Environmental health conditions in protracted displacement: A systematic scoping review

Sociocultural determinants of health-associated quality of life among Afghan refugees in Pakistan: evidence from a multi-stage cross-sectional study

BACKGROUND

In the past few decades, there has been a significant increase in the number of refugees worldwide. Every individual deserves access to the fundamental right to health, and migration can have a substantial beneficial or detrimental effect on one's health. Foreign invasions and political instability in Afghanistan affected neighboring countries with the large influx of refugees. Discrepancies in quality of life between the host and refugee populations may lead to health inequalities. Investigations in Pakistan on the quality of life of Afghan refugees were scarce despite more than four decades of refugee status. Therefore, this study was initiated to assess the sociocultural determinants influencing health-associated quality of life among Afghan refugees in Pakistan.

METHODS

The Punjab province and Khyber Pakhtunkhwa province refugee populations were selected as the study population for cross-sectional research based on the inclusion criteria of majority refugee representation and female participation. Quantitative research methodology with pre-validated WHOQOL-BREF questionnaires was used for data collection via multi-stage probability sampling techniques. We collected data from 1,185 study participants and applied univariate and bivariate analyses. Inferential analyses included independent t-tests and ANOVA.

RESULTS

The average scores for the entire sample of Afghan refugees were highest for the social domain (58.78 ± 22.74), followed by the physical domain (53.29 ± 19.46), the general health domain (50.44 ± 20.10), the environmental domain (48.43 ± 16.30), and the psychological domain (46.52 ± 14.78). Age, marital status, family setup, mother language, number of years in the host country, residence type, family monthly income, access to health care, current health status, chronic health illness, substance abuse (smoking), cultural compatibility, linguistic barriers, and social inclusion were non-significant with all the subdomains in the inferential analysis using the independent t-test and analysis of variance.

CONCLUSION

The Afghan refugees' average scores across all health-associated quality-of-life domains were lower than Pakistan's host population and the standard cutoff criteria (< 60 indicates poor quality of life). The development of a national policy to include refugees in health insurance programs seems essential to improve the health-associated quality of life among Afghan refugees in Pakistan.

Child feces disposal practices in humanitarian and non-humanitarian settings across 34 low- and middle-income countries

Globally, safe sanitation has improved significantly in the last two decades, but unsafe child feces disposal remains a growing challenge in many regions, exposing household members and communities to infectious pathogens. The drivers associated with child feces disposal in several contexts including humanitarian settings are not well understood. This study investigated child feces disposal (CFD) practices and associated factors in low- and middle-income countries, including in humanitarian settings. Data from 352,173 women in 34 countries, collected between 2012 and 2021 through Demographic and Health Surveys (DHS), were used. We utilized multivariate logistic regression to assess CFD practices among children under two years old and the factors linked to these practices. We incorporated data from the United Nations High Commissioner for Refugees (UNHCR) regarding refugee camps' locations in the analysis. Time series and local spatial autocorrelation analyses were run to examine changes in safe CFD practices over time and space, respectively. Results showed minimal improvement in safe child feces disposal over the past decade, with 55.6 % of respondents in non-humanitarian settings and 38.1 % in humanitarian settings improperly disposing of feces. Improper CFD significantly correlated with increased odds of diarrhea in non-humanitarian settings (OR 1.09 95 % CI: 1.05-1.13) but not in humanitarian settings (OR 1.14 95 % CI: 0.53-2.49). The most significant factors (p < 0.05) associated with safe CFD included being in the richest wealth quintile (OR 3.27 95 % CI: 3.06-3.49), having basic education (OR 1.28 95 % CI: 1.22-1.33), children eating solid food (OR 1.53 95 % CI: 1.48-1.57), improved sanitation access (OR 1.88 95 % CI: 1.81-1.96), and listening to radio at least weekly (OR 1.40 95 % CI: 135-1.46). Policymakers and development partners must include safe CFD guidelines in national policies and programs, as well as prioritize investments in household-level sanitation and educate caregivers about safe CFD practices.

