and diarrhoea account
for a substantial proportion (around a quarter) of these deaths and
are directly relevant to WASH circumstances during childbirth and
the immediate postpartum period through practices such as birth
attendant handwashing, cleanliness of the perineum and delivery
surface, hygienic cord care / cord cutting, bathing, and feeding
practices. Many of these links have been established by good quality
intervention studies in low and middle-income contexts (Mosha et
al., 2005; Rhee et al., 2008; Darmstadt et al., 2009; Mullany et al.,
2009; Blencowe et al., 2011; El Arifeen et al., 2012; Khan et al.,
2013).

Some of the other causes of death, such as pre-term complications

and small size for gestational age, which account for a third of
newborn deaths and congenital malformations, can also be linked
to WASH through the life course and maternal exposure to poor
water, sanitation and hygiene environments during childhood,
adolescence and adulthood (including during pregnancy). These
include, for example, maternal malnutrition, exposure to chemical
contaminants (such as arsenic or fluoride) and exposure to lead, but
also include infections such as influenza and malaria (Campbell et
al., 2014).
In addition to neonatal mortality, there are life-long and severe
consequences to morbidity related to poor WASH exposures, such
malnutrition, delayed development and reduced cognitive function
(Theiss et al., 2014).
The Every Newborn Action Plan, which has been endorsed by the
World Health Assembly and ratified by many stakeholders and
donors to reduce neonatal deaths and stillbirths to 10 per 1000
births by 2035, provides an evidence-based framework for scaling
up of essential interventions across the continuum of care. It has
the potential to prevent approximately three million deaths of
newborns and mothers, every year (Bhutta et al., 2014; Akseer et
al., 2015).

Answering the following questions would further strengthen the
case for increased investment, ensure that these investments are
appropriately targeted, and ensure better tailoring/designing of
interventions.
• Synthesising the state of the evidence on key risk mechanisms:
Additional systematic reviews are needed to explore key potential
risk mechanisms linking WASH to maternal and newborn outcomes
(Campbell et al., 2014);
• Quantifying cumulative risks across the female life course: How
does access to WASH at different points in a woman’s life course
affect these pathway(s) to MM (Benova et al., 2014b)?;
• Testing the most effective WASH interventions: What effects do
different types of WASH interventions have on specific maternal
health outcomes, and does the relative importance of these differ
across various settings (Velleman et al., 2014)?;

• Including a WASH dimension in Maternal Health programmes:

How best can WASH be incorporated? This should include, for
example, how to motivate the cleaning staff in health care
facilities and making sure that staff have the resources for
operation and maintenance of facilities (Afsana et al., 2014);
• Understanding needs across different levels of facilities:
Studies that link WASH exposures to maternal health outcomes at
different service levels would support the development of more
nuanced, targeted guidelines;
• Attributable disease burden: What maternal health disease
burden is associated with poor WASH across primary, secondary
and tertiary facilities? What is the contribution of poor WASH to
nosocomial infections?;
• Cost: Better metrics on the cost-effectiveness of WASH interventions
relative to other healthcare facility interventions improving
maternal health outcomes are needed.
Ongoing studies
As part of the UNICEF/WHO-led global action plan on WASH in health
care facilities, four taskforces have been set up, one of which is
tasked with taking the research agenda forward. This taskforce is
still in its nascent stage. In the meantime, several agencies including
WHO, UNICEF and WaterAid, are continuing to carry out assessments
of WASH coverage in birth settings in low and middle-income
countries.
Conclusion
There is good evidence that WASH plausibly impacts on maternal
and newborn health at the time of delivery and the immediate
postpartum period through multiple direct and indirect mechanisms.
There is good evidence that WASH coverage and conditions in delivery
settings in low and middle-income countries is extremely poor.
There is also suggestive evidence that WASH may have impact on
reproductive, maternal and newborn health through multiple direct
and indirect mechanisms (i.e. throughout the life course).
While further research is required for a greater understanding of the
risks to MNH associated with WASH and the magnitude of the impacts,
there is sufficient evidence to advocate for increased attention to this
dimension by both WASH and MNH policy makers and practitioners.
Encouraging a higher proportion of deliveries in healthcare facilities is
a well-established strategy to tackle maternal and newborn mortality

in low-income countries. However, the coverage and quality of WASH

in healthcare facilities is widely inadequate. Without combining
such a strategy with strong infection prevention and control policies
and procedures, including adequate access to and quality of WASH,
maternal and newborn outcomes are unlikely to improve at the
necessary pace.
© UNICEF/UNI186633/Schermbrucker
South Africa, 2014. Siphiwe Khumalo, 37, Mother, and her newborn baby, Lundiwe.

WASH and menstrual

hygiene management
The problem
Menstrual Hygiene Management (MHM) is defined as: “women and
adolescent girls using a clean menstrual management material to
absorb or collect menstrual blood, that can be changed in privacy
as often as necessary for the duration of a menstrual period, using
soap and water for washing the body as required, and having access
to safe and convenient facilities to dispose of used menstrual
management materials. Furthermore, they understand the basic
facts linked to the menstrual cycle and how to manage it with
dignity and without discomfort or fear” (drafted by WHO/UNICEF
JMP Hygiene Working Group, 2012).
Approximately 52% of the female population is of reproductive
age (Population Reference Bureau, 2011). Most of these women
will experience menstruation – a natural part of the reproductive
cycle – every month. Safe and dignified MHM requires education
and knowledge, menstrual hygiene materials, access to facilities
that provide privacy for changing materials and washing and drying
menstrual cloths, access to water and soap, and access to disposal
facilities and systems for used menstrual materials. The inability
to adequately manage menstrual hygiene can have multiple and
interrelated health and social effects (Kirk & Sommer, 2006).
How can WASH support safe MHM?

1. Menstrual hygiene attitudes and practices
MHM practices differ across the world and are determined by
factors such as socioeconomic status, personal preferences, local
traditions and beliefs, knowledge and awareness, and access to the
necessary resources. Understanding the influence of WASH on MHM
requires an appreciation of these contextual factors. Several cross-
sectional studies have been carried out in recent years investigating
menstrual hygiene practices, attitudes, and experiences in different
settings, reporting on the taboo associated with menstruation,
misconceptions about what menstruation is, and different practices,
social norms and restrictions (Goel et al., 2011; Mason et al., 2013;
Tamiru et al., 2015; Trinies et al., 2015).

