review of literature on sanitation pdf

System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review

Affiliations.

• 1 Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA.
• 2 USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA.
• 3 College of Engineering, George Fox University, Newberg, OR 97132, USA.
• PMID: 31973179
• PMCID: PMC7037755
• DOI: 10.3390/ijerph17030702

Endemic issues of sustainability in the water, sanitation, and hygiene (WASH) sector have led to the rapid expansion of 'system approaches' for assessing the multitude of interconnected factors that affect WASH outcomes. However, the sector lacks a systematic analysis and characterization of the knowledge base for systems approaches, in particular how and where they are being implemented and what outcomes have resulted from their application. To address this need, we conducted a wide-ranging systematic literature review of systems approaches for WASH across peer-reviewed, grey, and organizational literature. Our results show a myriad of methods, scopes, and applications within the sector, but an inadequate level of information in the literature to evaluate the utility and efficacy of systems approaches for improving WASH service sustainability. Based on this analysis, we propose four recommendations for improving the evidence base including: diversifying methods that explicitly evaluate interconnections between factors within WASH systems; expanding geopolitical applications; improving reporting on resources required to implement given approaches; and enhancing documentation of effects of systems approaches on WASH services. Overall, these findings provide a robust survey of the existing landscape of systems approaches for WASH and propose a path for future research in this emerging field.

Keywords: WASH; grey literature; systematic literature review; systems approaches.

Publication types

• Research Support, U.S. Gov't, Non-P.H.S.
• Systematic Review
• Sanitation*
• Water Supply / standards*

• Research article
• Open access
• Published: 06 February 2020

A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children

• Leanne J. Staniford 1 &
• Kelly A. Schmidtke   ORCID: orcid.org/0000-0001-5993-0358 1  

BMC Public Health volume  20 , Article number:  195 ( 2020 ) Cite this article

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Helping adults and children develop better hygiene habits is an important public health focus. As infection causing bacteria can live on one’s body and in the surrounding environment, more effective interventions should simultaneously encourage personal-hygiene (e.g. hand-hygiene) and environmental-disinfecting (e.g. cleaning surfaces). To inform the development of a future multi-faceted intervention to improve public health, a systematic literature review was conducted on behavior change interventions designed to increase hand-hygiene and environmental-disinfecting in settings likely to include children.

The search was conducted over two comprehensive data-bases, Ebsco Medline and Web of Science, to locate intervention studies that aimed to increase hand-hygiene or environmental-disinfecting behavior in settings likely to include children. Located article titles and abstracts were independently assessed, and the full-texts of agreed articles were collaboratively assessed for inclusion. Of the 2893 titles assessed, 29 met the eligibility criteria. The extracted data describe the Behavior Change Techniques (version 1) that the interventions employed and the interventions’ effectiveness. The techniques were then linked to their associated theoretical domains and to their capability-opportunity-motivation (i.e., COM-B model) components, as described in the Behavior Change Wheel. Due to the heterogeneity of the studies’ methods and measures, a meta-analysis was not conducted.

A total of 29 studies met the inclusion criteria. The majority of interventions were designed to increase hand-hygiene alone ( N  = 27), and the remaining two interventions were designed to increase both hand-hygiene and environmental-disinfecting. The most used techniques involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). Interventions that included techniques targeting four or more theoretical domains and all the capability-opportunity-motivation components were descriptively more effective.

Conclusions

In alignment with previous findings, the current review encourages future interventions to target multiple theoretical domains, across all capability-opportunity-motivation components. The discussion urges interventionists to consider the appropriateness of interventions in their development, feasibility/pilot, evaluation, and implementation stages.

Registration

Prospero ID - CRD42019133735.

Peer Review reports

The World Health Organization describes hygiene practices as those “that help to maintain health and prevent the spread of diseases” [ 1 ]. These practices include behaviors to disinfect one’s body and surrounding environment [ 2 ]. Because bacteria that cause infection can live on one’s body and in the surrounding environment, preventing the spread of infectious diseases may require interventions that simultaneously encourage both personal- and environmental-disinfecting [ 3 ]. To improve public health many hand-hygiene interventions have been conducted in school-settings, wherein students may act as “agents of change” by carrying lessons about hygiene from school back to their home to influence family behavior [ 4 , 5 , 6 ]. The current systematic review was conducted to inform the development of future multifaceted interventions that aim to increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Two recent systematic reviews closely informed the current review. The first is Willmott et al.’s 2016 review that included 18 school-based randomized controlled trials with hand-hygiene focused interventions [ 7 ]. The effectiveness of the interventions were assessed in terms of their ability to reduce negative health-related outcomes: absences and/or the spread of respiratory tract or gastrointestinal infections. The descriptions of the interventions suggest that most involved education/training ( N  = 15) and fewer involved infrastructural changes ( N  = 4). Only one study included measures of environmental-disinfecting ( N  = 1) and none included direct measures of hand-hygiene behavior ( N  = 0). Overall, they found equivocal evidence for the effectiveness of school-based interventions. However, as none of the studies directly measured hand-hygiene, it is uncertain whether they even influenced the process variable they were designed to most directly influence: hand-hygiene behavior. One of the effective interventions in this review took place in a childcare center, and this intervention simultaneously targeted hand-hygiene and environmental-disinfecting [ 8 ]. To this end, the current review aims to include studies that assess the effectiveness of interventions designed to improve hand-hygiene and/or environmental-disinfecting.

The second review that influenced the current review was conducted by Huis et al. in 2012 [ 9 ]. Huis et al.’s review included 41 intervention studies published between 2000 and 2009 to increase healthcare workers’ hand-hygiene compliance. In this review, the interventions were categorized according to the behavioral determinants that they were designed to influence [ 10 , 11 ]. In so doing, this review brings together a wide range of interventions with a purposeful intervention terminology to guide future intervention development via the Behavior Change Wheel [ 12 , 13 ]. The Behavior Change Wheel is a formal methodology that helps interventionists identify the most common reasons for sub-optimal behavior by providing a comprehensive list of empirically and theoretically informed reasons, e.g. lacking knowledge or resources to perform the desired behavior. The Behavior Change Wheel can be used as part of the first step in the Medical Research Council’s four-step Complex Intervention Development and Evaluation Framework. The steps include (1) Design, (2) Feasibility/piloting, (3) Evaluation and (4) Implementation [ 14 ]. This first step is important, because interventions designed to target uncommon reasons are unlikely to yield practically significant improvements.

Since Huis et al.’s review, the possible reasons for sub-optimal behavior have been more completely described in a taxonomy called the Theoretical Domain Framework (TDF) [ 15 ]. The TDF condenses 112 behavioral constructs into 14 domains that affect behavior: ‘Knowledge,’ ‘Behavioral Regulation,’ ‘Memory attention and decision processes,’ ‘Skills,’ ‘Goals,’ ‘Intentions,’ ‘Beliefs about consequences,’ ‘Beliefs about capabilities,’ ‘Optimism,’ Social/Professional role and identity,’ ‘Reinforcement,’ ‘Emotions,’ ‘Social influences,’ and ‘Environmental context and resources.’ These 14 domains are further condensed into the COM-B model’s three components, which exclusively and exhaustively explain why behaviors do or do not occur. The three COM-B components (and subcomponents) include C apability (physical/psychological), O pportunity (social/physical), and M otivation (reflective/automatic); the ‘B’ stands for B ehavior. If even a single COM-B component is lacking, then a desired behavior is less likely to occur.

The TDF domains and COM-B model components are displayed in the second and third columns of Fig.  1 . The links between them are indicated with shared colors, e.g. a dark red color is used to describe the link between the ‘Knowledge’ domain and the C apability-psychological component. After diagnosing the reasons for suboptimal behavior, the Behavior Change Wheel helps interventionists select the most appropriate intervention techniques. Ninety-three empirically and theoretically informed techniques are grouped into 16 clusters by the Behavior Change Techniques (BCTs) Taxonomy, version 1, e.g. shaping knowledge, goals and planning, social support , etc. [ 16 ]. In Fig. 1 , the 16 BCT clusters are linked to their associated TDF domains by lines drawn across the first and second columns [ 17 ]. For example, the shaping knowledge technique is best suited to influence the ‘Knowledge’ domain.

Links between the BCT clusters, TDF domains, and COM-B model

Huis et al.’s 2012 review found that interventions targeting only one domain, e.g. only ‘Knowledge’ or only ‘Goals,’ were less effective than those that targeted multiple domains, e.g. ‘Knowledge’ and ‘Goals.’ Therefore, they suggest that future interventions should simultaneously target multiple domains, likely across the COM-B components, to increase optimal behavior. As the current review aims to influence the development of future multifaceted interventions, Huis et al.’s use of a purposeful intervention development terminology is desirable. Thus, the current review also categorizes interventions according to the techniques used and the domains/components targeted. In so doing, the current review will also guide future intervention development via the Behavior Change Wheel.

In summary, the current literature review was planned around two broad objectives. First, we aimed to learn what behavior change techniques had already been assessed to increase hand-hygiene and environment-disinfecting in settings likely to include children, e.g. schools, homes, etc. Second, where possible, we aimed to compare the effectiveness of these techniques and the domains/components they targeted. The discussion puts forth recommendations for the development of future multifaceted interventions.

The current systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement [ 18 ]. The review’s protocol was registered on 28th of May 2019 with PROSPERO: International Prospective Register of Systematic Review (Registration ID: CRD42019133735).

Eligibility criteria

The eligibility criteria were determined using the PICO characteristics, i.e. characteristics describing the studies’ population, intervention(s), comparison(s) and outcome(s) [ 19 ]. The population characteristic was defined to include humans in settings likely to contain children less than 10-years-old and to exclude settings unlikely to contain children (e.g. manufacturing settings) and studies focused on non-human species. The intervention characteristic was defined to include studies that manipulated malleable factors likely to influence human behavior and to exclude comparisons of cleaning materials and non-malleable variables like gender. The comparison characteristic was defined to include any control or comparison condition, i.e. both randomized and pre-post observational trials. Finally, the outcome characteristic was defined to include hand-hygiene and environmental-disinfecting behavior measures. Environmental-disinfecting behavior was understood to entail the use of cleaning products to kill harmful germs that can cause illness.

Information sources and search strategy

The search terms and selected databases were reviewed by the research team and library staff (Table  1 ). In addition to the search terms three inclusion criteria were applied. First, the articles had to be written in English, because no translation services were available to the research team. Second, the articles had to be published in peer-reviewed journals, to narrow the scope of the review to articles more likely to include relevant information. Third, the articles had to be published on or after January 2009. The final search was conducted on the 27th of April 2019 over EBSCOhost Medline and Web of Science Core Collection.

Study selection and data collection process

One researcher located the articles and then uploaded them to EndNote™ to combine, detect, and delete duplicate references. The remaining articles were uploaded to Rayyan QCRI [ 20 ]. Then, two researchers used Rayyan QCRI to independently screen titles and abstracts for inclusion. Full-text articles were collaboratively screened. The stages of the search and screening process are described in Fig.  2 .

Prisma diagram describing how articles were located and screened

Data extraction

Two reviewers extracted study data from the articles using data extraction questions first piloted on smaller samples of included studies. After the data extraction questions were finalized, each reviewer independently extracted data from approximately half of the included articles. The extracted data included study details, intervention descriptions, outcome descriptions, and findings. The interventions were defined according to the Behavioral Change Techniques Taxonomy, version 1 [ 16 ], and each technique’s cluster was linked to the theoretical domains and COM-B components, as described in Fig. 1 (also see Additional file  1 for the list of behavior change techniques and clusters); as discussed in the introduction, these links are informed by previous research [ 15 , 16 , 17 ]. The data extraction process was planned to permit a narrative summary of what types and numbers of behavioral domains and components were most likely to increase hand-hygiene and environmental-disinfecting.

Overall quality assessment

One researcher reviewed articles to assess the studies’ overall quality using tools developed by the United States Department of Health and Human Services for controlled intervention and observational pre-post studies [ 21 ]. Each tool contains a checklist of items, e.g. asking about the sample-size and participant retention rates. To summarize the quality of the articles a five-star assessment was used. Four of the stars were assigned by taking the total number of positively indicated items divided by the total number of items: 1 star was given for positively indicating 25 to 49% of the items, 2 for 50 to 74%, 3 for 75 to 99%, and 4 stars for 100%. An additional star was given to those articles that use a randomized controlled trial methodology.

Data synthesis

Narrative syntheses, with tallies, are used to summarize the findings. Tables are used to describe and aggregate summaries.

Of the 2893 titles assessed, 29 met the eligibility criteria (see Additional file  2 ). The reviewer agreements were moderate for screened titles (89.56%, Kappa = 0.42, p  < 0.001) and abstracts (81.02%, Kappa = 0.36, p  < 0.001). The studies took place mostly in Bangladesh ( N  = 6), and Kenya ( N  = 4). Fewer took place in India ( N  = 2), Peru ( N  = 2), South Africa ( N  = 2), the United States of America ( N  = 2), Zambia ( N  = 2), China ( N  = 1), Indonesia ( N  = 1), Iraq ( N  = 1), Laos ( N  = 1), Malawi ( N  = 1), Malaysia ( N  = 1), Nepal ( N  = 1), Tanzania ( N  = 1), and Zimbabwe ( N  = 1). Most of the studies were publically funded ( N  = 24).