Outbreaks of faecal-orally transmitted diseases in displacement camps: A scoping review of pathogens, risk factors, exposure routes, and drivers of transmission

Many forcibly displaced people reside in camps characterised by precarious living conditions, exposing them to numerous health risks. This scoping review elucidated the risk factors and exposure routes implicated in outbreaks of faecal-oral pathogens in camps, as well as the context-specific drivers of transmission that shape these outbreaks. Journal articles were identified from PubMed, Embase, Scopus, and Web of Science. Portals for grey literature were also searched. A total of 48 records, published between 1937 and 2022, were included in the analysis. Cholera outbreaks were the most frequently reported. Risk factors included drinking water from shallow wells and rivers, consuming ice and leftover food, and inconsistent handwashing. These indicate exposure through vehicles of transmission in both public and domestic domains, emphasising the importance of a multipronged approach to outbreak prevention and control. Outbreaks were often exacerbated by extreme weather events and acute population influxes that damage or overwhelm water and sanitation facilities. Such shocks warrant explicit recommendations in preparedness and response guidelines. Development projects and outbreak response measures in surrounding areas may reduce the risk of importing pathogens into camps. Future research could further investigate faecal-oral pathogens other than Vibrio cholerae and analyse the co-occurrence of the identified transmission drivers.

Water, sanitation, and hygiene global research: evolution, trends, and knowledge structure

Water, sanitation, and hygiene (WASH) services play a crucial role in promoting public and environmental health as well as social and economic development. At the global level, particularly in the developing world, WASH issues continue to present significant challenges. These challenges have been further intensified by factors such as the COVID-19 pandemic, escalating conflicts, climate change, water scarcity, and rising inequality. The scientific community has actively engaged in constructive discussions on these issues, as evidenced by the notable research findings. Therefore, the aim of this study was to comprehensively examine and evaluate global knowledge on WASH. To search for relevant publications, the Scopus database was utilized using specific terms associated with WASH. VOSviewer 1.6.18 software was employed to generate network visualization maps, which assessed collaborative patterns and research trends in the field of WASH. The research output of countries was adjusted considering their gross domestic product (GDP) and population size. The total number of WASH-related publications, including all types of documents, was 1805. By narrowing the search to articles and reviews, the overall global productivity yielded 1589 documents: 1367 (86.0%) original articles and 222 (14.0%) review articles. The USA had the highest number of WASH publications (n = 668; 42.0%), followed by the UK (n = 396; 24.9%), Switzerland (n = 151; 9.5%), and Australia (n = 141; 8.9%). Ethiopia emerged as the leading country in terms of GDP per capita and the number of publications, followed by Uganda, Malawi, India, and Bangladesh. The USA, the UK, and Switzerland exhibited the most extensive collaboration among countries. The main research areas encompassed the role of WASH in sustainable development, the impacts of inadequate access to WASH services on gender equality, children, infants, and the outbreak of COVID-19 and other diseases, as well as the significance of hygiene practices and community and school-based WASH interventions in reducing infections. This study provides a novel analysis of global WASH-related research and highlights the distribution of outcomes across nations. Continued and increased collaboration between developed and developing nations will facilitate the sharing of responsibility for WASH research outcomes and the implementation of effective policies.

A review of the impact of shelter design on the health of displaced populations

There are currently millions of displaced people encamped in low-quality shelters that jeopardise the health of these displaced populations. These shelters, which exhibit poor thermal regulation and air quality, are often inhabited by households for several years. Recently, the internal environment of shelters has been recognised as a determinant of the health of the occupants and the indoor air quality (IAQ) and internal temperatures have been identified as critical factors affecting occupants' health. Attempts by researchers and private companies to develop healthier shelter solutions have mainly prioritised factors such as rapid deployment, transportability and sustainability. Via a systematic bibliometric analysis of the existing literature, this review examines the impact of shelters' internal environment on occupant health. Self-reports and building simulation are the most common methodologies reported in the literature, but there is a disconnect between the reported shelter issues and their impact on health. This is likely due to the multifaceted and site-specific factors analysed. Indoor air quality, thermal comfort and overcrowding are the most commonly identified shelter issues, which are strongly related to the presence of infectious and airborne diseases. An analysis of the available literature indicates that there is still a lack of clear guidance linking shelter quality to health. Moreover, evidence of the impact of shelters on health is harder to find, and there is a gap regarding the metrics and the methodology used to evaluate shelter quality. Therefore, further research is necessary to provide evidence of the impact of shelter design on health through transdisciplinary approaches.

Social and geographic inequalities in water, sanitation and hygiene access in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe

INTRODUCTION

Many refugees face challenges accessing water, sanitation, and hygiene (WASH) services. However, there is limited literature on WASH access for refugee populations, including for menstrual health services. Unmet WASH access needs may therefore be hidden, amplifying morbidity and mortality risks for already vulnerable refugee populations. The aim of this study was therefore to quantitatively analyze WASH access among refugee camps, with a focus on households with women of reproductive age.

