Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression
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OBJECTIVES: Safe drinking water, sanitation and hygiene are protective against diarrhoeal disease; a leading cause of child mortality. The main objective was an updated assessment of the impact of unsafe water, sanitation and hygiene (WaSH) on childhood diarrhoeal disease. METHODS: We undertook a systematic review of articles published between 1970 and February 2016. Study results were combined and analysed using meta-analysis and meta-regression. RESULTS: A total of 135 studies met the inclusion criteria. Several water, sanitation and hygiene interventions were associated with lower risk of diarrhoeal morbidity. Point-of-use filter interventions with safe storage reduced diarrhoea risk by 61% (RR = 0.39; 95% CI: 0.32, 0.48); piped water to premises of higher quality and continuous availability by 75% and 36% (RR = 0.25 (0.09, 0.67) and 0.64 (0.42, 0.98)), respectively compared to a baseline of unimproved drinking water; sanitation interventions by 25% (RR = 0.75 (0.63, 0.88)) with evidence for greater reductions when high sanitation coverage is reached; and interventions promoting handwashing with soap by 30% (RR = 0.70 (0.64, 0.77)) vs. no intervention. Results of the analysis of sanitation and hygiene interventions are sensitive to certain differences in study methods and conditions. Correcting for non-blinding would reduce the associations with diarrhoea to some extent. CONCLUSIONS: Although evidence is limited, results suggest that household connections of water supply and higher levels of community coverage for sanitation appear particularly impactful which is in line with targets of the Sustainable Development Goals.
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Safe and reliable drinking water, sanitation that separates excreta from human contact, and handwashing with soap at key times have positive effects on health and social and economic wellbeing.
“Safe and reliable drinking water, sanitation that separates excreta from human contact, and handwashing with soap at key times, such as after potential faecal contact and before eating or preparing food, have positive effects on health and social and economic wellbeing.1, 2, 3, 4, 5”
The findings of many interventions providing different levels of WASH services have been published since the last systematic review of WASH interventions.
“The findings of many interventions providing different levels of WASH services have been published since the last systematic review of WASH interventions.5”
A systematic review on different types of WASH interventions searched the literature up to early 2016 and found only one study reporting provision of higher-quality piped water and two studies of continuous water supply.
“A systematic review on different types of WASH interventions searched the literature up to early 2016 and found only one study reporting provision of higher-quality piped water and two studies of continuous water supply.5”
This review found lower reductions in risk of diarrhoea with drinking water of higher quality supplied on premises than the preceding WASH review.
“Results of the preceding WASH review5 are largely consistent with the findings in this meta-analysis; however, this review found lower reductions in risk of diarrhoea with drinking water of higher quality supplied on premises.”
Reviews have been restrictive in terms of included study designs.
“Third, reviews have been restrictive in terms of included study designs.”
A recent systematic review of the effect of handwashing on diarrhoeal disease included ten non-randomised studies.
“a recent systematic review of the effect of handwashing on diarrhoeal disease included ten non-randomised studies”
Risk of bias in individual studies was assessed using an adapted Newcastle-Ottawa scale.
“We assessed risk of bias in individual studies using an adapted Newcastle-Ottawa scale applied in previous systematic reviews of the effect of handwashing with soap on diarrhoea.”
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How Much Will Safe Sanitation for all Cost? Evidence from Five Cities
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Self-citation
- Authors
- Wolf, J., Hunter, P. R., Freeman, M. C., Cumming, O., Clasen, T., Bartram, J., Higgins, J. P. T., Johnston, R., Medlicott, K., Boisson, S., & Prüss‐Ustün, A.
- Affiliations
- World Health Organization (CH)
- University of East Anglia (GB)
- Emory University (US)
- London School of Hygiene & Tropical Medicine (GB)
- University of North Carolina at Chapel Hill (US)
- University of Bristol (GB)
- Department of Public Health, Environment and Social Determinants of Health WHO Geneva Switzerland
- ORCID
- Venue
- Tropical Medicine & International Health
- Publisher
- Wiley
- Published
- 2018-04-23
- Volume
- 23
- Issue
- 5
- Pages
- 508-525
- ISSN
- 1360-2276 (ISSN-L)
- 1365-3156
- OpenAlex
- W2791078272
- Cited by
- 403
- References
- 68
- Citations by year
- 2026: 34 · 2025: 30 · 2024: 28 · 2023: 56 · 2022: 61 · 2021: 73 · 2020: 63 · 2019: 47 · 2018: 10 · 2016: 1
- FWCI
- 6.19
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Tropical Medicine & International Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UEA Digital Repository (University of East Anglia) (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Bristol Research (University of Bristol) (submittedVersion, cc-by)
- Explore Bristol Research (submittedVersion, cc-by)
- Funders
- Department for International Development, UK Government
- Unilever
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
- Keywords
- childhood diarrhea, drinking water, sanitation, handwashing with soap, water, sanitation and hygiene interventions, point-of-use water filters, piped water supply, household water connections, sanitation coverage, child mortality
- MeSH terms
- Child, Developing Countries, Diarrhea, Female, Hand Disinfection, Humans, Hygiene, Male, Risk Factors, Socioeconomic Factors, Water Supply, Drinking Water
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