Study characteristics

Regarding the study designs, 7 were pre-post without randomization, 18 were pre-post with randomization, and the remaining 4 were randomized controlled trials with only post-intervention comparisons. Approximately one-third of the studies were pre-registered ( N  = 11). Nearly all of the studies indicated being granted approval by an ethics committee before commencing ( N  = 28). The remaining study did not indicate whether ethical approval was sought [ 22 ]. Prior to collecting data, a power analysis was conducted for most studies ( N  = 22), but this analysis was not always for an observable, behavioral measure, e.g. alternative primary outcomes included diarrhea episodes [ 23 ] and microbial counts [ 24 ]. Most of the interventions took place in schools ( N  = 12) or households with children ( N  = 13); fewer took place in pediatric settings ( N  = 2) or involved multiple locations, such as schools and other community centers or households ( N  = 2).

Regarding whose behavior was measured, 11 studies focused on the behavior of household members including children and adults, 16 focused on children/students, 1 looked at mother and child pairs [ 6 ], and 1 looked at pediatric healthcare workers [ 25 ]. Only 17 of the studies indicated the gender of their participants. In 23 studies some information about participants’ age was provided or could be inferred, e.g. from participants’ grade levels.

All of the studies included a behavioral measure of hand-hygiene, but only 20 reported a significant increase in at least one measure of hand-hygiene, i.e. handwashing, handwashing with soap, or handwashing at key times (e.g. after defecation or before food preparation), compared to a control group or a pre-intervention measure. Nine interventions found no significant effect of the intervention condition on hand-hygiene. Only two studies included a measure of environmental-disinfecting, both were related to food preparation and both found significant increases. As so few articles were found for environmental-disinfecting, the remainder of the current results section focuses on hand-hygiene. In nearly half of the studies ( N  = 13), a health outcome measure was also recorded, such as absenteeism, diarrhea-symptoms, hospitalization episodes, and infection rates. The Additional file  3 provides details about the studies’ settings, participants, interventions, comparisons, outcome measurements, and results.

Behavior change technique clusters and the COM-B model

The types and numbers of behavior change technique clusters (BCTs) employed are summarized in Table  2 . Across the 29 studies the most commonly employed BCTs involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). A moderate number of interventions involved associations ( N  = 14), social support ( N  = 12), feedback and monitoring ( N  = 10), comparison of behaviors ( N  = 8), and goals and planning ( N  = 7). Fewer interventions involved repetition and substitution ( N  = 5), reward and threat ( N  = 4), and scheduled consequences ( N  = 1) [ 26 ]. None of the interventions involved comparison of outcomes , regulation , self-belief , or covert learning . The interventions included as few as one BCT cluster [ 43 , 44 , 45 ] and as many as nine [ 34 , 42 ]. Of the 29 included studies, 3 used a single BCT cluster, 15 included 2 to 4, and 11 included 5 or more. The mean number of BCT clusters per intervention that did not find a significant benefit for hand-hygiene was 3.00 ( SD  = 1.94, Mdn  = 3). The mean number of interventions that did find a significant benefit was descriptively higher, i.e. 4.65 ( SD  = 2.30, Mdn  = 4).

Using the links provided in Fig. 1 , the number of studies that targeted each TDF domain and COM-B component were tallied. The most frequently targeted domains were ‘Knowledge’ and ‘Environmental context and resources’ (both N ’s = 22). Fewer studies targeted ‘Emotions’ ( N  = 20), ‘Beliefs in consequences’ ( N  = 15), ‘Social Influences’ ( N  = 14), ‘Behavioral Regulation’ ( N  = 10), ‘Goals’ ( N  = 7), ‘Intentions’ ( N  = 7), ‘Reinforcement’ ( N  = 5), ‘Skills’ ( N  = 4), and ‘Optimism’ ( N  = 1 [ 26 ];. No interventions targeted ‘Beliefs about capabilities.’ As a reminder no BCTs are linked to the ‘Memory attention and decision processes’ domain or ‘Social/Professional role and identity’ domain, and therefore it is not surprising that these domains were not targeted by any interventions. The studies targeted between 1 and 9 domains, with the average study targeting 4.38 domains ( SD  = 2.51, Mdn  = 4). Of the 14 studies that targeted less than 4 domains, 7 (50%) found positive effects of the intervention. In contrast, of the 15 studies that targeted 4 or more domains, 13 (87%) found positive effects of the intervention.

Regarding the COM-B model, almost all the studies targeted Capability ( N  = 28), and many targeted O pportunity ( N  = 24) and M otivation ( N  = 21). Five of the studies only targeted one component, of which four targeted O pportunity and one targeted M otivation; only three of these five studies (60%) found a significant benefit. Four of the studies only targeted two components, of which three targeted C apability and O pportunity and one targeted M otivation and O pportunity; only two of these studies (50%) found a significant benefit. The remaining 20 studies targeted all three COM-B components, and 15 of these studies (75%) found a significant benefit.

Methodological quality

The quality assessment for each study is provided in Additional file  4 . As a reminder the studies were assessed with five stars, where four stars were allocated based on the percentage of assessment criteria met, and one star was added to studies that used a randomized controlled trial methodology. Of the 29 studies included, 2 studies received one star [ 36 , 44 ], 21 received three stars, 2 received four stars [ 6 , 43 ], and 4 received two stars [ 25 , 27 , 32 , 33 ].

Synthesis of results

The co-authors agreed that a pooled estimate of the effects would be misleading, due to the heterogeneity of the populations examined, research methods employed, and outcomes measured.

The current systematic review located 29 studies with interventions designed to increase hand-hygiene in settings likely to include children. Of the 29 studies, only 2 were also designed to increase environmental-disinfecting behavior. Individual study results suggest that interventions may increase hand-hygiene and environmental-disinfecting, but the behavior change techniques they employed and domains/components they targeted varied. The most targeted domains were ‘Knowledge’ and ‘Environmental context and resources.’ Descriptively, interventions targeting four or more theoretical domains and those targeting all the COM-B components were more likely to succeed.

The findings of this literature review align with other reviews emphasizing the value of multifaceted interventions. As stated in the introduction, the COM-B model proposes that people need sufficient C apability, O pportunity, and M otivation to perform a desired behavior. If even a single component is lacking, then people will be less likely to perform the desired behavior [ 12 ]. Agreeing with the COM-B framework, Harvey and Kitson argue that interventions meant to influence a greater range of people with more complex problems often require multifaceted approaches [ 50 ]. As hand-hygiene is likely a complex behavioral problem, interventions designed to affect a single component may prove inadequate to produce either population-level benefits (as individuals experience different barriers) or individual-level benefits (as each individual experiences multiple barriers that need to be simultaneously overcome).

Comparing interventions designed to affect each TDF domain or COM-B component, in isolation and combination, would help interventionists better understand how these domains/components influence each other. However, such factorial experimental designs will prove difficult to conduct given real-world constraints. Further the scientific exactness of factorial designs are likely outside the scope of many studies with more practical aims. In many studies, hand-hygiene is operationalized as a process variable (that may or may not be measured) meant to impact a health outcome (that is measured), and previous systematic reviews have largely focused on practical health outcomes. For example, Willmott et al.’s (2016) review located 18 randomized controlled trials that investigated the effectiveness of hand-hygiene interventions on children’s absences and infections [ 7 ]; Meadows et al.’s (2004) review located 6 studies evaluating the effectiveness of antimicrobial rinse-free hand sanitizer interventions on elementary school children’s absenteeism due to communicable illness [ 51 ]; and Wilson et al.’s (2006) located 12 studies that investigated the effectiveness of hand-hygiene interventions to decrease infections and absenteeism [ 52 ].

Studies focusing on hand-hygiene behavior itself are likely more common in health care settings [ 53 , 54 , 55 ], where hand-hygiene compliance audits are already common. In contrast, in school-settings hand-hygiene compliance audits may prove difficult to fund, develop, and faithfully implement. As a result of these difficulties, interventions in school settings are often evaluated using the data that schools already regularly collect, e.g. absences, or that parents/students can self-report with reasonable face-validity, e.g. diarrhea episodes. While outcomes like absences and diarrhea episodes are certainly important, the present research team argues that there is already sufficient evidence that hand-hygiene impacts these health outcomes [ 56 , 57 ]. Therefore, more studies and reviews looking at the effectiveness of hand-hygiene interventions should prioritize observable hand-hygiene behavior measures when assessing their interventions’ effects.

Limitations

Several limitations of the current review will now be acknowledged. First, the search only included two data-bases, articles published in the English language, and did not extend to the grey literature. Given the current research team’s time and resource constraints, these restrictions were necessary. A future review aiming to understand what techniques have been attempted (with or without being assessed) may find it useful to include the grey literature. Another limitation of the review is its rigid focus on observable behaviors. Indeed, most studies discarded from the review during the full-text screening were lost because they did not include measures of observable behavior, but rather only included self-reported measures.

Recommendations for future intervention studies

The current review recommends that future interventions designed to increase hand-hygiene or environmental-disinfecting in settings likely to include children target multiple theoretical domains and all COM-B components. Which domains are targeted will depend on the particular setting and population. For example, if the particular setting already includes sufficient infrastructure for children to carry out hand-hygiene, e.g. soap and a water basin, then providing more soap or installing new water basins is unlikely to produce a beneficial effect; though, making children aware of such materials might. The only way to be more certain about what barriers a particular population experiences is to conduct formative research in the selected setting with the selected population, e.g. structured observations, focus groups, interviews, surveys, etc. Such formative research should aim to comprehensively examine all the possible barriers that could influence hand-hygiene, because if even a single component is lacking, then beneficial effects of the intervention are less likely to be realized. The Behavior Change Wheel can be used to guide the development of multifaceted interventions, and the selection of the most appropriate intervention functions (e.g. education or persuasion) and policy categories (e.g. guidelines or legislation) through which those interventions can be delivered [ 58 ].

Of course, selecting behavior change techniques is only part of the intervention development process. Beyond targeting the right barriers, the intervention must be implemented through an appropriate mode. To bolster the appropriateness of the ultimate intervention, interventionists can use the APEASE criteria [ 59 ]. APEASE is an acronym in which each letter stands for a different appropriateness-criterion: Affordability, Practicality, Effectiveness, Acceptability, Side-effects, and Equity. A sample of questions researchers might ask themselves about each criterion are provided in Table  3 . The APEASE criteria should be consulted iteratively during an intervention’s development, feasibility/pilot testing, evaluation, and implementation [ 58 ]. Considering the APEASE criteria during the development phase is important; if stakeholders do not believe the intervention is appropriate, then the intervention will prove difficult to scale and spread even if the intervention’s effects are found to be beneficial.

The present review focused on the behavior change techniques, theoretical domains, and COM-B components interventionists should consider when developing a multifaceted intervention. After developing a multifaceted intervention, the Behavior Change Wheel and the Medical Research Council’s Complex Intervention Development and Evaluation Framework recommend feasibility/pilot testing [ 12 , 14 ]. Specific information regarding how to feasibility/pilot test an intervention study is outside the scope of the present review. Briefly here, note that while one may be uncertain about the benefits of a intervention before full-scale testing, feasibility/pilot tests help one to become more certain about the parameters needed for a fair full-scale test of that intervention’s effectiveness. Many, often costly, trials that do not first feasibility/pilot test their interventions ultimately fail to find significant effects due to factors that better planning may have mitigated, e.g. the sample-size was too low, people found the intervention unacceptable, or intervention implementation was inadequate [ 60 , 61 , 62 ].

The current literature review identified 29 studies with interventions that aimed to increase hand-hygiene, 2 of which also aimed to increase environmental-disinfecting. In alignment with previous findings, this review finds that interventions that simultaneously target more theoretical domains and all COM-B components are descriptively more likely to succeed. The review also notes that very few trials examine hand-hygiene and environmental-disinfecting simultaneously and encourages more studies to do so, as this may be the most cost-effective way to halt reinfection cycles. In the discussion, interventionists were urged to consider the appropriateness of their interventions in the development, feasibility/pilot, evaluation, and implementation stages. This iterative and methodical process can encourage better scale and spread of effective interventions that increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Availability of data and materials

The reviews protocol is available on PROSPERO. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Control Group

Environmental Disinfecting

• Handwashing

Handwashing with soap

Intervention Group

Theoretical Domains Framework

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Acknowledgements

The authors would like to acknowledge the support of the funder and Manchester Metropolitan University’s library staff in conducting the current review. The authors also acknowledge Pendaran Roberts’ help editing the manuscript.

This research was supported by Global Hygiene Council. The Global Hygiene Council had no role in the design of the study and collection, analysis, and interpretation of data, and in writing the manuscript. The views expressed are those of the authors and not necessarily those of the Global Hygiene Council.

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Links between the Theoretical Domains and Behavior Change Technique (version 1) used in the current research project.

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References for articles included in the review.

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Characteristics of included studies in the systematic review.

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Quality assessments conducted using the United States Department of Health and Human Services tool for pre-post studies.

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Staniford, L.J., Schmidtke, K.A. A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children. BMC Public Health 20 , 195 (2020). https://doi.org/10.1186/s12889-020-8301-0

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School sanitation and student health status: a literature review

by Anita Dewi Moelyaningrum

2023, Journal of Public Health in Africa

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Barry Jay Graciadas

2018, FOUNDATION UNIVERSITY GRADUATE SCHOOL THESIS

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

Chandrasekhar Vallepalli

2010, Journal of Global Infectious Diseases

Sunita Agarwal

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

Nana Ackerson

International Journal of Research & Review (IJRR)

2020, https://www.ijrrjournal.com/IJRR_Vol.7_Issue.4_April2020/Abstract_IJRR0052.html

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

Arinzechukwu Okanya , Toochukwu C . Nwakile (PhD)

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

Jamie Bartram

2012, International Journal of Environmental Research and Public Health

Ravi Nimonkar

International Journal Of Community Medicine And Public Health

Background: A majority of morbidity and mortality in developing countries is attributed to communicable diseases. 31% of all deaths in Southeast Asia, are caused by infectious disease. Poor health among school children is results from lack of awareness of the health benefits of personal hygiene.Methods: The present cross sectional study was conducted among 440 school children in Government school in Kolkata (WB) over a period of 6 months.Results: We tried to assess the hygiene practices among the school children. Majority of children responded that there were sources of clean water at their houses (94%) and school (84%).Conclusions: The percentage of hygiene practices among school children was found to be satisfactory, however when asked to demonstrate correct hand washing procedure, 86.1% demonstrated the same in an incorrect manner.