METHODS

This was a cross-sectional study that utilized the Standardized WASH Knowledge, Attitude and Practice (KAP) Survey. A total of 5632 household questionnaires were completed by the United Nations Refugee Agency in 2019 in 21 refugee camps and settlements in Bangladesh, Kenya, South Sudan, Uganda, and Zimbabwe. WASH access (14 items) and social and geographic stratifiers were analyzed at the household-level including the refugee camp, country of the settlement, having women of reproductive age, members with disability/elderly status, and household size. We calculated frequencies, odds ratios, and performed bivariate and multivariate analyses to measure inequalities. We developed a Female WASH Access Index to characterize WASH access for households with women of reproductive age.

RESULTS

Most refugee households had high levels of access to improved water (95%), low levels of access to waste disposal facility (64%) and sanitation privacy (63%), and very low access to basic sanitation (30%) and hand hygiene facility (24%). 76% of households with women of reproductive age had access to menstrual health materials. WASH access indicators and the Female WASH Access Index showed large inequalities across social and geographic stratifiers. Households with disabled or elderly members, and fewer members had poorer WASH access. Households with women of reproductive age had lower access to basic sanitation.

CONCLUSIONS

Large inequalities in WASH access indicators were identified between refugee sites and across countries, in all metrics. We found high levels of access to improved water across most of the refugee camps and settlements studied. Access to basic hygiene and sanitation, sanitation privacy, waste disposal, and menstrual health materials, could be improved across refugee sites. Households with women of reproductive age, with 4+ members, and without members with disability/elderly status were associated with higher WASH access. The female WASH access index piloted here could be a useful tool to quickly summarize WASH access in households with women of reproductive age.

Characterizing baseline legacy chemical contamination in urban estuaries for disaster-research through systematic evidence mapping: A case study

Natural disasters such as floods and hurricanes impact urbanized estuarine environments. Some impacts pose potential environmental and public health risks because of legacy or emerging chemical contamination. However, characterizing the baseline spatial and temporal distribution of environmental chemical contamination before disasters remains a challenge. To address this gap, we propose using systematic evidence mapping (SEM) in order to comprehensively integrate available data from diverse sources. We demonstrate this approach is useful for tracking and clarifying legacy chemical contamination reporting in an urban estuary system. We conducted a systematic search of peer-reviewed articles, government monitoring data, and grey literature. Inclusion/exclusion criteria are used as defined by a Condition, Context, Population (CoCoPop) statement for literature from 1990 to 2019. Most of the peer-reviewed articles reported dioxins/furans or mercury within the Houston Ship Channel (HSC); there was limited reporting of other organics and metals. In contrast, monitoring data from two agencies included 89-280 individual chemicals on a near-annual basis. Regionally, peer-reviewed articles tended to record metals in Lower Galveston Bay (GB) but organics in the HSC, while the agency databases spanned a wider spatial range in GB/HSC. This SEM has shown that chemical data from peer-reviewed and grey literature articles are sparse and inconsistent. Even with inclusion of government monitoring data, full spatial and temporal distributions of baseline levels of legacy chemicals are difficult to determine. There is thus a need to expand the chemical, spatial, and temporal coverage of sampling and environmental data reporting in GB/HSC.

Drinking water provision and quality at the Sahrawi refugee camps in Tindouf (Algeria) from 2006 to 2016

Drinking water provision has been a constant challenge in the Sahrawi refugee camps, located in the desert near Tindouf (Algeria). The drinking water supply system is itself divided in three zones which pump groundwater from different deep aquifers. It is equipped with reverse osmosis plants and chlorination systems for treating water. The allocation of water supplied to the Saharawi refugees for human consumption in 2016 has been estimated at between 14 and 17 L/person/day on average. This supplied water volume is below recommended standards, and also below the strategic objective of the Sahrawi government (20 L/person/day). Yet the local groundwater resources are huge in comparison with estimated consumption, and hence there is great potential for increasing the supplied volume through effecting improvements in the supply system. The physico-chemical quality of the raw and supplied water between 2006 and 2016 has been assessed according to Algerian standards for human consumption. The raw water of two zones of the supply system presents a very high conductivity and high concentrations of chloride, nitrate, fluoride, sulfate, sodium, calcium, potassium and iodide concentrations of natural origin, which may entail health risks. The treatment of water in a reverse osmosis plant greatly improves its quality and osmosed water met the standards. However, the supply of osmosed and raw water needs to be combined in Zone 1, to avoid an excessive reduction in water volume, and the supplied raw water poses a risk to the health of the refugees. The present study provides an example of a drinking water supply system under extreme drought conditions and in the political and social conditions of a refugee camp. Furthermore, it establishes a reference for supplied water allocation and quality in the Sahrawi refugee camps.