2. The effect of MHM on health and

social outcomes
The effect of interest here is the reduction in adverse health
and psychosocial outcomes associated with MHM as a result of
improvements in WASH.
For health, the focus is on reproductive tract infections, while the
social effects of ineffective management of regular menstruation
may include school absenteeism and the exclusion from everyday
tasks including touching water, cooking, cleaning, attending
religious ceremonies, socialising or sleeping in one’s own home or
bed. All of these can have profound psychosocial effects on women
and girls.
It is biologically plausible that poor MHM influences the health
of women and girls. Use of inadequate absorbent materials and
insufficient or ineffective cleansing are likely to provide a propitious
environment for the development of urogenital infections (Das et
al., 2014). Furthermore, a number of cross-sectional studies provide
a rich and textured picture of the effect on the psychological well-
being of adolescent girls associated with embarrassment, fear of
stigma, anxiety, and school absenteeism (Sommer, 2009; Sommer,
2010; Sommer & Ackatia-Armah, 2012; Caruso et al., 2013; Connolly
et al., 2013; Crichton et al., 2013; Haver et al., 2013; Long et al.,
2013; Jewitt et al., 2014; Sommer et al., 2014; Sahoo et al., 2015).
However, while we know that menstruation presents significant
challenges for women in lower-income settings, a 2013 systematic
review to appraise the evidence on the health and psychosocial
outcomes of the methods of menstrual hygiene management found
no published quantitative evidence that improving menstrual
practices improved women’s reproductive health and attendance
at school. There is a particular gap in the evidence base for
randomized intervention studies that combine both hardware
and software interventions for both health and social outcomes
(Sumpter & Torondel, 2014).
However, there was good evidence that educational interventions
can improve menstrual hygiene practices and reduce social
restrictions other than attendance at school. Since this review,
a case-control study in India on the effect of MHM practice on
urogenital infections—the first to explore the relationship between
MHM and such infections using both symptoms and laboratory-
diagnosed health outcomes —concluded that interventions which
ensure women have access to private facilities with water and
educate women about safer, low-cost MHM materials could reduce

urogenital disease among women (Das et al., 2014). Further, a

recent cluster randomized controlled feasibility study qualitatively
evaluated both the success of an intervention to provide menstrual
cups and commercial sanitary pads in improving MHM and the
potential effect on school attendance in rural Kenya (Mason et al.,
2015). Once comfortable, girls using cups or pads reported being
free of embarrassing leakage, odour, and dislodged items, and only
girls using traditional materials reported school absenteeism and
impaired concentration. While future quantitative results will add
precision to these findings, parents’ narratives corroborate girls’
accounts, particularly on improved comfort, security and well-being
(Mason et al., 2015).
3. Effective approaches for safe MHM

WASH programmes to date have given MHM insufficient consideration
(House et al., 2012), though there are indications that this
is beginning to change. As a result, the needs of women and
adolescent girls with regard to MHM are not often taken into
account in the design and delivery of WASH programmes. The
following observational studies have sought to evaluate the effect
of some of recent programmatic attempts to better integrate MHM
into WASH interventions. A UNICEF programme in Pakistan used
formative research to improve their understanding of the factors
influencing MHM in girls’ schools in order to strengthen the design
of interventions. Results showed significant improvement in MHM
conditions in the targeted schools (Naeem et al., 2015). In the same
year, a before-and-after study concluded that an intervention in India
aimed at the sensitization of men and boys had successfully changed
their understanding and perceptions of MHM (Mahon et al., 2015). The
intervention created community groups and trained male teachers
and masons (for example to design toilets and incinerators) to provide
MHM services in school. Also in 2015, an evaluation of a play-based
approach to MHM through WASH school programmes in Ghana found
changes in awareness of and attitudes towards MHM, in teachers and
school children (Dorgbetor et al., 2015).
In the absence of rigorous trials, a small number of manuals have
been developed drawing on the existing body of qualitative studies
to support practitioners to improve menstrual hygiene for women
and girls in low and middle-income countries. One such manual is the
Menstrual Hygiene Matter Manual produced by WaterAid (House et
al., 2012). In 2013, the International Federation of Red Cross (IFRC)
developed a set of recommendations for meeting the MHM needs of
women and adolescent girls specifically in a humanitarian emergency
context, drawing on operational research to evaluate two different
MHM kits (IFRC, 2013).

There remains a need for more rigorous controlled intervention

studies that combine hardware and software interventions, not only
to better understand the health and social impacts of MHM, but also
to identify the most effective approaches to realising safe MHM.
Such solutions must be grounded in the local context, and designed
according to the recommendations of girls and women (Sommer,
2010b).

There are still several areas where knowledge is insufficient and
additional research is called for, and these have been summarized
in a recent concept note by Phillips-Howard and colleagues (2014).
The following topics cover the broad areas where future research is
needed:
•S
pecific infections: Recent research has shown a link between
inadequate MHM and urogenital infections. Further evidence is
required on the prevalence and transmission of specific infections;
•S
trength of the effect: A greater understanding of the strength
of the effect of inadequate WASH on MHM and, through this, on
the health and social environment of women and girls is important
to help advocate for increased attention in this area, and guide
investments and interventions;
•M
easuring and monitoring ‘good’ MHM: While MHM itself
has been defined, universal agreement is still required on the
definitions of outcome measures, such as targets to indicate
successful implementation;
•U
nderstanding what works: Formative research and impact
studies of actual interventions on the ground is required to
improve our understanding of what constitutes an effective WASH
in Schools (WinS) intervention.

Ongoing studies
A number of studies continue to study important questions for
MHM. MENISCUS is a feasibility and preparatory study for a cluster
randomized trial on menstrual hygiene and safe male circumcision
promotion in Ugandan schools. It is led by LSHTM and the Uganda
Virus Research Institute (UVRI) and funded by the UK Medical
Research Council (MRC). WASH in Schools for Girls, led by UNICEF
in collaboration with Emory University and Columbia University,
constitutes formative research on MHM in 14 countries, to enable
the development of tools and recommendations for incorporating
MHM effectively in WinS national policy and programming. A case-
control study to examine the association of infections such as
bacterial vaginosis (BV) and vulvovaginal candiasis (VVC) with
MHM practices is ongoing in Orissa, India, following on from the
above-mentioned case-control (Das, 2014). Further, a cluster RCT
is ongoing in western Kenya that follows completion of the above-
mentioned pilot study showing safe cup use by rural Kenyan primary
schoolgirls (Mason et al., 2015). Led by the Liverpool School of
Tropical Medicine, the trial will examine the impact and cost-
effectiveness of menstrual cups, compared or combined with a cash
transfer, to improve the retention of rural girls in secondary school
and protect their sexual and reproductive health (SRH).
Conclusion
Having the knowledge, facilities, and supplies to manage
menstruation safely, from a health point of view, and with dignity
and convenience, is fundamental to women’s full participation in
society, to the expansion of their freedoms and choices, and to the
full realization of their rights to equality and self-determination.
There is good qualitative evidence of the challenges and barriers
associated with MHM among schoolgirls and women. While the 2013
systematic review (Sumpter & Torondel, 2014) uncovered the weak
evidence base for the effect of poor MHM on social and health
outcomes for this cohort, this has since begun to be addressed, with
two rigorous studies providing suggestive evidence of the effect of
MHM on urogenital infections and school absenteeism respectively.
While more experimental research is undoubtedly needed for a
greater understanding of the characteristics and magnitude of the
health and psychosocial impacts associated with poor MHM, enough
is known at present to warrant increased attention to this issue by
the WASH and education sectors, as well as the reproductive health
sector. In essence, few would contest that a girl or woman without

access to water, soap, and a toilet, whether at home, school, or

work, will face great difficulties in managing her menstrual hygiene
effectively and with dignity. Furthermore, we know what is required
to enable safe, dignified management of menstrual hygiene:
knowledge, materials and facilities. Better understanding the
precise impacts of this problem (including the differentiated impact
on minority and vulnerable groups, such as women with disabilities
or in emergency settings) and how to measure them, as well as the
most effective interventions to address these, will certainly provide
a stronger case for investment in this area and greater guidance for
policy and practice. However, evidence to-date provides grounds
enough to advocate for greater policy and programmatic attention
on this issue.
© UNICEF/UNI91702/Taylor
India, 2005. A girl carrying a water container on a one and a half hour walk home. During
monsoons the roads are inaccessible, even by cars.