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Please cite this article in press as: Karon, A.J., et al., Improving water, sanitation, and hygiene in schools in Indonesia: A cross-sectional assessment on sustaining infrastructural and behavioral interventions. Int. J. Hyg. Environ. Health (2017), a b s t r a c t Water, sanitation, and hygiene (WASH) in schools are important for child health, development, and educational performance; yet coverage in Indonesian schools remains low. To address this deficiency, UNICEF and partners conducted a WASH intervention in 450 schools across three provinces in Indonesia. A survey evaluating the sustainability of infrastructure and behavioral interventions in comparison to control districts was conducted one year after completion of the intervention. The survey data were also compared with national government data to assess the suitability of government data to report progress on the Sustainable Development Goals (SDGs). Logistic regression was used to explore associations between WASH conditions and behaviors. Intervention schools were more likely to have handwashing stations with soap and water. In multivariable analyses, schools with a toilet operation and maintenance fund were more likely to have functional toilets. Students who learn hygiene skills from their teachers were less likely to defecate openly, more likely to share hygiene knowledge with their parents, and more likely to wash their hands. Survey data were comparable with government data, suggesting that Indonesian government monitoring may be a reliable source of data to measure progress on the SDGs. This research generates important policy and practice findings for scaling up and sustaining WASH in schools and may help improve WASH in schools programs in other low-resource contexts.

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Chetana Society, as part of its initiative, Joint Action Water, has done a survey of water and sanitation facilities in government schools in Hyderabad municipality area, in 2011-12. This study was supported by Water Aid India, and was done with the support of volunteers associated with M.V. Foundation, Hyderabad. Many schools do not have proper toilets and related facilities, including access to continuous water supply and water storage. Wherever toilet facilities are available, there is some problem or other, which prevents full utilization of such facility.

IAEME Publication

2019, IAEME

Health and hygiene pose grave problems in the entire world. Globally, billions of people do not have access to improved health and hygiene. Sanitation is least cared for. So, this study is undertaken with the objectives, to find the practices of health and hygiene among school children in Mangalore city and to compare the practices on health and hygiene between Government, Private and Aided school children. Tools used for the study were Survey method and Questionnaire. Children in the age range of 10-12 years were selected for the study. Sixteen schools, 8 from north and 8 from south were taken for the study. Questionnaires were distributed to 820 respondents, i.e. 183 Government, 309 Aided and 328 Private school children to elicit information regarding their practices on health and hygiene. Questions were explained to them clearly during the study. The opinions collected by using the questionnaire were scored and tabulated. It was seen from the finding that mean practice scores were found highest in Private school (74.2%) when compared to Government school (55.8%) and Aided school (55.4%) respondents. The data wasanalyzed statistically by using the F test and found that there was a highly significant difference between different types of school and the mean practice score on health and hygiene (F=733.32**).

Marielle Snel

2002, November-2002 (Vision-21)

Temnet Tefera

Odafivwotu Ohwo

Adequate water, sanitation and hygiene (WASH) services have positive implications on students learning outcomes. Hence, this study assessed the status of WASH services in public secondary schools in Yenagoa. The study adopted a descriptive cross-sectional survey design, which involved direct field observation of WASH facilities and the administration of structured questionnaire to the entire 16 public secondary schools in Yenagoa. However, the analysis involved 15 schools, as one of the schools did not return its questionnaire. Data obtained was analyzed using descriptive statistics and the Joint Monitoring Programme (JMP) classification of WASH services in schools. The results show that WASH services in most of the schools are inadequate and unsatisfactory. Hygiene service was the worst provided WASH services in the schools as only two (13.33%) schools had basic hygiene service, one (6.67%) school had limited hygiene service and 12 (80%) schools had no service. Next was water servi...

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This study attempted to determine the extent of the implementation of Water, Sanitation and Hygiene (WaSH) program and its relationship with hygiene and sanitation practice of intermediate pupils in Sta. Cruz Elementary School, City Schools Division of Antipolo during the School Year 2022-2023.The method of research used was the descriptive correlational type with the questionnaire as the data gathering instrument which was validated by the experts. The respondents of the study included 85 teachers and 362 pupils from Grades IV, V & VI. The statistical tool utilized to compute the data were weighted mean, one way analysis of variance and Pearson r Correlation.The findings included that the extent of the implementation of WaSH program as regards the aspect of disease preventive and control as well as community and environmental health to the hygiene and sanitation among intermediate pupils was High as perceived by both teachers and pupil respondents with the grand weighted mean of 3.07 and 3.08 respectively. Moreso, there was no significant difference between perceptions of the teachers and pupil respondents on the extent of the implementation of WaSH Program, while there was a significant relationship between the perceived implementation of WaSH program of the teachers and pupils and the hygiene and sanitation practices of pupils.An intervention measure in the implementation of the WaSH program was proposed to further improve its management and implementation.

Dr. Priyanka Sharma

Food safety has emerged as an important global issue with international trade and public health implications. Diseases related to inadequate water, sanitation and hygiene are a huge burden in developing countries. It is estimated that 88% of diarrheal disease is caused by unsafe water supply, and inadequate sanitation and hygiene (WHO, 2004). Schools often lack a proper system of drinking-water system, sanitation and hand washing facilities; alternatively, where such facilities do exist they are often inadequate in both quality and quantity. Schools with poor water, sanitation and hygiene conditions, and intense levels of person-to-person contact, are high-risk environments for children and staff, and exacerbate children‟s particular susceptibility to environmental health hazards. Providing adequate levels of water supply, sanitation and hygiene in schools is of direct relevance to the United Nations (UN) Millennium Development Goals of achieving universal primary education, promoting gender equality and reducing child mortality. Children are more exposed to pathogens in the environment because of poor or lack of sanitary habits. This is likely to be especially true of enteric pathogens, which are transmitted by the faecal oral route through water, soil and food. Most important is the immune system, the less developed the immune system in children could lead to more serious infections. The present study was undertaken to assess the hygiene and sanitation status in different pre-schools of East and Central Delhi. The study aimed at obtaining information about the general profile of the employees, handling food, their food handling practices, sanitation processes while preparing food and awareness about general hygiene. Thumb imprint of various food handlers were accounted for along with food contact and non -food contact surfaces. Thumb imprint of the fifteen food handlers and workers were collected during various stages of work from the five preschools. Since, hand hygiene is very critical and affects the quality of food; so hands both unwashed and washed with the available resources were accounted for and also during cooking and serving. The microbial load drastically reduced after the washing step. The results indicate that the personal hygiene needs to be reinforced in the handlers. The rinse method results showed majority of utensils were clean and not contributing to the microbial load although the exception was seen in case of school S2 where all the utensils carried a high microbial load. Among the utensils tested, the pressure cookers were found to be most contaminated which can be attributed to the fact that the gaskets and pressure whistle are not removed and cleaned. The swab data indicated a high level of contamination. After assessment, it was found that there was a strong need for educating the food handlers. Corrective actions were given which could help to fill up the existing lacunae in the prevailing situation by controlling the undesirable practices of the food service providers to ensure food safety. A leaflet was designed to act as a guideline for following correct food safety and hygienic practices in food service institutions.

vijaya lakshmi

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The three autonomous factors of public health concern are WASH, constituting water, sanitation, and hygiene. The availability of WASH facilities at schools is a little-researched aspect that might be a crucial enabler of academic success. The present study was carried out to evaluate the hygiene and sanitation practices like right-hand washing with soap (RHWWS), right tooth brushing twice a day (RTBTD), and open defecation (OD) free among the school children of Visakhapatnam of 6–11 years of age. About 110 schools were identified, which includes 56 urban, 21 semi-urban, and 33 rural schools in the Visakhapatnam district, from which 500 students were selected randomly. Only 31 (28%) schools were exposed to WASH-related involvements. In the studied schools, only 58% of them have adopted the WASH policy. The results relating to the hygiene practices among the selected schools were found to be significant but, overall, a bit low on criteria defined by the UN joint monitoring program in ...

philiman digal

Toochukwu C . Nwakile (PhD)

SCHOOL SANITATION AND Hygiene Education (SSHE), is globally recognized as a key intervention to promote children’s right to health and clean environment and to influence a generational change in health promotion behavior and attitudes. It is now known that not only the quality of teaching but also the environment, especially the availability of safe drinking water and sanitation together with good hygiene practices are key factors which influence learning. Since the beginning of 2000, UNICEF, together with the International Water and Sanitation Centre (IRC) is involved in a SSHE project in various states around India. The overall objective of the School Sanitation and Hygiene Education programme in India, also known as the SWASTHH programme (meaning School Water and Sanitation towards Health and Hygiene) is to develop, test and successfully demonstrate replicable models for hygiene education, water supply and environmental sanitation in rural primary schools and pre-schools. The SWA...

IJRMS Journal

Surveys reported that malnutrition, infectious diseases, intestinal parasites,diseases of skin, eye and ear and dental caries are more prevalent in children.Lack of personal hygiene along with poor sanitation causes person-to-person transmission of infection. Infection and malnutrition form a vicious circle and leads to retardation of children's physical development. Repeated attacks of infections compromise children's attendance and performance at school and not uncommonly, can result in death.Although studies have been conducted on health problems among school children in India there are still several localities for which epidemiological information is not available.Soap, water, and latrines are essential for proper hygiene practice in schools. Early identification of childhood illnesses through regular school health checkups help prevent complications

Niringiye Phillimon

The study examined “role of school teachers in promoting hygiene of learners in Conbert Modern Primary School and Nkumba Secondary in Katabi Town Council. It based on three objectives i) identifying the nature of hygiene being promoted among learners, ii) establishing the effectiveness of the school hygiene programme in promoting hygiene among learners, iii) examining the challenges faced while promoting hygiene among learners. The study used a cross sectional research design basing on both qualitative and quantitative data. In addition the study used purposive sampling and simple random sampling method which used a sample size of 89 respondents. The data was presented in table and charts and narrative texts for responses in the interview guide. It was analysed by explaining the relationship between the variables of the study qualitatively and quantitatively. Study findings revealed that majority of respondents that is 52.8% strongly agreed and 32.6% agreed that they had knowledge about hygiene. It was revealed that school hygiene is a healthcare science and is influenced by study of school environment and it explores affection of schooling to mental and physical health of learners. In conclusion, the study revealed that there are many ways of promoting hygiene as they include; washing uniforms, washing utensils and cleaning hands especially after visiting the toilets. For instance promotion of hygiene through washing uniform including presumably cleaning stockings, shoes, brushing tooth, cutting finger nails short and ears, nose arm pit cleaning. In both schools management put in place disposal bins for dumping rubbish. Also, teachers always encourage learners to collect rubbish or waste that is later dumped at the school dust bin for burning so that they prevent diseases spreading. Learners are taught on how to always dispose of polythene bags yet these are greatly discouraged for use since burning emits dangerous fumes or gasses that can affect learners and the entire school population. The major challenges are: limited toilets for both teachers and learners, overcrowding in class, negligence of staff on hygiene promotion activities, students don’t wish to cleaning activities and dirty school environments which is always full of fruit- trees for shed. In recommendation, the study suggested improving the condition of the school washrooms and providing adequate facilities supports increased hand washing rates and more positive attitudes in learners. The simple act of washing hands can reduce the risk of stomach bugs.

Hassan Yakubu Olanrewaju

2020, Open Access Journal of Environmental and Soil Sciences

The study investigates availability and adequacy of sanitation practices on learning in selected secondary schools in Ifako Ijaiye local government area of Lagos State, Nigeria. In order to select the secondary schools which, the study was cover, stratified sampling was employed to select 192 students in public and private secondary within the study area. The result of the findings revealed that there is variation in terms availability and adequacy of sanitation facilities across schools within the study area, and that highest percent of students’ claimed of washing hand twice, majority of school (85.3%) means of waste disposal was un-sustainable (open burning) detrimental to students health and well-being. In light of this, the study concludes that environmental sanitation facilities are available in both public and private schools selected in the study area but differs in term of quantity and quality. This calls for improve and increase sanitation facilities in the affected schools, rules and regulations, health educating parent on sanitation and health and development of maintenance strategy so as to make the facilities maintain their initial condition as at the time of installation

Peter M Chilipweli

2021, International Journal of Pharmaceutical and Bio-Medical Science

Background: Each year two million students die from diarrheal diseases, making it the second most serious killer of students under the age of five (WHO, 1998). The use of sanitation facilities is known to interrupt the transmission of faeco oral related disease. This study assessed proper use of latrine and handwashing facilities among primary school students as the potential behavior aspect for transmission of microbes. Methods: A descriptive cross sectional study was conducted involving 307 students and 12 Teachers who are heads of health clubs, making a total of 319 participants. The study was conducted at Mbagala charambe which is found in Temeke Municipal at Mbagala ward in Dar es Salaam region which involved primary schools which were Nzasa, Chemchem, kilamba ,St Mary’s international, Rangi tatu and charambe primary. Observation method, interview and questionnaire methods of data collection were employed. All the data were analyzed by the use of STATA to obtain proportional an...