An exploratory pilot study of the effect of modified hygiene kits on handwashing with soap among internally displaced persons in Ethiopia

Background

Internally displaced persons fleeing their homes due to conflict and drought are particularly at risk of morbidity and mortality from diarrhoeal diseases. Regular handwashing with soap (HWWS) could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits, including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among internally displaced persons in Moyale, Ethiopia.

Methods

The pilot study evaluated three interventions: providing liquid soap; scented soap bar; and the inclusion of a mirror in addition to the standard hygiene kit. The hygiene kits were distributed to four study arms. Three of the arms received one of the interventions in addition to the standard hygiene kit. Three to six weeks after distribution the change in behaviour and perceptions of the interventions were assessed through structured observations, surveys and focus group discussions.

Results

HWWS was rare at critical times for all study arms. In the liquid soap arm, HWWS was observed for only 20% of critical times. This result was not indicated significantly different from the control arm which had a prevalence of 17% (p-value = 0.348). In the mirror and scented soap bar intervention arms, HWWS prevalence was 11 and 10%, respectively. This was indicated to be significantly different from the control arm. Participants in the focus group discussions indicated that liquid soap, scented soap bar and the mirror made handwashing more desirable. In contrast, participants did not consider the soap bar normally distributed in hygiene kits as nice to use.

Conclusion

We found no evidence of an increased prevalence of handwashing with soap following distribution of the three modified hygiene kits. However, our study indicates the value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in a conflict-affected region had considerable implications on this study’s design and implementation.

Trial registration

The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00368-3.

Environmental health conditions in the transitional stage of forcible displacement: A systematic scoping review

In 2019, 30,000 people were forced to leave their homes due to conflict, persecution, and natural disaster each day. Eighty-five percent of refugees live in developing countries, and they often face underfunded and inadequate environmental health services. Many displaced persons live in camps and other temporary settlements long after the displacement event occurs. However, there is little evidence on environmental health conditions in the transitional phase-defined by the United Nations High Commissioner for Refugees as six months to two years after displacement. To address this gap in research, we conducted a systematic scoping review of environmental health conditions, exposures, and outcomes in transitional displacement settings, as well as reported obstacles and recommendations for improvement. Eighty-eight publications met the inclusion criteria. Water supply was the most frequently discussed environmental health topic. Overcrowding was the most common risk factor reported, Vibrio cholerae was the most common pathogen reported, and diarrhea was the most commonly reported health outcome. Obstacles and recommendations were categorized as institutional, political or implementation-based. Identified knowledge gaps included minimal information on setting logistics and on topics such as menstrual hygiene, oral hygiene and fomite contamination. In order to improve environmental health conditions in transitional displacement settings, all levels of government and non-governmental organizations should increase collaboration to improve resource provision. This study is the first to report on environmental health conditions in this important time of transition between the emergency and protracted stages of displacement.

Snowballing transmission of COVID-19 (SARS-CoV-2) through wastewater: Any sustainable preventive measures to curtail the scourge in low-income countries?

In this communication, we proposed sustainable preventive measures that may be adopted by the low-income countries to forestall the potential outbreak and transmission of COVID-19 (coronavirus disease 2019) through wastewater. Most low-income countries have poor sanitation and wastewater management policies, which create potential risks of COVID 19 spread. Hence, the proposed measures include decentralization of wastewater treatment facilities, community-wide monitoring and testing of SARS-CoV-2 in wastewater samples, improved sanitation, developing point-of-use devices for wastewater decontamination, and more focused policy interventions. Therefore, this paper adds useful insights into the monitoring and management of ongoing COVID-19 outbreak in low-income countries.

Snowballing transmission of COVID-19 (SARS-CoV-2) through wastewater: Any sustainable preventive measures to curtail the scourge in low-income countries?

In this communication, we proposed sustainable preventive measures that may be adopted by the low-income countries to forestall the potential outbreak and transmission of COVID-19 (coronavirus disease 2019) through wastewater. Most low-income countries have poor sanitation and wastewater management policies, which create potential risks of COVID 19 spread. Hence, the proposed measures include decentralization of wastewater treatment facilities, community-wide monitoring and testing of SARS-CoV-2 in wastewater samples, improved sanitation, developing point-of-use devices for wastewater decontamination, and more focused policy interventions. Therefore, this paper adds useful insights into the monitoring and management of ongoing COVID-19 outbreak in low-income countries.

COVID-19: urgent actions, critical reflections and future relevance of 'WaSH': lessons for the current and future pandemics

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.