WASH and school attendance

The problem
There is evidence to suggest that school absenteeism is related to
a decrease in academic performance, drop out rates and delays in
academic development (Lamdin, 1996; Reid, 2003; Bener et al.,
2007; Kearney, 2008; Moonie et al., 2008; Baxter et al., 2011).
While the available evidence is focused primarily on middle and
high-income countries, there is no reason to believe that these
impacts are not relevant in low-income countries.
The social and economic knock-on effects of reduced academic
performance or, in some cases, drop out, are likely to be far-
reaching for the individual, but also at the community, region and
country. For example, under-attainment in school can affect a
child’s job prospects and their livelihood, as well as their social
development, which in turn can hold back economic growth and
social development in the locality.
How does WASH influence school

attendance? Recent updates in
knowledge
1. Can WASH affect school attendance?
The effect of WASH on school attendance or educational
performance can manifest itself through five main pathways:
•P
upil absence due to diarrhoeal disease and/or respiratory
infections: It was n estimated that 194million school days would
be gained due to less diarrhoeal disease if MDG targets for
sanitation were met(WHO, 2004);
•G
irls’ absence due to difficulty of managing MHM: One
contributing factor is a lack of appropriate WASH facilities,
without which many girls are likely to miss school while they
menstruate. Without the appropriate facilities girls cannot
adequately manage their menstrual hygiene, resulting in
particular in fear of embarrassment or teasing associated with
unpleasant odours or stains (Sommer, 2010; McMahon et al., 2011);

•R
educed cognitive function and performance associated with
NTD infections and dehydration: Some of the most severe
consequences of chronic worm infections, which are strongly
associated with WASH (see p.38 for further information) are those
related to education, and intellectual achievement. Children
subject to intense infections with whipworm miss double the
number of school days as their infection-free peers (WHO, 2005).
Similarly, heavy-intensity hookworm infections in children have
been shown to produce growth retardation, impaired learning,
increased absences from school and decreased future economic
productivity (Miguel & Kremer, 2004). Dehydration is another
potential cause of reduced cognitive function and performance
(Hunter et al., 2014);
• Truancy associated with fear of assault: pupils of schools where
WASH facilities do not provide adequate privacy and safety may
fear assault or violence, which could lead to a decision not to
attend school;
•P
upil absence due to the need to fetch drinking water: This can
lead to missed classes, in particular if children have to make more
than one trip per day to collect water (Fisher, 2004; Hemson,
2007). One study in 25 countries in sub-Saharan Africa estimated
that, collectively, children spent 4 million hours per day collecting
water, which made them unable to attend school (WHO, 2012b).
2. Effect of WASH intervention on school

attendance
The effect of interest here is the reduction in school absenteeism as
a result of improvements in WASH.
While there is sufficient evidence to support the plausibility of the
above impact pathways, evidence from empirical studies on the
effect of WASH interventions on school attendance remains limited.
A 2011 systematic review found insufficient evidence for or against
the hypothesis that separate toilets for girls in schools may increase
school enrolment and attendance for girls (Birdthistle et al., 2011).
A more recent systematic review by Willmott and colleagues to
assess the potential of hand hygiene interventions in schools to
reduce absenteeism and illness, also found serious limitations
with the available evidence. However, this review nonetheless
concluded, on the basis of individual study findings, that such
interventions might decrease absence and respiratory tract
infections (Willmott et al., 2015).

One of the RCTs included in the 2015 review (Willmott et al., 2015)
was the SWASH project, a cluster randomized trial of school-based
WASH on pupil absence conducted in Nyanza Province, Kenya. The
trial tested the effect of WASH interventions on pupil absence,
diarrhoeal disease and reinfection with STH and found that the
water treatment (WT) and hygiene promotion (HP) interventions
combined reduced absenteeism by 39% in selected geographic
areas. Adding a sanitation component (latrine provision) resulted
in only marginally significant reductions. The impact was greater
on girls, with a reduction of 58% in girls’ absenteeism resulting
from the WT and HP interventions alone, but no effect on boys
(Freeman et al., 2012). The study also found that those pupils in the
intervention schools where there was an absence of adequate water
supply nearby showed a reduction in diarrhoea incidence and days
of illness, suggesting that a comprehensive WASH intervention at
the school level can be effective in preventing diarrhoea (Freeman
et al., 2014). Furthermore, the comprehensive WASH intervention
reduced reinfection rates and the prevalence and intensity of
Ascaris infections, even with sub-optimal intervention compliance.
The reduction in reinfection rates was only statistically significant
among girls in the intervention schools. The authors suggest that
this may be because girls are less likely to urinate or defecate in
the open, and may therefore benefit more when latrines are new or
clean, or when handwashing water and soap are available (Freeman
et al., 2013).
A recent collaboration between Emory University and UNICEF,
which investigated the personal challenges and needs that girls
have during menstruation in the school setting (Caruso et al., 2013;
Haver et al., 2013; Long et al., 2013) also focuses on the potentially
increased impact on girls of WASH in schools. Furthermore, a study
using annual school-level data from India, disaggregated by student
sex and grade, found that while at younger ages girls and boys both
benefit substantially from a latrine, regardless of whether it is sex-
specific, pubescent-age girls do not benefit from unisex latrines and
their enrolment increases substantially after the construction of
separate, sex-specific, latrines (Adukia, 2014). A cluster randomized
controlled feasibility study evaluating the impact of the provision of
menstrual cups and commercial sanitary pads on school attendance
in Kenya (Mason et al., 2015) suggested that those using the
new materials did not report school absenteeism and impaired
concentration.


Further research is required to adequately investigate the impact
of WASH interventions in schools, and in communities, on students’
school attendance and performance. Evidence gaps that should be
addressed include:
•D
eveloping effective measurements: Further investigation is
required on how to effectively measure education attendance and
attainment as key outcomes of interest;
•E
ffect of MHM interventions on girls’ schooling: This includes
exploring interventions that address physical structures, taboos
and harassment associated with MHM;
• Identifying effective school-based WASH interventions:
Successfully changing behaviours associated with hand hygiene
and sanitation practices in schools for boys and girls remains a
challenge. More models of successful behaviour change, resulting
from experimentation, optimization and adaptation grounded
in context-specific formative work, as well as how to translate
these into effective design of hygiene promotion programmes are
needed;
•R
ole of teaching staff: Understanding how teachers, both male
and female, can best contribute to a positive school environment
for MHM for girls.
Ongoing studies
WASH in Schools for Girls, led by UNICEF in collaboration with
Emory University and Columbia University, constitutes formative
research on MHM in 14 countries to enable development of tools
and recommendations for incorporating MHM in WinS national
programming.