Environment and Natural Resources Research

The paucity of information on the number of accessible sanitation facilities in secondary schools in developing countries has hindered efforts in attaining sustainable development in this area. Therefore, this study was designed to bridge that gap. The cross-sectional study utilized a 4-stage sampling technique to select 386 students from schools in Badagry, Lagos. Pre-tested questionnaire and observational checklists were used to obtain data. Data were analyzed using descriptive statistics and logistic regression at 5% level of significance. Respondents’ mean age was 15.8±1.5 years and 55.2% were female. On-site observation revealed that all the schools had improved sanitation facilities, while 37% of the available toilet compartments were inaccessible to the students. Majority (85%) of the facilities provided limited service, while 15% provided basic service. The student to toilet ratio for the public school girls and boys were 3191:1 and 642:1 respectively, while the private scho...

adeniyi aremu

Anjan Kumar Phoju

2021, International Journal of Research in Environmental Science

RASHMI HULLALLI

2017, International Journal of Community Medicine and Public Health

jasson kahembe

Samuel Abanyie

2021, American Journal of Environmental Science and Engineering

Irene Mosha

A Dissertation Submitted to the School of Public Administration and Management in Partial Fulfillment of the Requirements for Award of the Degree of Master of Science in Health Monitoring and Evaluation (MSc. HME) of Mzumbe University

Christensaint Culang

Original Research Article The objective of UNICEF in the area of water, sanitation and hygiene (WASH) is to contribute to the realization of children‟s rights to survival and development; increase equitable and sustainable access to, and use of safe water and basic sanitation services and promote improved personal hygiene. This study was conducted by the researchers to determine how the school management implements the Water, Sanitation, and Hygiene (WASH) In Schools Program in Zone 1 Division of Zambales, Philippines. The study also determined the challenges of the schools in the implement the WASH Program. The descriptive research design was utilized that helped determine the data gathering tool and the statistical tools to interpret and analyze the data collected from 672 respondents (school coordinators, parents and pupils). The instrument used to gather data is the questionnaire based on the instrument used by DepEd schools to evaluate the implementation of the program and how ...

Dr. Ahmad Kamruzzaman Majumder

Water Conservation and Management

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Access to and challenges in water, sanitation, and hygiene in healthcare facilities during the early phase of the COVID-19 pandemic in Ethiopia: A mixed-methods evaluation

Gete Berihun

1 Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Metadel Adane

Zebader walle.

2 Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Masresha Abebe

Yeshiwork alemnew.

3 Department of Biology, College of Natural Sciences, Wollo University, Dessie, Ethiopia

Tarikuwa Natnael

Atsedemariam andualem.

4 Department of Nursing, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Sewunet Ademe

Belachew tegegne, daniel teshome.

5 Department of Anatomy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Leykun Berhanu

Associated data.

All relevant data are within the paper and its Supporting Information files.

Inadequate water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) have an impact on the transmission of infectious diseases, including COVID-19 pandemic. But, there is limited data on the status of WASH facilities in the healthcare settings of Ethiopia. Therefore, this study aimed to assess WASH facilities and related challenges in the HCFs of Northeastern Ethiopia during the early phase of COVID-19 pandemic.

An institution-based cross-sectional study was conducted from July to August 2020. About 70 HCFs were selected using a simple random sampling technique. We used a mixed approach of qualitative and quantitative study. The quantitative data were collected by an interviewer-administered structured questionnaire and observational checklist, whereas the qualitative data were collected using a key-informant interview from the head of HCFs, janitors, and WASH coordinator of the HCFs. The quantitative data were entered in EpiData version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The quantitative data on access to WASH facilities was reported using WHO ladder guidelines, which include no access, limited access, and basic access, whereas the qualitative data on challenges to WASH facilities were triangulated with the quantitative result.

From the survey of 70 HCFs, three-fourths 53 (75.7%) were clinics, 12 (17.2%) were health centers, and 5 (7.1%) were hospitals. Most (88.6%) of the HCFs had basic access to water supply. The absence of a specific budget for WASH facilities, non-functional water pipes, the absence of water-quality monitoring systems, and frequent water interruptions were the major problems with water supply, which occurred primarily in clinics and health centers. Due to the absence of separate latrine designated for disabled people, none of the HCFs possessed basic sanitary facilities. Half (51.5%) of the HCFs had limited access to sanitation facilities. The major problems were the absence of separate latrines for healthcare workers and clients, as well as female and male staffs, an unbalanced number of functional latrines for the number of clients, non-functional latrines, poor cleanliness and misuse of the latrine. Less than a quarter of the HCFs 15 (21.4%) had basic access to handwashing facilities, while half 35 (50%) of the HCFs did not. The lack of functional handwashing facilities at expected sites and misuse of the facilities around the latrine, including theft of supplies by visitors, were the two most serious problems with hygiene facilities.

Despite the fact that the majority of HCFs had basic access to water, there were problems in their sanitation and handwashing facilities. The lack of physical infrastructure, poor quality of facilities, lack of separate budget to maintain WASH facilities, and inappropriate utilization of WASH facilities were the main problems in HCFs. Further investigation should be done to assess the enabling factors and constraints for the provision, use, and maintenance of WASH infrastructure at HCFs.

The provision of water, sanitation, and hygiene (WASH) facilities plays a crucial role in the reduction of healthcare-acquired infection (HCAI). Proper utilization of these facilities in healthcare settings is considered as a cornerstone for providing good quality care [ 1 ]. The common prevention measures against HCAI are source control, respiratory hygiene, early identification and isolation of patients with suspected disease, handwashing, and use of personal protective equipments (PPE) [ 2 , 3 ].

The issue of adequate WASH is a regional problem in countries around the world, it is most severe in low-and middle-income countries (LMICs), including Ethiopia [ 4 ]. It is usually aggravated by the presence of a weak healthcare system and insufficient investment in healthcare safety. Hence, the implementation of proper infection prevention and control measures is challenging due to inadequate supplies of PPE. During the COVID-19 pandemic, adequate care of COVID-19 patients and prevention of HCAI among healthcare workers is difficult because of simple, but often neglected factors such as a lack of water [ 5 ]. Around 1.4 million people are affected by a lack of clean and safe healthcare facilities around the world. The problem is 2 to 20 times higher in low-resource countries than in developed countries [ 6 ].

A quarter of HCFs worldwide lack basic water services, exposing 1.8 billion people at risk, especially the most vulnerable groups of the population, such as healthcare workers and patients that attend HCFs. Furthermore, one-third of HCFs lack hand hygiene facilities at the point of care, and 10% of HCFs lack sanitation services. Globally, in 47 least-developed countries, an estimated half of HCFs do not have basic water services and two-thirds of HCFs lack basic sanitation services. Seven out of ten HCFs in least-developed countries do not have basic healthcare waste management services. About 50% of the HCFs in least-developed countries had basic water services, 37% had basic sanitation, and 74% had basic hand hygiene facilities at the point of care [ 7 ].

Despite the improvement in access to essential health services in sub-Saharan Africa in recent years, the quality of care received remains inadequate to improve health outcomes. Health facilities lack the necessary infrastructure, equipment, medicines, commodities, and trained personnel to create an enabling environment, resulting in missed opportunities to provide good quality essential health services. About one-fifth of deaths occurring in LMICs are attributable to the lack of access to health services, one-third of deaths are a result of receiving poor quality of care, which is often linked to insufficient readiness of the facilities to provide services [ 8 ].

Access to WASH facilities in HCFs is a cornerstone of safe healthcare services [ 9 ]. The lack of these facilities poses significant health risks to patients, healthcare workers, and the whole community. WASH facilities in HCFs are fundamental to health security, preparedness, and response efforts, including the effort to stop the COVID-19 pandemic [ 7 ]. The lack of WASH facilities is one of the primary causes of the transmission of HCAI, including COVID-19 [ 10 ]. The Sustainable Development Goal (SDG) target 6 calls for universal access to WASH services in HCFs [ 11 ]. Globally, improving WASH facilities has the potential to prevent at least 9.1% of the disease burden in disability-adjusted life years or 6.3% of all deaths [ 12 ].

A study conducted in LMICs reported und that 38.0% of HCFs did not have a basic water supply, 19.0% did not have basic sanitation, and 35.0% did not have water and soap for handwashing [ 13 ]. The rate of provision of water is lowest in the African region, with 42.0% of all HCFs lacking an improved water source on-site or nearby [ 14 ]. Inadequate WASH in HCFs has a significant negative influence on the status of hospital patients’ health during their stay. Globally, an estimated 15% of patients may acquire one or more infections during their stay in the hospital. But, the prevalence may be even higher in LMIC where it ranges from 5.7% to 19.1% and the risks associated with sepsis are 34 times higher [ 15 ].

Effective WASH plays a vital to prevent and control the transmission of COVID-19 [ 16 ]. The current COVID-19 pandemic has highlighted deficiencies in access to WASH services in HCFs and underscored the need for increased political commitment and enhanced accountability to address WASH gaps in health facilities [ 8 ]. According to the reports of WHO, confirmed cases of COVID-19 reached more than 228 million as of September 19, 2021, and caused more than 4.7 million deaths across the world [ 17 ]. The number of COVID-19 infections among healthcare workers is far greater than among the general population due to their role in treatment and management of cases [ 18 , 19 ]. Globally, healthcare workers represent less than 3% of the population but account for 14% of COVID-19 cases [ 20 ]. The first case of COVID-19 in Ethiopia was reported on March 13, 2020 [ 21 – 24 ]. As of October 24, 2021, Ethiopia had reported a total of 362,088 COVID-19 confirmed cases and 6,347 deaths [ 25 ].

In May 2019, the World Health Assembly passed a resolution to accelerate global efforts on WASH in HCFs. This resolution led to a subsequent global meeting where countries presented their national commitments with concrete actions [ 26 ]. The government of Ethiopia has also implemented various COVID-19 prevention measures, such as partial or total lockdown, physical distancing, handwashing, and others [ 27 – 29 ].

Improving WASH in HCFs facilities is considered as a first-line defense against infectious disease [ 30 ]. But still there is no standard WASH guideline in HCFs of Ethiopia. To date, there is a lack of evidence on access to and challenges around WASH facilities in Ethiopian HCFs, including South Wollo Zone health facilities in Northeastern Ethiopia. Therefore, this study was designed to assess WASH facilities and related challenges in healthcare facilities of Northeastern Ethiopia in the early phase of the COVID-19 pandemic.

Methods and materials

Study design, period, and area.

An institution-based cross-sectional study was conducted during July and August 2020 in 70 HCFs found in the South Wollo Zone, one of 15 Zones in the Amhara Region of Ethiopia. Based on the 2014 population projection, South Wollo had a total population of 2,925,559 of which 1,448,174 and 1,477,385 were male and female, respectively [ 31 ]. According to the Zonal Health Department report, South Wollo Zone has 7 governmental hospitals and 3 private hospitals, 135 health centers, 496 health posts, and 175 clinics [ 32 ].

Source and study population

All HCFs that existed in the South Wollo Zone at the time of data collection were the source population. All randomly selected HCFs in South Wollo Zone were the study population.

Sample size determination and sampling procedures

From the total number of HCFs, 70 HCFs were randomly selected using a lottery method from the lists of HCFs from the zonal health department of South Wollo. For the qualitative data collection, senior janitors, WASH coordinators of the HCFs, heads of HCFs, and clients from in-patient departments were purposively selected. A total of 14 participants, including 3 heads of HCFs, 3 WASH coordinators, 4 janitors, and 4 clients from in-patient departments were participated in the qualitative data collection.

Operational definitions

Healthcare facilities.

All formally recognized facilities that provide healthcare, including primary (health posts and clinics), secondary, and tertiary (district or national hospitals), public and private (including faith-run), and temporary structures designed for emergency contexts [ 33 ].

All works related to water, sanitation, and hygiene, including the provision of safe and affordable access to a clean water supply, sanitation, and hygiene service facilities [ 33 ].

Improved water source

Water sources from piped water, boreholes or tube wells, protected dug wells, protected springs, and rainwater [ 33 ].

Improved sanitation

Facilities that are designed to hygienically separate excreta from human contact, including flush/pour-flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrines, composting toilets, or pit latrines with slabs [ 33 ].

Water supply

Basic access water supply.

Water is available from an improved water source on the premises [ 34 ].

Limited access water supply

Improved water sources within 500 m of the premises but not all requirements for basic services are met [ 34 ].

No water access

Water is taken from an unprotected dug well or spring or surface water source or improved water source that is located more than 500 meters from the premises, or there is no source of water [ 34 ].

Basic access sanitation

Improved sanitation facilities that are usable with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible to people with limited mobility [ 34 ].

Limited access to sanitation

At least one improved sanitation facility is available, but not all requirements for basic service are met [ 34 ].

No sanitation access

Toilet facilities are unimproved (e.g., pit latrines without a slab, or platform, hanging latrine, bucket latrine, or there is no latrine [ 34 ].

Hygiene facilities

Basic access hygiene facilities.

Functional handwashing facilities (with water and soap and/or an alcohol-based hand rub are available at the point of care and within five meters of toilets [ 34 ].

Limited access hygiene facilities

Functional hand hygiene facilities are available either at the point of care or near toilets, but not both [ 34 ].

No hygiene facilities access

No functional hand hygiene facilities are available either at the point of care or near toilets [ 34 ].

Proper waste management

Waste is safely segregated into at least three bins, and sharps and infectious waste are treated and disposed of safely [ 34 ].

Low cleanliness latrine

Visible faeces and/or urine observed on the floor around the latrine and latrine not swept at the time of data collection [ 35 ].

