Effectiveness of Drinking Water Interventions on Health Outcomes in Global Humanitarian Crisis:

Effectiveness of Drinking Water Interventions on Health Outcomes in Global Humanitarian Crisis:

A Systematic Review

Thesis Presented by Samiha Nuzhat (Student ID: 2031393) Supervised by Dr. Kamran ul Baset

School of Pharmacy and Public Health, Independent University Bangladesh

Date of Presentation: 19 May 2022

INTRODUCTION

Humanitarian Crisis:

“Any disaster (natural or man-made) which arises the need of international

humanitarian support for the affected population”

(Anderson & Gerber, 2018)

Access to Unsafe Water Sources:

Violation of environmental & social justice Causing 2.2% of global deaths

(WHO, 2022)

Water in Humanitarian Crisis:

Minimum standard: 15L/person/day

(UNHCR & WHO, 2021)

Common sources: Boreholes, unprotected dugwells, surface water, piped network etc.

274 million people

– in need of humanitarian aid

(UNOCHA, 2022)

• Mitigation

• Preparedness

• Response

• Recovery

(IOM, 2022)

Stages of Crisis

1 in 3 people

has no access to safe

drinking water sources

RESEARCH QUESTION

“How drinking water interventions

adopted in global humanitarian emergencies influenced health outcomes

of the beneficiaries?”

STUDY OBJECTIVES

General Objective:

To explore how different drinking water interventions adopted in global humanitarian emergencies influenced the health outcomes of the beneficiaries

Specific Objectives:

 To identify health outcomes that improved through different drinking water interventions adopted during global humanitarian emergencies.

 To determine drinking water interventions adopted during global humanitarian emergencies that couldn’t assure expected

improvements in health outcomes.

 To examine the quality and quantity of scientific evidence on

drinking water interventions-mediated health outcomes specifying to

the context of humanitarian emergencies.

METHODOLOGY

METHODOLOGY

Tools Used

Search Engines:

 Wiley Online Library

 EBSCO

 Springer

 Hand Search Using PubMed

 Hand Search Using Google Scholar

Information Management:

 Microsoft Excel 2013

 Mendeley

Concept Keywords

Population Refugee*, refugees, forcefully migrated population, forcefully displaced migrated population………

Intervention Humanitarian aid, drinking water, water treatment, water purification, chlorination…………..

Outcome Health*, healthy, unhealthy, disease*, diseases, water borne disease*, non-communicable

disease*……….

Table: List of Keywords

Study Quality Assessment:

 STROBE Checklist

(Observational Studies)

 CONSORT Checklist

(Interventional Trials)

METHODOLOGY

Topic Inclusion Criteria Exclusion Criteria

Interventions Drinking water intervention Studies with no health interventions or drinking water intervention

Targeted

Population Global populations receiving humanitarian

aid Populations receiving no humanitarian aid

Outcomes Studies that measured different health outcomes

Studies that measured environmental, economic or social outcomes of the

intervention Phase of the

Humanitarian

Crisis During the crisis phase and recovery phase Studies from pre-humanitarian crisis phase and from events that are not related with

any humanitarian crisis

Study Types Quantitative studies such as randomized or non-randomized controlled trials /

observational studies

- Qualitative study

- Quantitative studies with description of intervention without any health outcome

measurement

Time Interval 1 January 1981 to 30 November 2021 Published before 1 January 1981 and published after 30 November 2021

Study Language English Any language except English

Table: Study Selection Criteria

RESULTS

Records identified through database searching (n = 1240)

Additional records through hand searching

(n = 1009)

Records after duplicates removed (n = 1978)

Records screened (n = 1978)

Records excluded (n = 1955)

Full text articles assessed for eligibility (n = 23)

Full text articles excluded with reasons (n = 16)

Finally selected articles (n = 7)

Identification

Screening

Eligibility

Included

Figure: PRISMA Flow Diagram Summarizing the Findings from Literature Searching

Springer (1)

EBSCO (2) Wiley Online

Library (2) Hand Searching

(2)

Figure: Distribution of Finally Selected Articles according to

Search Engines

RESULTS

Type of Crisis

Armed Con- flict (4) Civil War

(1) Hurricane

(1) Earthquake

(1)

Type of Affected Population

Internally Displaced (4) Refugees

(1) Rural

(1)

Forcibly Dis- placed

(1)

Recovery (1) Early (1)

Early Recovery

(2) Acute (3)

Stage of the Crisis

Drinking Water Interventions

Safe Water Storage

(Distribution & Cleaning) (3) Post-collection Water Treatment

(Chlorine / Flocculant) (3) Water Filter (1) Diarrhea &

Cholera (1)

Diarrhea (6)

Health Outcomes

Paper ID Year of Publication  Country

ID 1 2001 Malawi

ID 2 2005 Sudan

ID 3 2006 Liberia

ID 4 2007 Central America

ID 5 2009 Sudan

ID 6 2012 Kenya

ID 7 2012 Haiti

Paper

ID Study

design Sampling Process of outcome

assessment Type of statistical analysis ID 1 IT Systematic sampling of 400 HHs inclusive of randomly

sampled 100 intervened HHs SR & survey RR, attack rate

ID 2 LS No sampling, population-scale intervention (7000 HHs) Clinical cases I ID 3 IT Stratified sampling (200 intervened and 200 control HHs

which had one or more children under age 5) SR P, I, ARR

ID 4 LS Random sampling of 800 HH (100 HH from each site) SR P, OR

ID 5 LS Convenience sampling (~90% camp residents) SR; laboratory testing;

clinic cases I, cumulative I, correlation

ID 6 IT Random sampling (224) SR & surveys AOR, risks

ID 7 IT Random sampling (201 in intervention group & 425 as

control) SR; survey & laboratory

testing I

Table: Study methodology of the seven selected studies

RESULTS

* IT = Intervention Trial; LS = Longitudinal Study; SR = Self-report; I = Incidence; P = Prevalence

ID Notable statistical findings Confounding factors

ID 1

3.81% less episodes (p-value < 0.05) among intervened children under age 5

Diarrheal reduction: With p-value = 0.06, the provided buckets could reduce 31.1% diarrheal episodes.

