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Delivering water, sanitation and hygiene interventions to women and children in conflict settings: a systematic review

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Источники
BMJ
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By: Daina Als, Sarah Meteke, Marianne Stefopulos, Michelle F Gaffey, Mahdis Kamali, Mariella Munyuzangabo, Shailja Shah, Reena P Jain, Amruta Radhakrishnan, Fahad J Siddiqui, Anushka Ataullahjan, Zulfiqar A Bhutta

Introduction

Water, sanitation and hygiene (WASH) are fundamental determinants of an individual’s overall health, with access to safe water and sanitation facilities and adoption of effective hygiene practices playing important roles in the prevention of morbidity and mortality globally, particularly among children.2 Various organisations have been working to increase access to WASH services and reduce unsafe water-related mortality for decades. Despite these efforts, in 2015, the WHO and United Nations Children's Fund (UNICEF) Joint Monitoring Programme estimated that globally, 844million people were without basic drinking water services, 2.3billion lived without basic sanitation facilities and just under 900million people were practicing open defecation.3

War and conflict are responsible for the forcible displacement of more than 17million children as of 2017,4 and nearly 50% of the world’s refugee population in 2018 was comprised of women and young girls.5 In conflict-affected populations, alongside mass displacement, people are also at risk of exposure to collapsing infrastructure, food insecurity, unsafe water and insufficient water supply as well as inadequate sanitation facilities. Among refugees and internally displaced persons (IDPs), overcrowding in camps and inadequate WASH infrastructure increase the risks of diarrhoea, cholera and infection from parasites such as soil-transmitted helminths, further perpetuating the risk of fecal–oral disease transmission.6 7 Additionally, women and children face an increased risk of sexual and physical violence8 as well as work/school absenteeism9 as a result of inadequate or complete lack of sanitation facilities and poor menstrual hygiene management.

An estimated 16% of the world’s children were living in conflict-affected areas in 2016.10 Recent analyses of data from 35 African countries found that conflict within 50km of a child’s dwelling was associated with a 7.7% increase in the risk of dying in the first year of life,11 with conflict also posing increased mortality risk for women and mothers in these unstable environments, especially indirectly through the breakdown of health and other infrastructure.12 Among children under 5, the number of deaths indirectly attributable to conflict were three to five times higher than directly attributable deaths11; damaged or deteriorated WASH infrastructure will have been a driver of least some of this indirect conflict mortality.

This review is one of a series of reviews examining health and nutrition intervention delivery to conflictaffected women and children in low- and middle-income countries (LMICs). The aim of the present review was to synthesise information from the indexed and grey literature on the delivery of WASH interventions to women and children in conflict settings. The primary objective was to synthesise information on how WASH interventions have been delivered to conflict-affected women and children, with a focus on personnel, platforms and sites, with a secondary objective of synthesising the available evidence on achieved intervention coverage and effectiveness for those women and children. A third objective was to synthesise reported information on factors affecting intervention delivery, either positively or negatively.