High cleanliness latrine

Pit not full, no faecal matter seen around the pit latrine, area properly swept, and absence of bad smell at the time of data collection [ 35 ].

Data collection tools and quality assurance

A structured questionnaire that was adapted from WHO guidelines and published papers [ 34 , 36 – 38 ] and contextualized based on the study setting. The questionnaire was prepared in English, translated to the local language (Amharic), and then re-translated to the English language for consistency. The questionnaire consisted of questions on general background information on the HFCs, water supply, sanitation facilities, hygiene facilities, and major challenges of the WASH facilities.

The quantitative data was collected using a combination of an interviewer-administered questionnaire and an observational checklist. For the qualitative data, we used key-informant interviews from purposively selected janitors, WASH coordinators of HCFs, heads of HCFs, and clients of the HCFs from in-patient departments. The data were collected by four professionals with Bachelor of Science (BSc.) in environmental health who had experience of working in WASH activities and supervision was conducted by two WASH experts.

Two days of training was given by the principal investigator for the data collectors and supervisors on the data collection procedures, the content of the tool, and ethical considerations. The questionnaire was pre-tested in 5% of the final sample size to assure the validity of the measuring tool; amendments were made based on the feedback from the pre-test including improving the order of questions, editing unclear questions, and eliminating less important questions. The collected data was checked daily and any missed data were collected immediately by re-visiting the health facility. Re-checking of the entered data was done using 10% of the sample size to control data entry errors and then data cleaning was done before statistical analysis.

Data processing and analysis

The data were entered in EpiData version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for data cleaning and analysis. For quantitative data, descriptive statistics were calculated for categorical variables and mean ± standard deviations (SD) for continuous variables. The access to WASH facilities at HCFs was categorized based on WHO ladder guidelines in terms of basic, limited, or no access. The finding of the qualitative survey was triangulated with the access to WASH in HCFs findings to provide stronger evidence.

Ethical considerations

Ethical clearance was obtained from the ethical review committee of Wollo University, College of Medicine and Health Sciences with ethical letter protocol number: CMHS/451/013/2020. Permission was obtained from South Wollo Zone Health Bureau and the respective HCFs. Before beginning data collection, the purpose of the study was explained to the study participants. Written consent was obtained from participants who could read and write whereas verbal/ oral consent was obtained from those who could not. The data collectors wore facemasks and maintained social distancing as per the WHO guidelines for the prevention of COVID-19. Facemasks were provided for study participants who did not wear them during the data collection period. The anonymity of the study participants was ensured by avoiding possible identifiers such as names. All the information obtained from the study participants was kept confidential.

Background information of the HCFs

Of the total surveyed 70 HCFs, three-fourths 53 (75.7%) of them were clinics, 12 (17.2%) were health centers, and the remaining 5 (7.1%) were hospitals. More than three-fourths 57 (81.4%) of the HCFs employed Environmental Health professionals who were responsible for coordinating WASH facilities in the healthcare setting. The mean daily client flow rate was 55±108 ( Table 1 ).

The head of HCF reported that “the major problem of WASH in our healthcare facility is the absence of environmental health professionals to monitor WASH facilities and unorganized WASH committee.”

Access and challenges water supply facilities in HCFs

Regarding water supply, all investigated HCFs used tap water as the main source of water. Eight (11.4%) of HCFs did not have water during the time of data collection. One-third 27 (38.6%) of the HCFs had water storage containers that could be used as a reservoir during interruptions of the main water supply. The average number of taps in hospitals, health centers, and clinics were 80, 10, and 5, respectively. More than three-quarters of the HCFs 56 (80%) did not have a system for frequent water quality monitoring in their healthcare setting. Finally, 62 (88.6%) of the HCFs had basic access to a water supply ( Table 2 ).

The head of HCFs said that: “the major problem regarding the water supply was the absence of a separate budget for WASH facilities such as repairing of the damaged pipes.”

Clients from an inpatient department said that “we do not use water from healthcare facilities especially at night because of its distance from the in-patient ward; as a result, we are obligated to use other sources of water such as bottled water, which exposes us to extra cost.”

Access to and challenges around sanitation facilities in HCFs

About half 36 (51.5%) of the HCFs used improved sanitation facilities. This study also revealed that slightly more than half 39 (55.7%) of HCFs had separate toilets for male and female while one-third 23 (32.9%) had separate toilets for clients and workers. None of the HCFs had a latrine designed for disabled people. More than three-quarters 57 (81.4%) of the HCFs reported that there was an insufficient supply of PPE for healthcare workers in their healthcare setting ( Table 3 ).

The focal persons of WASH said that “the major problem with sanitation in the HCFs was unbalanced patient load with the availability of a functional latrine on selected dates Monday, Friday, and market days, particularly in the morning session.”

An in-patient client of HCF said that “the major problem of sanitation in the HCF was the non-functionality of latrines (broken doors, locked latrines), absence of separate toilets to take a sample, and lack of cleanliness of the surface of the latrine.”

A janitor of the healthcare facility said that “the existing challenges regarding sanitation are that although we clean the slab of latrine frequently, there are great problems in proper disposal of faeces and urine, particularly during sample collection by clients for laboratory examination.”

Access to and challenges around hygienic facilities in HCFs

In this study, half 35 (50%) of HCFs had no access to handwashing facilities and 28 (40%) had functional sinks. Less than a quarter 15 (21.4%) of the HCFs had handwashing facilities (soap and water) at the point of care and near latrines. The study also showed that only 28 (40%) of HCFs practiced proper segregation of waste using three color-coded collection containers. On the contrary, 42 (60%) of HCFs (mainly clinics and health centers) had no proper waste management system ( Table 4 ).

ABHR = Alcohol-based hand rub.

A client from a private hospital said that “the major WASH problem was the owner of the healthcare facility mainly focuses on owner’s benefit rather than providing necessary facilities.”

A client from a health center said that “there were no sufficient supplies of handwashing materials (water, soap or alcohol-based hand rub), mainly around latrines.”

A WASH coordinator said that “Although we put out handwashing materials (water, soap and alcohol-based hand rub), there is a behavioral problem in the utilization of the facilities and some clients may even steal from these facilities, particularly at latrines.”

Lack of access to WASH services hampers the implementation of preventive measures against SARS-CoV-2 and causes high mortality from diseases caused by diarrhea and lower respiratory infections [ 39 ]. Therefore, ensuring good and consistent WASH facilities in all settings, particularly in HCFs helps to prevent transmission of the SARS-CoV-2 virus.

A safe and adequate water supply in healthcare facilities is vital for reducing the transmission of infectious diseases, including the current pandemic of COVID-19. HCFs require adequate quantity and quality of water to maintain a safe environment [ 40 ]. This study revealed that most 62 (88.6%) of the HCFs had basic access to a water supply, which was higher than the studies conducted in African countries (71.2%) [ 41 ], Ethiopia (30%), Uganda (44%), Tanzania (56%), Somalia (67%), and Rwanda (73%) [ 7 ], and Uganda (86%) [ 14 ].

The major problems regarding the water supply were interruption of the water supply system, absence of a water quality monitoring system, and a lack of a separate budget for the WASH services. The finding also revealed that no HCFs had any plan for WASH risk assessment maintenance. The lack of planning may be due to the absence of a separate budget for WASH service at HCFs mainly in LMICs which reported between 0.08 and 2.54% of Gross Domestic Product (GDP) invested in WASH. The major sources of funding are official development assistance, foundations and charities, and loans from international sources, which accounted for 12% of total finance in 2016–2018 [ 42 ].

Regarding sanitation, only half (51.5%) of the HCFs had improved sanitation facilities, which was lower than the studies conducted in African countries, such as Ethiopia (66%), Kenya (86%), Mozambique (79%), Rwanda (93%), Uganda (93%) and Zambia (96%) [ 41 ], LMIC (67%) [ 12 ], Rwanda (44%) [ 40 ], sub-Saharan Africa (94.3%) [ 8 ], LMIC (81%) [ 39 ], Ethiopia (76%), Rwanda (99%), Djibouti (95%) and Uganda (75%) [ 7 ], and Zimbabwe (98%) [ 28 ]. The average ratio of latrines to clients for HCFs were 1:12 which was lower than the WHO guideline of 1:20 [ 7 ]. Clinics had the highest ratio (1:6), followed by health centers (1:16), and hospitals (1:18), which was consistent with a study conducted in Uganda [ 13 ]. In low resource settings, including Ethiopia, sanitation services in HCFs are of low priority and are often neglected [ 43 ].

Although all the HCFs had access to sanitation services, none of them had basic sanitation services, which was mainly attributed to the absence of latrines designed for disabled people. Half (51.5%) of the HCFs had limited access to sanitation services, which was lower than the finding in Uganda (84.5%) but higher than the finding in Ethiopia (17%) [ 7 ]. The possible reason for this variation may be the change in the study period and government commitment towards improving WASH facilities in healthcare settings.

WHO recommends people with suspected or confirmed SARS-CoV-2 should be provided a separate toilet, and if not possible, certain toilets should be designated as solely for the shared use of COVID-19 patients and not used by non-COVID-19 patients [ 20 ]. In this study, 56% of the HCFs had separate toilets for males and females, which was lower than the study finding in Ethiopia 94.3% [ 44 ]. This finding also revealed that 7.1% of HCFs had low cleanliness of the latrine, which may be associated with the absence of a functional lock on the latrine door and lack of lighting, frequency of cleaning, and the behavior of clients in utilizing of latrines. A systematic review conducted in LMIC revealed that the lack of cleanliness of toilets was a bigger problem than the absence of toilets, and that was attributed to a lack of safe and adequate access to water [ 43 ].

The presence of handwashing facilities with clean water and soap is a key preventive measure against the transmission of infectious diseases, including COVID-19 [ 27 ]. According to the WHO standard, functional hand hygiene facilities should be available at all critical points of the HCFs [ 7 ]. Less than a quarter (21.4%) of the HCFs had functional handwashing facilities (with water and soap) both in latrines and at point of care, which was lower than the studies conducted in Africa (28%) [ 41 ], Zimbabwe (30%) (26), LMICs [ 12 ], sub-Saharan Africa (67%) [ 8 ], Rwanda (32%) [ 40 ], Nigeria (66%), Rwanda (65%), Zimbabwe (58%) [ 7 ] and Ethiopia (74.28%) [ 44 ] but higher than Niger (4%) [ 7 ].

Only half (50%) of the HCFs had basic access to handwashing facilities, which was lower than the studies conducted in Uganda (56.9%) [ 45 ], sub-Saharan Africa (74%) [ 8 ], and Nigeria (85%) [ 46 ]. On the other hand, the current finding was higher than a study conducted in LMICs (22%) [ 40 ]. This low achievement of hygiene facilities may be due to poor access to water supply and misconduct of clients in the utilization of these facilities. Hence, the lack of fundamental hygiene facilities in HCFs may affect the quality of service given and may create a suitable environment for the transmission of HAI, including COVID-19 [ 12 , 47 ].

One-third (37.1%) of the HCFs, soap was observed at the point of care, which was in line with a study conducted in Rwanda (33%) [ 40 ]. On the other hand, it was lower than the studies conducted in LMICs (61%) [ 13 ], Uganda (75%), Rwanda (70%), Burundi (66%), Ethiopia (65%), and Somalia (58%), but higher than Djibouti (35%) [ 7 ]. On the other hand, heads and WASH coordinators of HCFs reported that they had put sufficient soap near the latrine and at the point of care, mainly since the occurrence of the COVID-19 pandemic in Ethiopia. But, they mentioned that there is misuse and/ theft of handwashing facilities, which was supported by a study conducted in Rwanda [ 40 ]. Therefore, the provision of adequate hand hygiene facilities requires not only the presence of access to washing materials (water and soap) but also appropriate behaviors [ 42 , 48 ].

Limitation of the study

This study has certain limitations. Due to the nature of the data, which was taken from a small sample size, we were unable to carry out statistical analysis. The health posts were excluded from the study due to their insignificant roles in the treatment and management of COVID-19. The other limitation of the study is that the exact number of HCFs with basic access to the water supply may be lower than the current finding due to the lack of laboratory examination of water quality assessment. Furthermore, the use of a cross-sectional study design, which cannot show the causality of the study, was also a limitation of the study.

Conclusions

Although most of the HCFs had basic access to a water supply, there were frequent interruptions of water, absence of water quality monitoring system, absence of a separate budget for WASH services, and non-functional water sources. About half of the HCFs had limited access to sanitation facilities. The major problems were the absence of accessible latrines for disabled people, lack of separate latrines for healthcare workers and clients, as well as female and male staff, unbalanced numbers of functional latrines with number of clients, non-functional latrines, and misuse of the latrine mainly during sample taking for laboratory investigation. Less than a quarter of the HCFs had basic access to handwashing facilities at both the point of care and near the latrine.

The major problems were the lack of functional handwashing facilities at the critical points and misuse, particularly around the latrine. Therefore, to reduce the risk of HAIs, including COVID-19, immediate actions should be taken by the concerned governmental and non-governmental organizations to provide sufficient water for all users, disability-friendly sanitation facilities, and handwashing facilities. The issue of WASH should be encouraged in government planning and budgeting. The technical and logistical capabilities of health and safety committees should be strengthened in order to prevent the spread of coronavirus through education and awareness campaigns. Further investigation should be done to assess the enabling factors and constraints for the provision, use, and maintenance of WASH infrastructure at HCFs.

Supporting information

Acknowledgments.

We acknowledge South Wollo Zone Health Bureau for providing all the necessary information when needed. Our thanks also extended to the studied healthcare facilities and heads of healthcare facilities in the South Wollo Zone. We also thanks data collectors, supervisors, and study participants for their valuable cooperation during the data collection.

