Estimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs). In this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164. 19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41–0·60]), solar treatment (n=13; 0·63 [0·50–0·80]), and chlorination (n=25; 0·66 [0·56–0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26–0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61–0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30–0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64–0·76]). WASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG. WHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.

Assessments of disease burden are important to inform national, regional, and global strategies and to guide investment. We aimed to estimate the drinking water, sanitation, and hygiene (WASH)-attributable burden of disease for diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiasis, using the WASH service levels used to monitor the UN Sustainable Development Goals (SDGs) as counterfactual minimum risk-exposure levels. We assessed the WASH-attributable disease burden of the four health outcomes overall and disaggregated by region, age, and sex for the year 2019. We calculated WASH-attributable fractions of diarrhoea and acute respiratory infections by country using modelled WASH exposures and exposure-response relationships from two updated meta-analyses. We used the WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene public database to estimate population exposure to different WASH service levels. WASH-attributable undernutrition was estimated by combining the population attributable fractions (PAF) of diarrhoea caused by unsafe WASH and the PAF of undernutrition caused by diarrhoea. Soil-transmitted helminthiasis was fully attributed to unsafe WASH. We estimate that 1·4 (95% CI 1·3-1·5) million deaths and 74 (68-80) million disability-adjusted life-years (DALYs) could have been prevented by safe WASH in 2019 across the four designated outcomes, representing 2·5% of global deaths and 2·9% of global DALYs from all causes. The proportion of diarrhoea that is attributable to unsafe WASH is 0·69 (0·65-0·72), 0·14 (0·13-0·17) for acute respiratory infections, and 0·10 (0·09-0·10) for undernutrition, and we assume that the entire disease burden from soil-transmitted helminthiasis was attributable to unsafe WASH. WASH-attributable burden of disease estimates based on the levels of service established under the SDG framework show that progress towards the internationally agreed goal of safely managed WASH services for all would yield major public-health returns. WHO and Foreign, Commonwealth & Development Office.

Novel-coronavirus disease-2019 (COVID-19) is currently a pandemic and public health emergency of international concern, as avowed by the World Health Organization (WHO). Ethiopia has become one of the affected countries as of March 15, 2020. This study aimed to assess the knowledge, perceptions, and practices among the Jimma University medical center (JUMC) visitors in Jimma town. A cross-sectional study was conducted on 247 sampled visitors, from 20–24 March 2020. Consecutive sampling was used to recruit the participants. The study tools were adapted from WHO resources. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0. Descriptive statistics were used to describe the status of knowledge, perception, and practices. Logistic regression was executed to assess the predictors of dominant preventive practices. Of the 247 respondents, 205 (83.0%) knew the main clinical symptoms of COVID-19. 72.0% knew that older people who have chronic illnesses are at high risk of developing a severe form of COVID-19. About 95.1% knew that the COVID-19 virus spreads via respiratory droplets of infected people, while 77 (31.2%) of the respondents knew about the possibility of asymptomatic transmission. Only 15 (6.1%) knew that children and young adults had to involve preventive measures. Overall, 41.3% of the visitors had high knowledge. The majority, 170(68.8%), felt self-efficacious to controlling COVID-19. 207(83.3%) believed that COVID-19 is a stigmatized disease. Frequent hand washing (77.3%) and avoidance of shaking hands (53.8%) were the dominant practices. Knowledge status and self-efficacy (positively), older age, and unemployment (negatively) predicted hand washing and avoidance of handshaking. The status of knowledge and desirable practices were not sufficient enough to combat this rapidly spreading virus. COVID-19 risk communication and public education efforts should focus on building an appropriate level of knowledge while enhancing the adoption of recommended self-care practices with special emphasis on high-risk audience segments.

Over 650 million people worldwide lack access to safe water supplies, and even among those who have gained access to ‘improved’ sources, water may be seasonally unreliable, far from homes, expensive, and provide insufficient quantity. Measurement of water access at the level of communities and households remains crude, and better measures of household water insecurity are urgently needed to inform needs assessments and monitoring and evaluation. We set out to assess the validity of a quantitative scale of household water insecurity, and to investigate (1) whether improvements to community water supply reduce water insecurity, (2) whether water interventions affect women’s psychological distress, and (3) the impacts of water insecurity on psychological distress, independent of socio-economic status, food security, and harvest quality. Measures were taken before and one to six months after a community water supply improvement in three villages in rural northern Ethiopia. Villages similar in size and access to water sources and other amenities did not receive interventions, and served as controls. Household water insecurity was assessed using a 21-item scale based on prior qualitative work in Ethiopia. Women’s psychological distress was assessed using the WHO Self-Reporting Questionnaire (SRQ-20). Respondents were either female heads of household or wives of the heads of household (n = 247 at baseline, n = 223 at endline); 123 households provided data at both rounds. The intervention was associated with a decline of approximately 2 points on the water insecurity scale between baseline and endline compared to the control (beta -1.99; 95% CI’s -3.15, -0.84). We did not find evidence of impact of the intervention on women’s psychological distress. Water insecurity was, however, predictive of psychological distress (p <0.01), independent of household food security and the quality of the previous year’s harvest. These results contribute to the construct validity of our water insecurity scale, and establish our approach to measuring water insecurity as a plausible means of evaluating water interventions. Improvements to community water supplies were effective in reducing household water insecurity, but not psychological distress, in this population. Water insecurity was an important predictor of psychological distress. This study contributes to an emerging literature on quantitative assessment of household water insecurity, and draws attention to the potential impact of improved access to water on women’s mental well-being.