Conclusion
There is good evidence to suggest that WASH can affect school
absenteeism through a number of mechanisms. There is suggestive
evidence as to the effect of WASH interventions on school
absenteeism. While systematic reviews point to the weak quality
and limited quantity of studies seeking to quantify this relationship,
a small number of studies carried out since then have begun to
bolster this evidence base.
While further rigorous trials are required to explore the various
mechanisms through which WASH can affect school absenteeism and
to seek to effectively quantify these effects, there is nonetheless
already a clear human rights mandate for the WASH and education
sectors to work together to provide appropriate WASH in schools.
© UNICEF/UNI108113/Asselin
Sierra Leone, 2011. A boy washes his hands with soap after using a latrine at the Missionary
Baptist primary school in Pendembu, Kailahun district.

WASH and oral vaccine

performance
The problem
Vaccination is a cost-effective intervention for communicable disease
control, preventing 2 million to 3 million deaths per year (WHO,
2014b). The success of vaccination as a public health strategy has
been marked by a number of important milestones, including the
eradication of smallpox in 1980, the reduction in the number of polio-
endemic countries from 125 in 1988 to just four today (Jamison et
al., 2006; GAVI, 2015), and a 78% decrease in global measles mortality
between 2000 and 2008 (WHO, 2009; GAVI, 2015).
Oral vaccines are preferred to injectable vaccines, because they
protect better against enteric infections and are more amenable to
mass administration. However, clinical trials in sub-Saharan Africa
and South Asia suggest that oral rotavirus vaccine (RV) efficacy
varies significantly by region: from over 90% in Europe and North
America to approximately 45% in high-burden countries in South Asia
and sub-Saharan Africa (Walker et al., 2011). Despite the enormous
potential for reducing the burden of communicable disease through
immunization, oral RV appears to perform less well in low-income
settings – where the need is greatest (Sack et al., 2008, Serazin et
al., 2010; Clemens et al., 2011; Qadri et al., 2013). This phenomenon
has been observed for other oral vaccines as far back as the early oral
polio vaccine trials of the late-1950s (LeBrun et al., 1959; Plotkin et
al., 1959; Horstman et al., 1960; Soares-Weiser et al., 2012).
How might WASH influence vaccine

performance? Recent updates in
knowledge
1. Can WASH affect vaccine efficacy?
A number of competing hypotheses have been proposed to explain the
observed variation in oral vaccine performance, including maternal
antibody interference (Ahmed et al., 2009, Qadri et al., 2013),
malnutrition, (Ahmed et al., 2009; Snider et al., 2011; Rashidul et al.,
2014) and the disease state of the host (Patel et al., 2013). However,
many of these hypotheses have been tested in trial settings without
confirmation (Rongsen-Chandola et al., 2014; Ali et al., 2015; Ali, A.
et al., 2015; Saleem et al., 2015; Mychaleckyj et al., 2016).

One potential explanation for this is that enteric co-infections in

low-income settings may result in reduced oral vaccine responses
(Madhi et al., 2010). This is consistent with findings for vaccines
for cholera (Simanjuntak et al., 1992), polio (John, 1976) and
typhoid (Simaniuntak et al., 1991), as well as earlier generations of
RVs (Georges-Courbot et al., 1991). Furthermore, there is growing
interest in the potential role of sustained environmental exposure
to enteric pathogens resulting from poor WASH, which may drive
EED, a subclinical gut disorder (Humphrey 2009; Prendergast et
al., 2012, Keusch et al., 2014); EED may plausibly reduce oral
vaccine performance. If enteric co-infections reduce vaccine
response in low-income settings, then reductions in environmental
enteric exposures through improved sanitation and hygiene could
potentially increase vaccine efficacy, making the two intervention
strategies synergistic.
2. The effect of WASH interventions on vaccine

efficacy
While plausible, there have been no rigorous intervention studies to
demonstrate the effect of WASH improvements on vaccine efficacy
to date.

While the above hypothesis to explain reduced vaccine efficacy is
plausible, further scientific evidence is required to substantiate
our understanding of the contribution of improved WASH to vaccine
efficacy.
•L
ive oral vaccine efficacy: An assessment of the impact of poor
sanitation and hygiene on this effectiveness is required;
• Effective integration strategies: More work is needed to identify
effective strategies for incorporating WASH behaviour change into
vaccination programmes, or developing integrated programmes.
Ongoing studies
A number of important large-scale studies are underway that, when
finalized, should significantly improve our understanding of the
contribution of WASH to the optimization of oral vaccine efficacy.
A study entitled Exploration of the biologic basis for the
underperformance of enteric vaccines in Zimbabwean infants, led
by Queen Mary University of London, aims to better understand why
the polio vaccine is less immunogenic when given to children in

developing countries compared to children in developed countries.

It will evaluate the impact of intestinal health, HIV exposure,
interference from passive maternal and breast milk antibodies
and high-dose neonatal Vitamin A supplementation. The SHINE
trial, conducted by the same group of investigators in Zimbabwe,
is a cluster randomized, community-based trial investigating the
independent and combined effects of improved infant diet and/or
improved WASH on stunting and anaemia (NCT01824940). This trial
will also evaluate the impact of WASH on oral RV immunogenicity
in a subgroup of children. The MAL-ED study, described on p.16,
studies specific enteric infections and their effect on child growth
and development, including an evaluation of the immunogenicity
of oral vaccines. The SaniVac trial (a controlled, before-and-after
trial), a nested sub-study of the MapSan trial described on p.14
(Brown et al., 2015), will assess whether the performance of oral
RV can be improved by a sanitation intervention that reduces
environmental exposure to enteric pathogens in a low-income, high-
burden setting. The intervention provides low-income households
in informal settlements with improved shared sanitation. Outcome
measures include enteric infections as indicated in stool samples,
markers of EED, anthropometry, and salivary IGF1.
The PROVIDE study, coordinated by the Centre for Public Health
Genomics, University of Virginia, is investigating the association
of EED and other possible explanatory factors with oral polio and
rotavirus vaccine failure in communities in Dhaka, Bangladesh, and
Kolkata, India. One further study is currently underway in India,
led by Vellore’s Christian Medical College, on the impact of oral
antibiotics and oral vaccine immunogenicity. While neither of these
two studies includes an evaluation of a WASH intervention, their
focus on the effect of EED and enteric infections on oral vaccine
immunogenicity should shed further light on the role that WASH has
to play in improving oral vaccine performance.
Conclusion
There is suggestive evidence that intestinal health is an important
determinant of oral vaccine immunogenicity and that WASH may
therefore have an effect on oral vaccine performance. Although
research demonstrating the effect of WASH interventions is
currently lacking, three ongoing trials are likely to make a
significant contribution in this respect.

Irrespective of the benefits for vaccine performance, routine

immunization campaigns may be a useful entry point for promoting
safe hygiene among caregivers for young children (Velleman et al.,
2013). Work is currently underway with the Ministry of Health of the
Government of Nepal to pilot the integration of hygiene promotion
messaging within immunization programmes.

© UNICEF/UNI81842/Mojumder
Bangladesh, 2010. A boy is taking a vaccine from a volunteer during Measles Vaccination
Campaign in a community clinic in Sirajgonj.