Abbreviations

Funding statement.

Wollo University funded this research project. The funders had no role in study design, data collection and analysis, decisions to publish, interpretation of the data, and preparation of the manuscript for publication.

Data Availability

• PLoS One. 2022; 17(5): e0268272.

Decision Letter 0

PONE-D-21-35346Assessment of water, sanitation, and hygiene facilities access and challenges in Healthcare Facilities of Northeastern Ethiopia in COVID-19 Era: A mixed methods evaluationPLOS ONE

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Reviewer #1: This paper looks at water, sanitation and hygiene access during the period of COVID-19 in Ethiopia.

1.) The name of the institutional review board that approved the study is included only. Please add the approval number and indicate the form of consent obtained (written/oral). The research does not meet all applicable standards for the ethics of experimentation and research integrity.

2.) Data Availability states “Yes - all data are fully available without restriction.” Please include the full dataset as a supplement to this paper or include a link where it can be downloaded. The article does not adher to appropriate reporting guidelines and community standards for data availability.

3.) Line 69. Reference is missing to the WHO/UNICEF WASH in healthcare facilities ( https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf )

4.) Line 69 to 73, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

5.) This statement is false “HCAI including the current pandemic of COVID-19 has occurred due to a lack of WASH facilities and improper utilization of it (9)” COVID-19 is a respiratory disease. Correct this statement.

6.) Line 80 to 82, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

7.) Line 96, “October 29” What year?

8.) Line 98. The date of the first case of COVID-19 globally is incorrect. It was in December 2019.

9.) Line 105. There is data on Ethiopia and COVID-19 in the WHO/UNICEF report. “In Ethiopia, a large assessment of facilities carried out as part of the COVID-19 response resulted in the mobilization of US$ 5 million to support IPC and WASH activities in 74 high-load hospitals. WHO and UNICEF launched the ‘Hand Hygiene for All’ (HH4A) global initiative in June 2020. It is a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19”

10.) Line 127, what is tottery?

11.) Was distance to water sources measured with a tape measure?

12.) Statistics, and other analyses are not performed to a high technical standard and are not described in sufficient detail. This is listed as a limitation later, but needs to be done prior to acceptance of the paper.

13.) The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.

14.) The study needs to compare to the recent Ethiopia WASH in healthcare facility work during COVID-19, this is a major gap of this manuscript https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf

15.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

16.) Conclusions presented are not supported by the data. Expand the conclusions. How could the findings of this work be implemented for better access, not just in Ethiopia but lessons learned for other low- and middle-income countries? At least give some practical options for solutions in a bulleted list. What can be done within resource limited environments? How much financial investment is needed at a minimum to improve conditions? Also, I missed seeing what further research you can suggest in this field.

17.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Other comments:

1.) healthcare facilities should not be in capital in the title, or throughout the manuscript. Only proper nouns should be in capital letters.

Reviewer #2: Abstract

Sampling why not you use proportional allocation to the number of health care facilities since all health facilities are known by the regional health bureau.

Line 33 add the word “by” before the word “using “ and add “interviewer administered” before “structured questioner”

Line 50 who are nongovernmental health facilities? Change the word either NGO or partners

line 98 it doesn’t state in which country specifically that CoVID-19 is occurred on March 13, Hence re-write this sentence.

Line99-100 the sentence is not complete.

Line 101 278 HCFs are in nationwide, or regionally or zonal level???????

Study design

Remove line 113,114,115 which talks about the boarder of Wello zone that much is not necessary

Line 121 All HCFs which is present…… change the word present by the word “exist”

Line 125 why not you mention the number of the total health facilities found in the zone to see whether the sample (70) is representative or not? And what was your base to take 70? Why not 80, 90,100 or above?

Out of the total sample, 80% are private clinics what was your base to take larger sample from private clinics.

Line 125 Since there is enough data on the number of health institutions found in the zonal health department, why don’t you use proportional sampling technique rather than simple random to make it more uniform and representative of each health facility category?

Line 127-131 how qualitative data were collected? Is it in-depth interview or FGDs? Explain well which method is best in exploring the challenges of an issue?

Line 150 what about the definition of limited access for sanitation??

Line 165 contextualized to the study……

Line 170 you use spot observation to collect data but you didn’t mention the result that you obtain through this method in your result part.

Line 188 how the qualitative data were analyzed? It is not exhaustively written. Hence you should mention the method that used to analyze it.

Line 204-206; do you think that your result represent the HCFs that are found in the zone?

Line 206 are an environmental health professionals the only professionals who coordinates the WaSH activities? Did you ask the presence of even other professionals in the position?

Line 207 average is not the appropriate measures rather you use mean +/- SD since the average is 55 but the highest value is 320, do you see the gap?

Line 208; though the highest number of patient flow is in the hospital, you included in your study only 7% of them. Do you think your sample is representative?

Line 234 I think it is better to write “…HCFs was unbalanced patient load with functional…. ”

Line 240 it is better to change the word “the floor” by the word “the slab”…..disposal of “faces” by “faeces “ after that add the word “and” before urine

Line 242 ….challenges of hygienic facilities

Line 243 since it is 35 or half of your sample, you can’t say more than half of…..

Line 248 “proper waste management” what does it mean in this research context. It needs operational definition for this research

Line 248 …..and they disposed off …. Add one “f”

Line 249-252; the sentence is not clear. Is it about cleaning or cleaning protocol or the janitors training status?

Line 253-255 I didn’t understand about your sample the person from private health care facilities customer? If it is so remove it since they are two independent setting i.e governmental and private hospitals you compared two different institutions. Besides, in your sampling section, there is no list of participant from private health institution users. From where did you bring this information?

Line 262-263 it is better to add references to the written sentence

Line 265-267 the sentence which describes the aim should be omitted since it is already mentioned earlier

Line 267. Can we say all HCFs have accessed to water supply? In you result part line 214, 11% of them have no water during data collection time. Some time it is more than that. Hence you should modify this statement

Line 267-271 you should treat each component independently otherwise there will be writing the result repeatedly which will be boring to the reader. Hence write the discussion separately for water, sanitation and hygiene

Line 273 and 274 it needs re-writing and is it possible to put the different country status by average number? Why not you mention for each country status to know and compare it

Line 275; your justification doesn’t convince the reader i.e why don’t you find the similar setting to compare it either rural or urban?

Line 278 your justification is the variation in the HCFs why not you compare with similar setting?

Line 278 remove the bracket at the end of line 278

Line 279-282 “almost all …….in private clinics” this statement should be placed after discussing water, sanitation and hygiene results and even compare the result and the situation with studies done in other parts of Ethiopia.

Line 287 you said that the ratio 11.5 is greater than WHO standard. What is the WHO standard put the number. Besides, there is no reference, hence put your reference

Line 288 the statement “….between the level….” Should be changed to between the HCFs. Even it is better to put the ratio result (in number) with in each HCF.

Line 291-301 the paragraph seems the result part since you didn’t discuss any of your result by comparing your result with the other studies. Hence this paragraph needs re-writing again

Line 304 “HCFs had no function…..” change the word function to “functional”

Line 305 what about the other study setting you didn’t discuss your finding simply put the number that you wrote in the result part here again.

Line 307-309; this justification is for the 60% (HCFS had no function hand washing facilities) or 21% (HCFs had functional handwashing facilities with water and soaps)? It is confusing discussion part. Hence it is better to treat independently.

Line 314-320 you simply put your result again that you wrote in your result part. Hence it needs further discussion by comparing your result with other findings and give your justification why the variation occurs.

Where is the qualitative data discussion part? you didn’t put anything. Why you collect the qualitative data? And how you analyzed it? Is it by open code, thematic, ATLAS-Ti or by what technique? Nothing is said about this. Please write something on it. You said in your methodology mixed where is the mixed nature? I didn’t see it or realized it.

Line 323 “exclusion of health post” I preferred you were included these health post rather than the private clinics that you included. The reason is that

1. There is a mix up of different setting that is governmental and private which are almost completely different setting in Ethiopian condition

2. Your study design is not comparative cross sectional method

3. You didn’t compare the result of private clinics with the government or even to the other similar setting of different countries. The data that you got from private clinics are confined in the governmental HCFs and treated as they are governmental HCFs

Limitation part what about the cross-sectional nature of the data?

Line 335 make correct on the word “…..concerned exerts……” change to concerned experts

Table 3 on page 24 “overall latrine cleanliness” i.e high, medium, low, it needs operational definition.

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Reviewer #2:  Yes:  Mathewos Moges

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Submitted filename: comment.docx

Author response to Decision Letter 0

15 Feb 2022

Response to editor

Question #1 Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: Thank you for this remark. We re-formatted the revised manuscript using the PLoS ONE format guidelines. The whole content of the manuscript, including the abstract, introduction, methods, discussion and reference are formatted using the guidelines (Please see the revised version for each section).

Question #2 Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.” as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now . This information should be included in your cover letter; we will change the online submission form on your behalf

Response: thank you for your remark; we have incorporated it in the cover letter.

Question #3. Data availability

Response. We have attached the data on the supplementary information

Response to Reviewer 1

Question ##1) The name of the institutional review board that approved the study is included only. Please add the approval number and indicate the form of consent obtained (written/oral). The research does not meet all applicable standards for the ethics of experimentation and research integrity.

Response: We have added the approval number and the form of consent in the revised manuscript.

Question #2.) Data Availability states “Yes - all data are fully available without restriction.” Please include the full dataset as a supplement to this paper or include a link where it can be downloaded. The article does not adhere to appropriate reporting guidelines and community standards for data availability.

Response: We have included all necessary supplementary data in the revised version manuscript.

Question #3.) Line 69. Reference is missing to the WHO/UNICEF WASH in healthcare facilities ( https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf )

Response: we have included the reference in the revised manuscript.

Question #4.) Line 69 to 73, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

Response: thank you for your comment. We have used the most recent WHO/UNICEF 2020 report in the revised manuscript.

Question #5.) This statement is false “HCAI including the current pandemic of COVID-19 has occurred due to a lack of WASH facilities and improper utilization of it (9)” COVID-19 is a respiratory disease. Correct this statement.

Response: sorry for the confusion we have created. Hence, we have re-written the sentence in the revised manuscript. Question #6.) Line 80 to 82, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

Response: thank you for your comment. Hence, we have used the most recent 2020 WHO/UNICEF report in the revised manuscript.

Question #7 Line 96, “October 29” What year?

Response: Sorry for the problem we have created. Hence, we have incorporated the missed data in the revised version of the manuscript.

Question #8.) Line 98, the date of the first case of COVID-19 globally is incorrect. It was in December 2019.

Response: Sorry for the confusion we have created in the original manuscript. The idea of the sentence was the first case of COVID-19 in Ethiopia, not at the global level. Hence, we have rephrased the sentence accordingly in the revised manuscript.

Question #9) Line 105. There is data on Ethiopia and COVID-19 in the WHO/UNICEF report. “In Ethiopia, a large assessment of facilities carried out as part of the COVID-19 response resulted in the mobilization of US$ 5 million to support IPC and WASH activities in 74 high-load hospitals. WHO and UNICEF launched the ‘Hand Hygiene for All’ (HH4A) global initiative in June 2020. It is a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19”

Response: thank you very much for your comment. We have included further literatures based on your recommendation in the revised version of the manuscript.

Question #10) Line 127, what is tottery?

Response: sorry for the editorial problem we have created. Hence, we have edited the word tottery to the word lottery method in the revised manuscript.

Question #11) Was distance to water sources measured with a tape measure?

Response: If the water source is available in the premise of the Healthcare facilities, no need of measuring the distance. On the other hand, when the water source is out of the premise, the distance of water source was measured using appropriate distance measuring tool.

Question 12). Statistics and other analyses are not performed to a high technical standard and are not described in sufficient detail. This is listed as a limitation later, but needs to be done prior to acceptance of the paper.

Response: thank you very much for your comment. The statistical analysis depends on the objective of the study. The objective of the current study can be expressed by using descriptive statistics using frequency, mean with standard deviation. Furthermore, we have presented the absence of advanced statistical analysis as the limitation of the study.

Question#13). The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.

Response: We have incorporated your comment in the revised version of the manuscript.

Question#14) The study needs to compare to the recent Ethiopia WASH in healthcare facility work during COVID-19, this is a major gap of this manuscript https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf

Response : Thank you very for your comment we have tried to use further papers which were conducted indifferent parts of the world for comparison with the finding the current study. (See the revised version of the manuscript)

Question#15.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

Response Thank you very for your comment. We have used similar papers which were conducted in low resource setting mainly in African countries in order to compare with this study finding. But there is limitation of the stud in these areas (See the revised version of the manuscript)

Question#16.) Conclusions presented are not supported by the data. Expand the conclusions. How could the findings of this work be implemented for better access, not just in Ethiopia but lessons learned for other low- and middle-income countries? At least give some practical options for solutions in a bulleted list. What can be done within resource limited environments? How much financial investment is needed at a minimum to improve conditions? Also, I missed seeing what further research you can suggest in this field.

Response: We have tried to modify the conclusion based on the finding of the study. (See the revised version of the manuscript).

Question#17.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Response: Thank you very much for your valuable comment. We have modified all the problems you mentioned. (See the revised version of the manuscript)

Response to Reviewer 2

Question #1 Healthcare facilities should not be in capital in the title, or throughout the manuscript. Only proper nouns should be in capital letters.

Response: thank you for your comments; hence we have incorporated it in the revised manuscripts

Question #2 sampling why not you use proportional allocation to the number of health care facilities since all health facilities are known by the regional health bureau.