WASH education, sanitation status

ID 2 88% reduction in diarrheal cases (p-value < 0.05) None exists ID 3 90% reduction in diarrheal incidence

Over 11-times higher percentage of prevalence for the controls (p-value < 0.001) Quality of water storage containers

ID 4 4-15% reduction in diarrheal prevalence among children <5 years of age

Association between WASH indicators and diarrhea in children<3 years (univariate):

Stored household water covered [OR = 0.58 (p = 0.0004)]

Sanitation situation and hygiene behavior

ID 5 Diarrheal prevalence: 15% during pre-intervention; 2.3% during post-intervention.

Diarrheal incidence declined in clinic attendance (p<0.0001) Didn’t identify ID 6 Risk factor: Presence of dirty water storage containers increase the occurrence of diarrhea /

cholera (p=0.03) Hygiene behavior, availability /

affordability of soaps ID 7 Fewer children < 5 had an episode of diarrhea (32% versus 52%; P < 0.001) with 59% reduced

odds (odds ratio = 0.41) Didn’t identify

Table: Major study findings of the seven selected studies

RESULTS

Figure: Quality rating of the seven selected studies

RESULTS

ID 1 ID 2 ID 3 ID 4 ID 5 ID 6 ID 7

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

54.55%

27.73%

68.18% 72.73%

45.45%

36.22%

42.24%

Paper ID

Sc or e

CONSORT

STROBE

DISCUSSIONS

Variety of Contexts Covered:

 Study contexts covered concentrated camp setting to dispersed

humanitarian emergency crisis context, studies from two continents, natural catastrophic crisis to human-made crisis , variety in study designs and multiple stages of the crisis etc.

 Lack of documentation has been noticed for emergencies held in Asian regions

Study Quality Assessment:

 Overall assessment on study quality is not up to the mark as per

STROBE & CONSORT guidelines.

DISCUSSIONS

Effective Drinking Water Interventions during Emergencies:

 Can be classified as followed – a) Safe water storage (distribution & cleaning) b) Post-collection water treatment

c) Water filter

 Water contamination is common at source and even at the stages associated with collection, transportation & storage.

 Ineffectiveness of water interventions intensifies with poor sanitation and hygiene practices

(WHO, 2022)

 Comparatively more positive outcomes are noticed at the recovery stages of the

humanitarian crisis

(Anderson & Gerber, 2018)

DISCUSSIONS

Health Outcome Assessment during Emergencies:

 Self-reporting (arranged through frequent visits) is the most popular tool for health outcome assessment when there are limited scopes for clinical and laboratory analysis

 Health outcomes (i. e. mortality, morbidity, non-communicable

diseases etc.) are rarely connected with drinking water interventions

(Branca et al., 2019; Wimalawansa, 2016)

 Drastic reductions in diarrheal episodes can be assured by safe water storage during emergency, especially among children

(Clasen, 2015)

 Time limitations & frequent changes in crisis stages limits scopes for

health outcome assessment

(Patel et al., 2014)

DISCUSSIONS

Limitations of the Study:

 Limited number of databases searched;

to overcome this more effort was put into hand-searching in PubMed &

Google Scholar

 Very specific and narrowed down study selection criteria

 Lack of variation in the number of

health outcomes assessed

CONCLUSION

 Evidence show positive health outcomes brought by different drinking water

interventions adopted during emergencies.

 Adequacy and quality of available research is not much satisfactory as per quality rating using STROBE & CONSORT checklist.

 Health outcomes-mediated by drinking water is often limited to diarrheal diseases only.

 Drinking water interventions improved the conditions of diarrheal outbreak-prone camp setups.

RECOMMENDATIONS

 Inclusion of wide-scale public health aspects with drinking water

interventions

 More epidemiological data collection during humanitarian emergencies

 Potential biases and confounding factors

should be well-identified

REFERENCES

Anderson, M. & Gerber, M. (2018). Introduction to Humanitarian Crisis, Health in Humanitarian Emergencies, Cambridge University Press.

Branca, F., Lartey, A., Oenema, S., Aguayo, V., Stordalen, G. A., Richardson, R., ... & Afshin, A. (2019). Transforming the food system to fight non-communicable diseases. Bmj, 364.

Clasen, T. (2015). Household water treatment and safe storage to prevent diarrheal disease in developing countries. Current environmental health reports, 2(1), 69-74.

IOM (2022). Humanitarian Emergencies: Overview. iom.int.

Patel, M. D., Brice, J. H., Moss, C., Suchindran, C. M., Evenson, K. R., Rose, K. M., & Rosamond, W. D. (2014). An evaluation of emergency medical services stroke protocols and scene times. Prehospital Emergency Care, 18(1), 15-21.

UNHCR & WHO (2021). Water, Sanitation and Health: Humanitarian Emergencies, who.int.

UNOCHA (2022). Global Humanitarian Overview 2022, unocha.org.

WHO (1995) Guidelines for the control of epidemics due to Shigella dysenteriae type 1. WHO/CDR/ 95.4. WHO, Geneva.

WHO (2022). Drinking-water: Key facts, who.int.

Wimalawansa, S. J. (2016). Effect of Water Hardness on Non-Communicable Diseases. Including Chronic Kidney Disease of Multifactorial Origin (CKDmfo/CKDuo), 1-11.