WASH and neglected

tropical diseases
The problem
Neglected tropical diseases (NTDs) are a diverse group of
communicable diseases that prevail in tropical and subtropical
conditions (WHO). Several NTDs are related to WASH: trachoma,
schistosomiasis, STH infections, neglected zoonoses, dengue
haemorrhagic fever, dracunculiasis (guinea-worm disease) and
lymphatic filariasis (elephantiasis). The following NTDs are discussed
in more detail in this section: STH infections, trachoma, and
schistosomiasis.
STH infections are among the most common infections worldwide
and affect the poorest and most deprived communities. They are
transmitted via eggs present in human faeces, which contaminate
soil in areas where sanitation is poor (WHO). The most common
STH infections are roundworm (Ascaris lumbricoides), whipworm
(Trichuris trichiura) and human hookworm (Necator americanus and
Ancylostoma duodenale). These infections together affect over 1
billion people globally (Bethony et al., 2006). There is still debate
as to the global health impact of these worm infections, with
estimates ranging between 4 million and 39 million DALYs (Brooker,
2010). The majority of the disease burden associated to STH
infections is understood to be in children of school age. Moderate
to heavy infections with whipworm and roundworm in children can
lead to undernutrition and growth faltering (O’Lorcain & Holland,
2000). Moderate to heavy infections with any STH in children can
also impair cognitive development (Jukes et al., 2008; Stephenson
et al., 2000). Chronic and recurring hookworm infections throughout
childbearing age can cause maternal anaemia, which contributes
to a higher risk of low birth-weight, spontaneous abortions,
higher risk of foetal morbidity and mortality, and higher morbidity
and mortality for women (Brooker et al., 2008). Severe cases of
roundworm can result in intestinal obstruction, and it has been
estimated that this complication can explain 10,000 deaths per year
(de Silva et al., 1997).
Trachoma is caused by the bacteria Chlamydia trachomatis and is
the leading cause of infectious blindness in the world. The infection
is transmitted through contact with eye and nose discharge of
infected people, particularly young children who are the principal

reservoir of infection. The filth fly (Musca sorbens) is considered an

important mechanical vector of the disease, by feeding on ocular
and nasal secretions of infected people (WHO). The fly prefers to
breed almost exclusively in scattered faeces.
Schistosomiasis is a disease caused by worms. Schistosomiasis
is transmitted when people come into contact with fresh water
infested with the larval forms of parasitic blood flukes known as
schistosomes (WHO). It can cause chronic and often irreversible
liver and kidney failure. Children are more likely to get infected
than adults. Although these estimates require review, it is believed
that 200 million people are infected worldwide, leading to the loss
of 1·53 million DALYs. (Gryseels et al., 2006).
How does WASH influence NTDs

transmission? Recent updates in
knowledge
1. Can WASH affect STH, trachoma and
schistosomiasis?
Evidence of the transmission pathways of the three above NTDs
provides an indication of the impact of WASH on infection.
The following section presents the evidence base with respect
specifically to STH, trachoma and schistosomiasis.
STH: Inadequate sanitation is important for the transmission of
STH. The majority of worm infections are transmitted through
contact with soil contaminated with worm eggs coming from the
faeces of infected humans. They enter the human host either
through penetration of the skin (hookworm) or ingestion from
contaminated hands or agricultural produce (roundworm and
whipworm). Adequate sanitation prevents release of faeces into the
environment, thereby preventing transmission.
Trachoma: Lack of hygiene and access to water plays an important
role in trachoma transmission. Musca sorbens flies act as mechanical
vectors of the trachoma. It has been estimated that Musca sorbens
flies that breed in scattered human faeces account for over 70% of
trachoma incidence (Emerson et al., 2004; Montgomery & Bartram,
2010). Inadequate personal hygiene, which is often predicated
on the lack of enough water, leads to child-to-child transmission
of trachoma as well as attracting the trachoma-carrying flies to
unclean faces.

Schistosomiasis: Inadequate access to water plays a significant role

in the transmission of schistosomiasis, as this can force households
to rely on surface water sources for their domestic water needs.
Snails that live in surface water are an essential intermediate host
for the transmission to a human. They shed infected larvae into the
water that will penetrate skin when a potential host comes into
contact with contaminated water. For example, women or children
collecting water, washing or bathing.
2. Effect of WASH interventions on NTD

infection
The effect of interest here is the reduction in NTD infection or
reinfection as a result of improvements in WASH.
At present, strategies to tackle these diseases focus on MDA
programmes, which are not only costly, but have been shown to be
associated with high re-infection rates (Ziegelbauer et al., 2012;
Jia et al., 2012). There is evidence to suggest that progress would
significantly improve through the integration into MDA programmes
of WASH interventions, as preventive measures that address the
environmental causes of these diseases.
STH: In 2012 a systematic review for the effect of latrine
availability and use on STH infections found that the latter reduced
the risk of combined STH infection by about 50% (Ziegelbauer et
al., 2012). A more recent review considered all WASH interventions;
94 eligible studies were found, five of which were RCTs. Despite
the overall low quality of studies, the review found that WASH
access and practices were generally associated with reduced odds
of STH infection (Strunz et al., 2014). Sanitation was found to
be associated with lower odds of infection with any STH. While a
lower effect from water supply and hygiene should be expected,
given that infection occurs through contaminated soil, the review
nonetheless found substantially reduced odds of infection associated
with access to water and hygiene. For hygiene, three RCTs provided
strong evidence linking hygiene practices – especially handwashing
with soap – to reductions in STH infection (Balen, 2011; Bieri, 2013;
Gyorkos, 2013). Despite the low number and quality of studies on
the use of treated water and piped water, associations were also
found.
Since the systematic review, three studies have been published
that provide further evidence of the impact of WASH interventions
on STH prevalence and reinfection. One cross-sectional study, in
Kenya, points to the importance of WASH in explaining the variable

performance of school-based deworming programmes across the

country and within counties (Nicolay et al., 2015). Another cross-
sectional study, in Argentina, reports an association between
poor sanitation and water according to the route of entry of STH
infections to the human host – demonstrating the potential role
of sanitation interventions in preventing STH skin-penetrators and
improved water on stopping transmission of orally ingested STHs.
(Echazú et al., 2015). This finding could have implications for the
more effective design of interventions where specific transmission
routes need to be targeted.
Trachoma: The SAFE strategy, adopted by the WHO Global Alliance
for the Elimination of Trachoma by the Year 2020, includes four
components: eyelid Surgery, Antibiotics, Facial cleanliness and
Environmental improvement. WASH interventions play an integral
role in components ‘F’ and ‘E’. In 2012 a synthesis conducted by
Cumming and colleagues of existing systematic reviews on these
SAFE components concluded that there was sufficient evidence on
all four elements to justify the urgent execution of this strategy in
endemic regions (see table 1 below). In 2014, Stocks and colleagues
Table 1: Summary of systematic reviews on