Response: Ok thank you for your comments. We have lists of Healthcare facilities in the study catchment. Therefore we can use sample random sampling technique to select the study participants using the lists of the healthcare facilities as the sampling frame.

Question #3 Line 33 add the word “by” before the word “using “ and add “interviewer administered” before “structured questioner”

Response: we have amended it accordingly.

Question #4 Line 50 who are nongovernmental health facilities? Change the word either NGO or partners

Response: sorry for the confusion. We want to say concerned partners. Hence we have amended it accordingly.

Question #5 line 98 it doesn’t state in which country specifically that CoVID-19 is occurred on March 13, Hence re-write this sentence.

Response: sorry for the confusion; it is to mean for Ethiopia therefore, we have amended it accordingly in the revised manuscript.

Question #6 Line99-100 the sentence is not complete.

Response: sorry for the confusion, we have improved it in the revised manuscript.

Question #7 Line 101 278 HCFs are in nationwide, or regionally or zonal level???????

Response: sorry for the confusion, the report was representing the nationwide of Ethiopia. Hence we have incorporated in the revised version.

Question #8 Remove line 113,114,115 which talks about the boarder of Wollo zone that much is not necessary

Response: thank you for your important comment. We have removed in the revised manuscript

Question #9 Line 121 All HCFs which is present…… change the word present by the word “exist”

Response: thank you for your comment we have modified it accordingly.

Question #10 Line 125 why not you mention the number of the total health facilities found in the zone to see whether the sample (70) is representative or not? And what was your base to take 70? Why not 80, 90,100 or above? Out of the total sample, 80% are private clinics what was your base to take larger sample from private clinics.

Response: thank you for your comment we have already mentioned the total number of healthcare facilities in the method section of the manuscript. The sample was taken based on the number of existence healthcare facilities in the study area. The number of clinics in the study area was higher than other healthcare facilities which motivate us to take larger sample than others. The base for the sample was resource limitations and lockdown which restricts the movements of data collectors.

Question #11 Line 125 Since there is enough data on the number of health institutions found in the zonal health department, why don’t you use proportional sampling technique rather than simple random to make it more uniform and representative of each health facility category?

Response: thank you for your comment. We have frames of healthcare facilities in the health authorities of the study area. Hence, we used simple random sampling techniques using the lottery method to avoid bias in the selection of the study participants.

Question #12 Line 127-131 how qualitative data were collected? Is it in-depth interview or FGDs? Explain well which method is best in exploring the challenges of an issue?

Response: the qualitative data was collected using in-depth interview. But to explore the challenges of such types of issues FGD may be more appropriate

Question #13 Line 150 what about the definition of limited access for sanitation??

Response: sorry for the confusion we have incorporated it in the revised manuscript.

Question #14 Line 165 contextualized to the study……

Response: we have corrected it accordingly in the revised manuscript.

Question #15 Line 170 you use spot observation to collect data but you didn’t mention the result that you obtain through this method in your result part.

Response: sorry for the confusion we have created; as you see in the method section we used different methods of data collection which is interview and observation. The data which was collected by these methods are presented in the result section of the manuscript. For example the data of handwashing facilities were collected by observational methods

Question #16 Line 188 how the qualitative data were analyzed? It is not exhaustively written. Hence you should mention the method that used to analyze it.

Response: the qualitative data was analyzed using thematization method.

Question #17 Line 204-206; do you think that your result represent the HCFs that are found in the zone?

Response: yes; in the study catchment there are heath posts, clinics, health centers, and hospitals. We tried to take samples from different categories of healthcare facility categories based on the number of healthcare facilities existed during the data collection time.

Question #18 Line 206 are an environmental health professionals the only professionals who coordinates the WaSH activities? Did you ask the presence of even other professionals in the position?

Response: Environmental Health professionals are not the only professional who coordinates WASH activities but they are the best professionals who can coordinate such types of activities. Furthermore, we have assessed as there are there professionals who are wring on the position.

Question #19 Line 207 average is not the appropriate measures rather you use mean +/- SD since the average is 55 but the highest value is 320, do you see the gap?

Response: thank you for your comment. Despite we used mean and the highest value in the result section, we have expressed it using mean with standard deviation in the tables. Therefore, we have incorporated it in the result section of the revised manuscript.

Question #20 Line 208; though the highest number of patient flow is in the hospital, you included in your study only 7% of them. Do you think your sample is representative?

Response: we think the sample is representative of the whole sample. This is because the existed number of hospitals in the study catchment is less than 5% but we take larger samples which are 7% to accommodate the highest client flow rate in such types of healthcare facilities.

Question #21 Line 234 I think it is better to write “…HCFs was unbalanced patient load with functional…. ”

Response: Thank you for the comment. We have amended it accordingly in the revised manuscript.

Question #22 Line 240 it is better to change the word “the floor” by the word “the slab”…..disposal of “faces” by “faeces “ after that add the word “and” before urine

Response: we have incorporated your comments accordingly in the revised manuscripts.

Question #23 Line 242 ….challenges of hygienic facilities

Response: We have modified the comment accordingly in the revised manuscript.

Question #24 Line 243 since it is 35 or half of your sample, you can’t say more than half of…..

Response: sorry for the problem. Hence, we have corrected it accordingly in the revised manuscript.

Question #25 Line 248 “proper waste management” what does it mean in this research context. It needs operational definition for this research

Response: thank you for the comment. We have incorporated the comment in the revised manuscript.

Question #26 Line 248 …..and they disposed off …. Add one “f”

Question #27 Lines 249-252; the sentence is not clear. Is it about cleaning or cleaning protocol or the janitors training status?

Response: sorry for the confusion. We re-write it in the revised manuscript.

Question #28 Line 253-255 I didn’t understand about your sample the person from private health care facilities customer? If it is so remove it since they are two independent setting i.e governmental and private hospitals you compared two different institutions. Besides, in your sampling section, there is no list of participant from private health institution users. From where did you bring this information?

Response: the study incorporates both government and non-governmental health care facilities (health center, clinics, and hospitals) which exist in the study setting. In the qualitative section, we have selected individual participants using purposive sampling technique using an in-depth interview from both types of institutions to assess the major challenges faced in there heath institutions mainly after the occurrences of COVID-19 pandemic. Therefore, the finding of the current study represents governmental and non- governmental healthcare facilities of the study catchment.

Question #29 Line 262-263 it is better to add references to the written sentence

Response: thank you for your comment. We have added reference accordingly in the revised manuscript.

Question #30 Line 265-267 the sentence which describes the aim should be omitted since it is already mentioned earlier

Response: Ok; we have omitted in the revised manuscript.

Question #31 Line 267. Can we say all HCFs have accessed to water supply? In you result part line 214, 11% of them have no water during data collection time. Some time it is more than that. Hence you should modify this statement

Response: thank you for the comment. We have amended it accordingly (see the revised manuscript)

Question #32 Line 267-271 you should treat each component independently otherwise there will be writing the result repeatedly which will be boring to the reader. Hence write the discussion separately for water, sanitation and hygiene

Response: thank you; we have modified it in the revised manuscript. Hence write the discussion separately for water, sanitation and hygiene in the revised manuscript.

Question #33 Line 273 and 274 it needs re-writing and is it possible to put the different country status by average number? Why not you mention for each country status to know and compare it

Response: we have modified it accordingly in the revised manuscript.

Question #34 Line 275; your justification doesn’t convince the reader i.e why don’t you find the similar setting to compare it either rural or urban?

Response: we have tried to search out similar setting for easy comparison of the current finding with other finding. But, we cannot get sufficient literatures based on your recommendation

Question #35 Line 278 your justification is the variation in the HCFs why not you compare with similar setting?

Question #36 Line 278 remove the bracket at the end of line 278

Response: we have removed it in the revised manuscript.

Question #37 Line 279-282 “almost all …….in private clinics” this statement should be placed after discussing water, sanitation and hygiene results and even compare the result and the situation with studies done in other parts of Ethiopia.

Response: thank you for your comment; we tried to compare this study finding with other countries mainly in low resource setting for comparison. But there is deficiency of study conducted in Ethiopia in this aspect.

Question #38 Line 287 you said that the ratio 11.5 is greater than WHO standard. What is the WHO standard put the number. Besides, there is no reference, hence put your reference

Response: we have incorporated your comment in the revised manuscript.

Question #39 Line 288 the statement “….between the level….” Should be changed to between the HCFs. Even it is better to put the ratio result (in number) with in each HCF.

Response: Ok, we have incorporated your comment in the revised manuscript.

Question #40 Line 291-301 the paragraph seems the result part since you didn’t discuss any of your result by comparing your result with the other studies. Hence this paragraph needs re-writing again

Response: thank you for your comment. Hence, we have tried to compare the current finding with other studies conducted in different parts of the word, mainly in developing countries.

Question #41 Line 304 “HCFs had no function…..” change the word function to “functional”

Response: Ok; we have modified in the revised manuscript.

Question #42 Line 305 what about the other study setting you didn’t discuss your finding simply put the number that you wrote in the result part here again.

Response: thank you for your comment. Hence, we have tried to modify the discussion by comparing this finding with other study finding.

Question #43 Line 307-309; this justification is for the 60% (HCFS had no function hand washing facilities) or 21% (HCFs had functional handwashing facilities with water and soaps)? It is confusing discussion part. Hence it is better to treat independently.

Response: sorry for the confusion we have created. Therefore, we have amended it in the revised manuscript.

Question #44 Line 314-320 you simply put your result again that you wrote in your result part. Hence it needs further discussion by comparing your result with other findings and give your justification why the variation occurs.

Response: thank you very much for your critical comment. We have incorporated the qualitative section in discussion in line with the quantitative one. The qualitative data are very important in identifying the major challenges of WASH facilities in the healthcare setting. The qualitative data was analyzed using the thematization technique. The mixed nature of the study incorporates both qualitative and quantitative. The access of WASH facilities were studied using quantitative method whereas the challenges of WASH facilities were studied using the qualitative technique

Question #45 Line 323 “exclusion of health post” I preferred you were included these health post rather than the private clinics that you included. The reason is that

Response: The study tried to associate the COVID-19 prevention in healthcare setting. in the case of Ethiopia particularly in the study setting, most of the populations usually get treatment for different healthcare facilities including hospitals, heath centers, and clinics. In the case of heath posts, the major service usually focuses on the prevention of disease including the current pandemic of COVID-19. Hence, clients are not expected to visit the health post which motivates us to exclude from the study.

Question #46 Limitation part what about the cross-sectional nature of the data?

Response: We have incorporated it in the revised manuscripts accordingly.

Question #47 Line 335 make correct on the word “…..concerned exerts……” change to concerned experts

Response: we have corrected it in the revised manuscript.

Question #48 Annex Table, 3 on page 24 “overall latrine cleanliness” i.e high, medium, low, it needs operational definition.

Response: thank you for your comment. We have included the operational definition of the word latrine cleanliness in the revised manuscript.

Submitted filename: response to reviewers.docx

Decision Letter 1

28 Feb 2022

PONE-D-21-35346R1Access to and challenges in water, sanitation, and hygiene in healthcare facilities of Northeastern Ethiopia in the COVID-19 era: A mixed methods evaluationPLOS ONE

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Many thanks for the improvements to the manuscript but there is still some work to be done to bring it up to the required standard.  The findings need to be compared to other studies.   These can be within Sub Saharan Africa but must be outside Ethiopia.   Searching in a free engine like Google Scholar should bring the desired results.   Please look carefully at the other points from reviewer 1 too.

Please submit your revised manuscript by Apr 14 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at  gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: 1.) I continue to be concerned with the wider use of literature. For the use of “worldmeter” references 18 and 22, I would prefer to see official Ethiopian government sources. Also, the use of a WHO/UNICEF 2015 JMP report in reference 38. Please update and use the most recent 2021 WHO/UNICEF report.

2.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

3.) As previously commented, the authors have not made this change. “The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.” In Revision 1, Table 1 and 2 still list results to 0.1%

4.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Reviewer #2: all comments that I raised in the first round were properly addressed by the authors. That was nice. But I have one comment on the reference section. Your references are not similar in style. Hence you should rewrite all references again

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #2: No

Author response to Decision Letter 1

#1: I continue to be concerned with the wider use of literature. For the use of “Worldometer” references 18 and 22, I would prefer to see official Ethiopian government sources. Also, the use of a WHO/UNICEF 2015 JMP report in reference 38. Please update and use the most recent 2021 WHO/UNICEF report.

Response:-thank you very much for your comments. Hence, we have incorporated your comments in the revised version of the manuscript.

Response:-thank you for your constrictive comment too. We have tried to use researches which were conducted in Ethiopia and other low and middle countries as much as possible in the revised manuscript.

Response:-ok we have modified it based on your comments in the revised manuscript (see the revised version).

Response:-thank you for the comment; we have tried to incorporate all issues you have raised.(see the revised version of the manuscript)

Response to reviewer 2

#1: all comments that I raised in the first round were properly addressed by the authors. That was nice. But I have one comment on the reference section. Your references are not similar in style. Hence you should rewrite all references again

Response:-thank you for the comment. We have modified the references based on the standard guideline of the journal. (see the revised version of the manuscript)

Submitted filename: response to the reviwers.docx

Decision Letter 2

31 Mar 2022

PONE-D-21-35346R2Access to and challenges in water, sanitation, and hygiene (WASH) in healthcare facilities of Northeastern Ethiopia in the COVID-19 era: A mixed-methods evaluationPLOS ONE

I have assessed your submission, and whilst the science is now adequate, I have concerns about the overall readability of the manuscript. I therefore request that you revise the text to fix the grammatical errors and improve the overall readability of the text. 