SAFE components
Review S A F E
Non-WASH WASH
Evans et al., 2011
Hu et al., 2010
Rabiu et al., 2007
Ejere et al., 2007
Yorston et al., 2006
Prüss-Üstün &
Mariotti, 2000
Emerson et al., 2 0
Stocks et al., 2014
SOURCE: Updated from Cumming et al., 2012

conducted a systematic review on the effect of water, sanitation and

hygiene on the prevention of trachoma. This review substantiated
the findings of earlier reviews focusing on the WASH related
components of the SAFE strategy. Eighty-six eligible studies were
found that reported an effect of WASH on trachoma, and the authors
found evidence of an association between improved WASH conditions
and exposures and reduced trachoma in 11 of the 15 meta-analyses
conducted. The strongest association was found between facial
cleanliness and lower levels of trachoma. A strong association was
also found for access to sanitation, while the effect was smaller for
distance to water source. While a number of studies reported an
association between improved water quantity and reduced odds of
trachoma, the low number of articles precluded the possibility of a
meta-analysis. The review concluded that, despite the low quality of
the studies included, there is strong evidence to support the ‘F’ and
‘E’ components of the WHO SAFE strategy, and the importance of
WASH in trachoma elimination strategies (Stocks et al., 2014).
Schistosomiasis: The importance of WASH in preventing
schistosomiasis has long been noted. In 1991, Esrey and colleagues
concluded, based on four studies regarded to be rigorous on the
effect of providing water supply and washing facilities, that the
median reduction in schistosomiasis morbidity reached 77%. More
recently, a systematic review on the relationship between water,
sanitation and schistosomiasis has shown that existing studies
substantiate this claim. The review found a total of 44 eligible
studies reporting schistosomiasis infection in people who did or did
not have access to safe water and adequate sanitation. Despite
the largely poor quality of the studies, the majority of which
were cross-sectional, safe water supplies were associated with
significantly lower odds of schistosomiasis and adequate sanitation
was associated with lower odds. Furthermore, the difference
in infection rates between people with and without access to
clean water and sanitation varied widely between studies. This
suggests that the impact of water and sanitation on schistosomiasis
transmission is mediated by many other social and environmental
factors, which require further investigation (Grimes et al., 2014).

Evidence suggests WASH contributes in varying degrees to NTD
prevention and to treatment and care. As a result the provision
of WASH is one of the five key interventions within the global NTD
roadmap. However, in order to achieve further reductions in the
transmission and burden of NTDs, especially those linked to poor
WASH conditions, more evidence is needed to:

•U
nderstand the effect of different WASH interventions: Using
rigorous experimental studies to better understand the effect of
WASH interventions on disease transmission pathways (Grimes et
al., 2014; Stocks et al., 2014; Strunz et al., 2014);
•A
ssess and quantify the magnitude of effect: Assessment of
the magnitude of the benefit from WASH interventions for NTDs
(Strunz et al., 2014);
•U
nderstand the impact of shared sanitation: Further
investigation of the impact of sharing latrines or latrine
maintenance on STH and trachoma is needed (Stocks et al., 2014;
Strunz et al., 2014);
•U
nderstand the effect of treating water: Further exploration of
the effect of treating water on NTD infection (Strunz et al., 2014)
is needed;
•C
haracterise the role of geophagy: The practice of eating earth,
known as geophagy, will plausibly have an effect on infection or
reinfection from STH, but further evidence is required to explore
this (Strunz et al., 2014);
•U
nderstand the impact of WASH on Faecal STH egg count:
Further investigation of the relationship between faecal egg
count—a proxy for intensity of infection—and WASH. Intensity of
infection represents a more relevant predictor for morbidity than
prevalence alone (Strunz et al., 2014).
Ongoing studies
Two large trials are currently ongoing which seek to address some
of these gaps in knowledge. The WASH Benefits Study, details of
which are on p. 15-16, will measure the health and developmental
benefits of water, sanitation, handwashing and nutritional
interventions among newborn infants in rural Bangladesh and
Kenya, including effects on certain NTDs. The Mikono Safi Study,
due to startlate-2016, will be an RCT involving 20 schools (and 6000
children), and will explore the impact of a handwashing with soap
behaviour change intervention targeted at school children on the
prevalence and intensity of two soil-transmitted helminth infections
(A. lumbricoides and T. trichuris) in this population. The study will
entail developing, implementing and evaluating a scalable school-
based HWWS intervention in Mwanza, Tanzania. It is a collaboration
between the Mwanza Intervention Trials Unit in Tanzania and the
London School of Hygiene and Tropical Medicine.

Conclusion
There is suggestive evidence on the effect of WASH interventions
on STH, trachoma and schistosomiasis. However, while there is
a continued need for further rigorous experimental studies to
strengthen our understanding of and quantify this effect, there
is nonetheless a strong rationale for action by the WASH sector in
this area. The nature of the disease transmission pathways for the
diseases in question renders the impact of WASH on this transmission
highly plausible. As such, WASH interventions offer an obvious and
potentially hugely effective barrier to this transmission.
© UNICEF/UNI111964/Asselin
Sierra Leone, 2011. A boy washes hands after using a latrine at Kathala Community Primary
School in the village of Kathala, in Bombali District.

WASH and disability

The problem
According to the Convention on the Rights of Persons with
Disabilities (CRPD), “persons with disabilities include those
who have long-term physical, mental, intellectual or sensory
impairments which in interaction with various barriers may hinder
their full and effective participation in society on an equal basis
with others” (UNGA, 2006).
People with disabilities, older people and the chronically ill make
up a considerable proportion of the global population. The World
Disability Report reported in 2011 that an estimated 15% of the
world’s population have a disability (WHO, 2011), 80% of whom live
in low and middle-income countries (WHO, 2011; WHO, 2014). The
Australian government estimates that only 3%-4% of people with
a disability benefit from international development programmes
(AusAID, 2011). Another population group likely to face similar
barriers as a result of their frailty, physical or mental impairment
are older people. It is estimated that there are 600 million people
over 60 years old (OHCHR, 2011). By the end of the decade, this
number is estimated to rise to 1 billion (HAI, 2013).
Disability disproportionately affects the poorest in society.
The World Disability Report estimates that 80% of people with
disabilities live in the developing world (WHO/World Bank, 2011)
a finding which is consistent with Elwan’s suggestion in 1999, well
over a decade ago, that among the poorest quintiles of populations
in low-income countries, as many as 1 in 5 individuals are likely
to have a disability (Elwan, 1999). This would suggest that almost
every poor family in low-income countries is affected in some way
by disability (Jones et al., 2002).
Disability is both a cause and a consequence of poverty (Jones et
al., 2002). People with a disability are more likely to be poor due
to the high cost of health services and assistive equipment, lack of
education or employment, and discrimination (Jones et al., 2002).
On the other hand, a number of factors associated with poverty
increase the risk of impairment amongst the poorer quintiles of
society, including poor nutrition, inadequate access to basic services
and limited health services.
The rights of people with disabilities to the full and equal
enjoyment of all human rights and fundamental freedoms are
enshrined, promoted and protected in the CRPD. This includes

the rights to accessibility (Article 9) and the right to an adequate

standard of living and to social protection (Article 28). The
international community has also moved towards appropriately
reflecting these rights in the new global development framework;
disabilities are explicit in seven Sustainable Development Goals,
with specific targets addressing equitable, inclusive and safe
access to sanitation and water, especially for those in vulnerable
situations.4 However, in practice, despite instruments and
undertakings designed to protect persons with disabilities, examples
persist across the globe of continued barriers in their participation
as equal members of society and violations of their human rights.
The Special Rapporteur for Persons with Disabilities has documented
these amply in recent submissions to the UN General Assembly
(Devandas-Aguilar, 2015; Heller, 2015).
The social model of disability, set out in 1970s by the Union of the
Physically Impaired Against Segregation, sees three distinct types of
barriers that people with a disability face to their participation in
activities of daily life: environmental, institutional and attitudinal
barriers (Jones et al., 2002). These are described in greater detail
in the section below, with specific reference to inclusive and
accessible WASH.
For most people with disabilities in low-income communities,
safeguarding their human rights to life, food, water and shelter is
a daily struggle (Seeley, 2001a; Singleton et al., 2001; Jones et al.,
2002; UN, 2002). With regard to education, only 10% of all children
with disabilities are in school and, of this number, only half actually
complete their primary education (UNESCO, 2007). Furthermore,
in many low-income countries only 5% to 15% of people with
disabilities who need assistive devices and equipment are able to
obtain them (UNICEF, 2015). In addition, the exclusion of people
with disabilities has an impact on their families and communities,
“in both human and economic terms” (Jones et al., 2002).
How does WASH affect people with a

disability? Recent updates in knowledge
Access to water and sanitation is as much a human right for people
with a disability as it is for the wider population, and, like the rest
of the population, this group is vulnerable to diseases caused by
faecal-oral contamination. Given the provision of accessible WASH
facilities, people with a disability should experience the same rights
and health-based benefits as the wider population.
4 UnEnable Disability-Inclusive Sustainable Development Goals Infographic. http://www.

un.org/disabilities/documents/sdgs/disability_inclusive_sdgs.pdf

However, people with a disability are reportedly at a higher risk of

having inadequate access to WASH facilities (OHCHR, 2011; WHO/
World Bank, 2011). According to one estimate, households in the
poorest quintile, those same households at risk of being affected by
disability, are 5.5 times more likely to lack improved water access
and 3.3 times more likely to lack adequate sanitation compared
with the highest wealth quintile in the same country (White et
al., 2016). Furthermore, more often than not, when facilities are
present they are not accessible to those with a disability (Danquah,
2014; Danquah, 2015; White et al., 2015). The built environment
“is so constructed that only a specific type of user can manoeuvre
around it” (UNESCAP, 1995a).
Little is known about the impact of poor WASH on the lives of
people with a disability and their families in low-income settings,
as concluded by a literature review of water supply and sanitation
access and use by people with physical disabilities carried out by
Jones and colleagues in 2002 (Jones et al., 2002). This review, and
a more recent mapping study (Jones et al., 2013) detailed barriers
faced by individuals with physical limitations that impaired their
access to WASH. These included the inability to carry out day-to-day
tasks and household chores – such as washing clothes or dishes, and
pouring water – were due to impairments, physical weakness or pain
(Jones et al., 2002). Environmental barriers included inaccessible
physical infrastructure or the environment, making it difficult to
access water sources and sanitation facilities, as well as affecting the
© UNICEF/UNI48759/Estey
Indonesia, 2007. A boy, assisted by his mother, leaves a wheelchair accessible latrine.

ability to transport water (Jones et al., 2002). Inaccessible toilets

can force children with disabilities and caregivers with disabilities to
wait until dark to defecate, increasing their risk of abuse (Devendas-
Aguilar, 2015). Institutional barriers include negative stereotypes and
discriminatory social policies about people with disabilities, which in
turn validate and reinforce negative attitudes (Jones et al., 2002).
Attitudinal barriers relate to the negative attitudes and behaviour of
family, community members, and service providers. This “complex
of cultural, social and economic rules” (UNESCAP, 1995a) can often
be an even greater problem for people with disability than the
impairment itself (Gunnarson, 1998).
Two recent studies have shed further light on the barriers faced by
people with disability when accessing WASH facilities. An action-
research project in Uganda and Zambia supported by WaterAid,
the Water, Engineering and Development Centre (WEDC) and
Leonard Cheshire Disability (LDC) to design and test inclusive
WASH interventions, mapped the environmental, institutional and
attitudinal barriers that people with disabilities, older people and
the chronically ill face when accessing standard WASH services.
Their findings echoed those found in 2002 by Jones and colleagues.
The project found evidence that inaccessible WASH designs force
people with physical impairments to crawl on the floor to use a
toilet or defecate in the open (WaterAid, 2011). A high proportion
of vulnerable household members are reliant on others to use the
toilet, sometimes soiling themselves while waiting, and many limit
their consumption of food and water to reduce the need to relieve
themselves (Wilbur, 2014). There was also evidence that people with
disabilities were considered contagious and therefore they were
prevented from using communal facilities (Wilbur & Danquah, 2015).
While Wilbur and Danquah’s 2015 study did not focus on the
barriers/challenges posed by the individual impairments themselves,
focusing rather on external barriers, more recent research by
White and colleagues in Malawi found an interesting variation
between individuals with regard to the WASH barriers that they
face, according to the nature of their individual impairments. For
example, individuals with a physical disability faced predominantly
physical barriers however this was not reported by those with
hearing impairments, epilepsy or mental health challenges (White et
al., 2016). Institutional barriers were faced by all, to some extent,
although people with sensory impairments were found to be most
significantly disadvantaged when it came to participation in WASH
events and access to information (White et al., 2016). Furthermore,
social barriers associated with traditional beliefs were reported to
affect people with cognitive impairments, epilepsy and albinism
more than others (White et al., 2016).

he effect of WASH interventions on the lives

T
of people with a disability
The effect of interest here is the reduction of adverse health
and social outcomes in people with disabilities as a result of
improvements in WASH.
At the time of writing, the authors were not aware of any
studies seeking to evaluate and/or quantify the effect of WASH
interventions on the lives of people with disabilities. However, the
existing literature on the nature of the barriers and challenges
facing people with disabilities with respect to WASH, as well
as studies to map existing best practice, suggest that WASH
interventions can improve the quality of life of this vulnerable group
and the realization of their rights.
Removing or reducing barriers is likely to be the primary means
by which WASH interventions might achieve greater inclusion of
people with disabilities (Danquah, 2014; Danquah, 2015). A checklist
for WASH practitioners on inclusive WASH, developed by WaterAid
and WEDC, following the action research in Uganda and Zambia
(Danquah, 2014; Danquah, 2015) lists specific characteristics
necessary in a WASH programme for it to be inclusive. This goes
from the initial situation analysis and baseline through community
mobilization and infrastructural plans, to monitoring and
evaluation, shining a spotlight throughout on the needs of the most
vulnerable in the community (WaterAid & WEDC, 2014a). The same
authors have also developed a Compendium of accessible WASH
technologies, which provides examples of inexpensive adaptations
of standard WASH technologies that families can adapt to suit their
needs and budgets (WaterAid & WEDC, 2014b).
According to White and colleagues, in addition to addressing
the barriers identified, it is also important for programmes to
understand WASH consequences, and WASH needs. Understanding
consequences – the experiences associated with WASH barriers
and needs, including increased pain and effects on health and
self-esteem – can provide context that can inform priority setting
and highlight the links between inclusive and accessible WASH,
poverty, ill health and self-esteem for people with disabilities.
Understanding WASH needs – anything that requires an individual to
use WASH facilities differently due to their personal characteristics
and impairment – can guide interventions towards provision of
equitable and appropriate access (White et al., 2016).
In addition to these broader recommendations for WASH
programmes, WEDC and WaterAid have drawn on their research in
Uganda and Zambia (Danquah, 2014; Danqah, 2015) to draft a set

of practical recommendations for facilitators and everyone engaged

with Community-Led Total Sanitation (CLTS) to make the process
fully inclusive (Wilbur et al., 2014). In a similar vein, White and
colleagues have drafted a proposed plan for ‘CLTS+’, to champion
a more inclusive process, drawing on and as a follow on to their
research in Malawi, soon to be published (White et al., 2016).