PLOS ONE suggests you have a fluent, preferably native, English-language speaker thoroughly copy-edit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can do this, you may wish to consider employing a professional scientific editing service. Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of the partnership with AJE, visit the AJE website ( https://www.aje.com/go/plos/ ) for a 15% discount off AJE services. To take advantage of the partnership with Editage, visit the Editage website ( www.editage.com ) and enter referral code PLOSEDIT for a 15% discount off Editage services. 

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Please note that PLOS ONE does not copy-edit accepted manuscripts and that one of the criteria for publication is that articles must be presented in an intelligible fashion and written in clear, correct, and unambiguous English ( http://www.plosone.org/static/publication#language ). If the language is not sufficiently improved, I may have no choice but to reject the manuscript.

Please submit your revised manuscript by May 15 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at  gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Author response to Decision Letter 2

23 Apr 2022

Question #1 I have assessed your submission, and whilst the science is now adequate, I have concerns about the overall readability of the manuscript. I therefore request that you revise the text to fix the grammatical errors and improve the overall readability of the text.

Response: Thank you for this remark. We have revised the whole manuscript to reduce the grammatical errors and improve the overall readability of the text by the help of known researcher Dr Metadel Adane Mesifin (Please see the revised version for each section).

Question #2 Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: thank you very much for critical comment. Hence we have improved the whole listed references using the guideline of PLOSE ONE (see the revised version for each section).

Decision Letter 3

27 Apr 2022

Access to and challenges in water, sanitation, and hygiene (WASH) in healthcare facilities of Northeastern Ethiopia in the early phase of the COVID-19 pandemic: A mixed-methods evaluation

PONE-D-21-35346R3

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Acceptance letter

Dear Dr. Berihun:

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Literature Review Of Drinking Water And Sanitation

Drinking water fracking.

According to the Millennium Development Goals Report 2012, “783 million people, or 11 per cent of the global population, remain without access to an improved source of drinking water. Such sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collections.” (United Nations, 2012) The United Nations Water Conference in 1977 along with a few other conferences, addressed helping approximately “1.3 billion people in developing countries gain access to safe drinking water.” (United Nations, 2012) While there is progress being made, we see that various regions without clean drinking water. Reports show, “In four of nine developing regions, 90 per cent or more of the population now uses an improved drinking water source. In contrast, coverage remains very low in Oceania and sub-Saharan Africa, neither of which is on track to meet the MDG drinking water target by 2015. Over 40 per cent of all people without improved drinking water live in sub-Saharan Africa.” (United Nations, 2012) It is shown that rural areas still lack drinkable water as opposed to urban areas. Consistent improvement has been made to supply populated areas with a reliable source of drinking water. However, research shows, “Coverage with improved drinking water sources for rural populations is still lagging. In 2010, 96 per cent of the urban population used an

Global Water Crises Around The World And The Effects They Have On People Who Inhabit Those Regions

A problem that affects the daily life of more than a hundred million people is inadequate sanitation and a lack of proper sanitation facilities. For example, only 87% of Indians in urban areas have access to a sanitized latrine, while only 33% of Indians in rural areas have access to a toilet, (The Guardian). This statistic is alarming, as it increases the susceptibility to diseases such as

Is Water a Human Right?

“Access to safe water is a fundamental human need and, therefore, a basic human right. Contaminated water jeopardizes both the physical and social health of all people. It is an affront to human dignity.” — Kofi Annan, prior United Nations Secretary-General

Persuasive Speech About Water Pollution

Main Point: Third world countries lack accessibility to clean water exposing them to disease and harmful toxins that result in 2.4 million deaths annually (Bartram, 2010).

Safe Water In Australia

Around the world people are suffering from the problem of having a safe and clean water, there are more than 633 million people lack access to safe water. Remote countries in Africa are mostly the victim of having unsanitary water sources.

Persuasive Essay On Bottled Water

Having had the chance to travel to some the most primitive areas around the world for missions work, lack of clean water affects the health and hygiene of a people. Improper disposal of human waste and trash are key contributors to water contamination in underdeveloped countries. “In 2016, 143 communities and 57 schools received clean water in Sierra Leone, Kenya and Uganda” (“2016 Annual Report”). Organizations, like The Water Project, are making great efforts around the world to make a difference in these areas by installing wells and providing water purification systems. Until the proper infrastructure is in place, bottled water is the perfect stopgap. Bottled water can provide those living in these unreached areas a way to get their daily intake of water without fear of sickness.

Bsbwor501 Unit 4

That “over 1 billion people lack access to safe water supplies;” and that “2.6 billion people lack adequate sanitation.” (WHO, 2005)

Persuasive Essay On Clean Water

Sanitation, even in healthcare facilities, is a problem. In southeast Asia, 42% of healthcare facilities don’t have adequate toilets. In sub-Saharan Africa, 36% of healthcare facilities don’t even have soap

Birita Filter Research Paper

People in Developing countries drink pond, stream, pond water which could be contaminated by animals and people. In third world countries they’re not really educated so they don’t know that the water they drink is bad for them. Another way they get water is by digging deep holes until they find water, it may be cleaner than the surface water but there would be still be a chance that it could be contaminated, which could end up giving them diseases and even death. 884 million people in the world don’t have water that is safe to drink. Also more 80 percent of sewage in third world countries contaminates their water source. Schools also don’t clean/safe water for kids to drink. In developing countries women and children spend 6 hours every day trying to collecting water and on

Coke And World War Essay

A fifth of the world’s population (1.2 billion people) lack access to safe water today.

Clean Water In The United States

any countries in the world are short of precious water. Given that water is so essential to everyday activities, such as cooking,washing, and growing crops, without the quality of water can affect our nation, even causing economic or social instability. The cdc estimates 780 million people around the world,more than 1 in 10, do not have access to an improved water source one that is protected from outside contaminants.

Drinking Water Shortage in Sub-Saharan Africa

Two out of every five people living in Sub-Saharan Africa lack safe water. A baby there is 500 times more likely to die from water-related illness than one from the United States. This is a serious ongoing issue that requires the rest of the world to take action. Water spreads diseases easily if the necessary precautions are not taken. Many developing African countries don’t have sewage treatment, or the people don’t have methods to filter and disinfect. Once a person is sick either there is no way to cure them, or medical care is too expensive, so they are left untreated with a high risk of death. Although many believe that the fight for sanitary water in Africa is insurmountable, people in these developing countries can overcome their challenge to access clean water and avoid water-borne diseases through proper sewage treatment facilities, universal water filtration and medical care.

Role Of Public Health In The 21st Century

Watch this TED Talk video by Francis de los Reyes:‘Sanitation is a basic human right’ and post a comment on the discussion forum in relation to the role of government in funding these sorts of projects.

Importance Of Clean Water

One of the most important natural resources we have on this planet is water. Water covers roughly 70 percent of our planet and is the very foundation for every single species on earth. We as humans, rely on water more than any other resource on the planet and we simply can’t live without it. Although water is abundant around the world, clean water for millions of people is inaccessible. Around the world, there are people struggling to get water yet along clean water and it greatly affects our health. Improving clean water supply and sanitation, and better access to clean water resources, can increase countries’ economic development and can contribute greatly to poverty reduction and overall people’s health.

The Health Of Clean Water

Few resources are essential to human survival. Access to clean water is the most critical of all. Water is a vital resource responsible for sustaining all life on earth. However, clean water is in short supply, but in high demand in all parts of the world. It is thought that most Americans have access to safe, affordable, clean water right from their taps. However, the media is uncovering the true nature of America’s deteriorating water situation. Americans have reason to be seriously concerned about the state of their drinking water. So what really is on tap in America?

Related Topics

• Drinking water
• Waterborne diseases

To read this content please select one of the options below:

Please note you do not have access to teaching notes, the economic consequences of money laundering: a review of empirical literature.

Journal of Money Laundering Control

ISSN : 1368-5201

Article publication date: 28 November 2023

The purpose of this study is to provide a timely synthesis of the empirical literature focusing on the economic consequences of money laundering, as this topic has been gaining momentum among policymakers and academic researchers due to its adverse effects.

Design/methodology/approach

Empirical studies are collected by consulting accounting and finance journals in diverse digital sources (e.g. Science Direct, Blackwell, Taylor and Francis, Springer, Sage and Emerald). Key words used to identify relevant papers include “money laundering” and “anti-money laundering regulations,” with specific focus on the economic consequences. Our search strategy includes 24 published papers over the period of 2018–2023.

Findings show that most studies represent cross-country investigations; the main topics investigated focus on accounting field (e.g. audit fees, real and accrual earnings management), tax evasion, financial stability, sustainability, economic indicators (inflation, economic growth, foreign direct investment) and financial inclusion; and the economic consequences of money laundering have been also examined within banking industry (e.g. banking profitability, banking stability). Reported findings of reviewed studies suggest that money laundering has diverse adverse impacts at the country level (e.g. increased tax evasion, higher inflation rate, less sustainability and foreign direct investments), at the firm level (e.g. increased audit risk and aggressive real and accrual earnings management) and within banking industry through negative impact of money laundering on bank’s loan portfolio quality, stability and profitability.

Practical implications

With respect to policymakers, strengthening anti-money laundering regulations may play a critical role in reducing money laundering activities. Furthermore, financial institutions should implement specific rules dealing with anti-money regulations to ensure adequate compliance and disclosure. Finally, policymakers should be aware about the importance of digital transformation to combat money laundering activities since it facilitates the detection of financial crimes due to their traceability.

Originality/value

The summary of the empirical literature focusing on the economic consequence of money laundering represents a historical record and an introduction for accounting researchers. It also urges them to further explore the economic implications of anti-money laundering disclosure within banking industry.

• The economic consequences of money laundering
• Anti‐money laundering regulations
• Literature review

Acknowledgements

The authors would like to thank Prince Sultan University for their support.

Khelil, I. , Khlif, H. and Achek, I. (2023), "The economic consequences of money laundering: a review of empirical literature", Journal of Money Laundering Control , Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/JMLC-09-2023-0143

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Copyright © 2023, Emerald Publishing Limited

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Apple unveils the top books of 2023 and a new Year in Review experience

Discover Year in Review

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Explore the Best and Top Books and Audiobooks of 2023

• Spare by Prince Harry, The Duke of Sussex
• The Woman in Me by Britney Spears
• The Wager: A Tale of Shipwreck, Mutiny and Murder by David Grann
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• Elon Musk by Walter Isaacson
• Fourth Wing by Rebecca Yarros
• Iron Flame by Rebecca Yarros
• Happy Place by Emily Henry
• Hello Beautiful by Ann Napolitano
• The Covenant of Water by Abraham Verghese
• The Creative Act: A Way of Being by Rick Rubin
• Only the Dead by Jack Carr
• Tom Lake by Ann Patchett
• Year in Review is available for free for Apple Books users in Australia, Canada, France, Germany, the U.K., and the U.S.
• For users with at least three books marked as finished, Year in Review is available on iPhone with iOS 17.1 and iPadOS 17.1 at books.apple.com/year-in-review .
• Users can share purchased titles with up to five family members using Family Sharing.

Text of this article

November 28, 2023

Apple unveils the top books :br(l)::br(xl):of 2023 and a new Year in Review experience

Users can browse the top books and audiobooks of 2023 and explore personalized insights about the books they enjoyed this year

Apple Books is the single destination for all the books and audiobooks readers love, featuring the ability to set Reading Goals, organize books into collections, share purchases using Family Sharing, and browse personalized recommendations for new titles.

Today, Apple Books unveiled the top books and audiobooks of 2023 and launched Year in Review, a new in-app experience that helps readers to celebrate the titles, authors, and genres that defined their year. With Year in Review, users can view personalized reading highlights about the books and audiobooks they enjoyed in 2023, including their total time spent reading, the longest book or audiobook they read, the series they completed, their most-read author and genre, and their highest-rated book — all presented in a simple and engaging experience with visuals that are easy to share.

Here’s how to access Year in Review on Apple Books:

Year in Review is available on iPhone and iPad within the Read Now tab under Top Picks to users with at least three titles marked as finished.

To add books or audiobooks, readers can tap and hold on any book in the app and choose Mark as Finished. To change the finished date shown, users can hold down on the book and select Edit Finished Date. For titles read elsewhere, such as in hardcover or paperback, users can search for them in Apple Books and select Mark as Finished to add them to their Year in Review.

Year in Review uses anonymized reader insights to determine a personal reading type. There are six reader types to discover, including The Contemporary for readers of trendy titles; The Completist for readers of multiple books in a series; The Seeker for nonfiction readers; The Wanderer for multigenre readers; The Deep Diver for single-genre readers; or The Free Spirit for readers with wide-ranging interests across the book world.

At the end of a user’s Year in Review, they can see an overview of their year in Books, featuring the total books read and total minutes spent reading, with an accompanying grid of book covers they’ve finished.

To close the chapter on a remarkable year, Apple Books published the Best of 2023, an editorially curated collection of standout books and audiobooks across a variety of genres, and the most popular titles of the year. Topping the charts in many countries were two prominent celebrity memoirs that bookended 2023: Prince Harry’s Spare in January and Britney Spears’s The Woman in Me , narrated by actor Michelle Williams, in October. Fourth Wing by Rebecca Yarros was also a must-read for fans of romance and fantasy during the spring and summer. Check out the most popular books and audiobooks of 2023 and browse the top charts for all titles on Apple Books.

Top Nonfiction Books of 2023

Top Fiction Books of 2023

Top Nonfiction Audiobooks of 2023

Top Fiction Audiobooks of 2023

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