Since the literature review in 2002 (Jones et al.,) key studies have
improved our understanding of how poor WASH can affect the lives
of people with a disability. However, a number of knowledge gaps
remain, including:
• Understanding the hygiene needs of girls and women with
disabilities: How does inaccessible WASH affect the ability of girls
with disabilities to manage their menstrual hygiene with safety
and dignity? What are the main bottlenecks to providing private
and safe access for girls with disabilities?;
• Understanding the WASH needs of people with disabilities in
emergency settings: How does inaccessible WASH in emergency
settings affect people with disabilities?;
• Measuring inequalities: How can both intra- and inter-household
inequalities be measured through existing monitoring systems?;
• Quantifying the effectiveness of interventions: What measurable
effect do inclusive WASH programmes have on the lives of people
living with a disability?;
• Characterising the challenges faced by people with non-physical
impairments: What challenges do people with mental health,
intellectual and psychosocial disabilities face?;
• Understanding the impact of accessible WASH on schoolchildren
with disabilities: One-third of children out of school have
a disability (UNICEF, 2013a). Further research is needed to
understand the impact of improved WASH in communities and
schools on school enrolment for children with disabilities.

Ongoing studies
Further results from studies in Malawi and Bangladesh as part of
the DFAT-funded project ‘Disability and its impact on safe hygiene
and sanitation’, are being prepared for publication in early 2017.
These are expected to assess the impact of awareness raising and
access to adaptive sanitation hardware for people with disabilities.
Under the same project a revised questionnaire to assess the
quality of access to WASH services for people with a disability has
been prepared with the intention of pilot testing before the end of
2016. The Disability Centre at LSHTM is analysing survey data from
Bangladesh, Malawi, India, Cameroon to explore the prevalence and
nature of disability-related WASH access problems in these study
populations. Findings from this analysis are expected in 2017.
Conclusion
There is suggestive evidence that inaccessible WASH provision has
a negative effect on the lives of people with a disability. There is
also suggestive evidence that well-designed, inclusively delivered,
accessible WASH interventions can be effective in removing some of
the external barriers facing people with disabilities, and need not
cost more.
There is a need for rigorous research that builds a clearer picture
of the effects of inaccessible WASH on people with disabilities and
that further develops our understanding of how best to design and
deliver WASH interventions that improve the lives of this often-
vulnerable group. However, common sense and existing qualitative
evidence makes a strong case for the need for WASH interventions
to be fully inclusive in their approaches, if the human rights of
people with disabilities are to be upheld and the new ambition for
universal access and inclusive provision for WASH is to be achieved.
A recent mapping report by UNICEF (WASH and Disabilities) took
the measure of inclusive and accessible WASH activities in UNICEF
country offices globally. The study consolidated information about
what constitutes good practice, and found and documented several
examples of good practice in UNICEF country programmes. Drawing
on these examples, the report finds broad agreement among
WASH practitioners on the basic characteristics of good practice in
accessible and inclusive WASH:
ngage with the enabling environment (e.g. upstream policy
•E
advocacy, standards setting, addressing stigma, rights to
information in multiple formats);

onsult with and be participatory involving children with

•C
disabilities and Disabled Persons Organizations (DPOs);
•C
omprehensively define accessibility as combining sensitization
and social norms as well as technical and hardware solutions.
Furthermore, the UNICEF report, which was validated
through consultative processes with stakeholders, makes six
recommendations vis-à-vis planning and delivery of inclusive WASH
services:
1. S ocial/child Protection-WASH-C4D should collaborate in tackling
stigma;
2. W
ASH strategies should prioritize collaboration with DPOs for
upstream advocacy;
3. R
egional and country offices should be equipped with inclusive
WASH guidance and tools;
4. K
nowledge-sharing about inclusive WASH activities should be
incorporated into systems;
5. G
lobal data/evidence monitoring on inclusive WASH should be
advocated;
6. A
n investment case for inclusive and accessible WASH should be
developed.

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THE IMPACT OF WATER, SANITATION AND HYGIENE

ON KEY HEALTH AND SOCIAL OUTCOMES:

Sanitation and Hygiene Applied Research for Equity (SHARE)

UNICEF advisors: Sue Cavill, Greg Keast, Cindy Kushner

External reviewers: Lenka Benova, London School of Hygiene &

Editors: Vina Barahman, Phillip Poirier

This material has been funded by UK aid

WASH and diarrhoea 15

WASH and undernutrition 25

WASH and complementary food hygiene 32

The Impact of WASH on Key Health & Social Outcomes • PAGE 2

WASH, violence against women and girls,

WASH and maternal and newborn health 44

WASH and menstrual hygiene management 52

WASH and school attendance 58

The Impact of WASH on Key Health & Social Outcomes • PAGE 3

WASH and Oral Vaccine Performance 63

WASH and neglected tropical diseases 67

WASH and disability 74

The Impact of WASH on Key Health & Social Outcomes • PAGE 4

DALYs Disability-adjusted life years

DFID UK Department for International Development

DHS Demographic and Health Survey

EED Environmental Enteric Dysfunction

ETEC Enterotoxigenic Escherichia coli

GBV Gender-based violence

HWWS Handwashing with soap

IASC Inter-Agency Standing Committee

MDA Mass drug administration

MDGs Millennium Development Goals

MHM Menstrual hygiene management

MHPSS Mental health and psychosocial support

NTDs Neglected tropical diseases

PPSSP Programme de Promotion des Soins de Santé Primaires

RCT Randomized controlled trial

SDGs Sustainable Development Goals

STH Soil-transmitted helminth

UNICEF United Nations Children’s Fund

VAWG Violence against women and girls

WASH Water, sanitation and hygiene

WHO World Health Organization

WinS WASH in schools

The Impact of WASH on Key Health & Social Outcomes • PAGE 5

The Impact of WASH on Key Health & Social Outcomes • PAGE 6

The Impact of WASH on Key Health & Social Outcomes • PAGE 7

9. While investments to address NTDs remain largely focused on

The Impact of WASH on Key Health & Social Outcomes • PAGE 8

The Impact of WASH on Key Health & Social Outcomes • PAGE 9

This evidence paper does not make specific recommendations on

1. Assessing the scale of the problem

To achieve this, each thematic chapter addressing a different

The Impact of WASH on Key Health & Social Outcomes • PAGE 10

Interpreting the evidence on WASH

The Impact of WASH on Key Health & Social Outcomes • PAGE 11

outcome of GRADE when navigating questions with high biological

The Impact of WASH on Key Health & Social Outcomes • PAGE 12

There is clearly a tension that exists between achieving internal

Box 1: Bradford Hill’s ‘viewpoints’ for assessing causality

The Impact of WASH on Key Health & Social Outcomes • PAGE 13

9. While investments to address NTDs remain largely focused on

2.The effect of WASH interventions on

2 Nutrition-sensitive interventions: Interventions or programs that address the underlying

Figure 2: Interventions and programmes required to tackle child undernutrition

2.The effect of WASH interventions

2. The effect of WASH interventions on