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Food and drinking water as sources of pathogenic protozoans: an update.

1. Introduction

3. waterborne and foodborne protozoan infections, 3.1. parasitic protozoans in the general population in different world regions, 3.2. parasitic protozoans in immunocompromised patients, 3.3. parasitic protozoans in food handlers, 3.4. pathogenic protozoans in drinking water, 3.5. pathogenic protozoans in raw vegetables, 4. cryptosporidium spp., 4.1. diseases caused by cryptosporidium spp ., 4.2. epidemiology of cryptosporidiosis, 4.3. cryptosporidium spp . in drinking water, 4.4. cryptosporidium spp . in food, 5. giardia intestinalis, 5.1. diseases caused by g. intestinalis, 5.2. epidemiology of giardiasis, 5.3. g. intestinalis infections from food and drinking water, 6. toxoplasma gondii, 6.1. diseases caused by t. gondii, 6.2. involvement of food and drinking water in t. gondii infections, 6.3. distribution of t. gondii in food producing animals and derived products, 7. entamoeba spp., 7.1. diseases caused by entamoeba spp ., 7.2. epidemiology of entamoeba spp ., 8. blastocystis hominis, 9. cyclospora cayetanensis, 9.1. diseases caused by c. cayetanensis, 9.2. epidemiology of c. cayetanensis, 9.3. dietary sources of c. cayetanensis, 10. trypanosoma cruzi, epidemiology and symptoms of t. cruzi infection, 11. sarcocystis, 11.1. diseases caused by sarcocystis spp ., 11.2. epidemiology of sarcocystis spp ., 11.3. prevalence of sarcocystis spp . in food-producing animals, 12. cystoisospora belli, 12.1. diseases caused by c. belli, 12.2. epidemiology of c. belli, 13. balantioides coli, 14. dientamoeba fragilis, 15. endolimax nana, 16. pentatrichomonas hominis, 17. methods for the detection/identification of protozoans in food and drinking water, 18. discussion, 19. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Rossi, F.; Santonicola, S.; Amadoro, C.; Marino, L.; Colavita, G. Food and Drinking Water as Sources of Pathogenic Protozoans: An Update. Appl. Sci. 2024 , 14 , 5339. https://doi.org/10.3390/app14125339

Rossi F, Santonicola S, Amadoro C, Marino L, Colavita G. Food and Drinking Water as Sources of Pathogenic Protozoans: An Update. Applied Sciences . 2024; 14(12):5339. https://doi.org/10.3390/app14125339

Rossi, Franca, Serena Santonicola, Carmela Amadoro, Lucio Marino, and Giampaolo Colavita. 2024. "Food and Drinking Water as Sources of Pathogenic Protozoans: An Update" Applied Sciences 14, no. 12: 5339. https://doi.org/10.3390/app14125339

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Occupational health outcomes among sanitation workers: A systematic review and meta-analysis

Affiliations.

• 1 Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
• 2 Department of Environment, Climate Change and Health, World Health Organization, Geneva, Switzerland.
• 3 Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA. Electronic address: [email protected].
• PMID: 34942466
• PMCID: PMC8837624
• DOI: 10.1016/j.ijheh.2021.113907

Background: Sanitation workers are essential to global public health and societal wellbeing. However, the health risks and outcomes associated with exposure to occupational risk factors among sanitation workers are neither well understood nor well quantified. We undertook a systematic review to (1) identify occupational risk factors among sanitation workers and (2) assess the effect of occupational exposure to human fecal sludge and wastewater on selected health outcomes among these workers.

Methods: We searched four databases (i.e., PubMED, MEDLINE, EMBASE, and LILACS) for eligible studies from inception through to January 01, 2020. The included population was workers ≥15 years engaged, formally or informally, in installing, operating, servicing, cleaning or emptying a sanitation technology at any step of the sanitation chain. The included comparator was workers in other occupations or the general population. Eligible outcomes were: mortality (any or all causes), gastroenteritis, occupational injuries, respiratory diseases, musculoskeletal disorders, and mental and social health conditions. Risk of bias was assessed separately on exposure assessment and health outcome using a modified Liverpool Quality Assessment Tool (LQAT). We pooled sufficiently homogenous studies using inverse variance meta-analysis with random effects.

Results: A total of 65 studies (9 cohort studies, 56 cross-sectional studies) met the inclusion criteria. One quarter of studies (n = 15) were from middle-income countries. Few studies assessed occupational risk factor exposures directly; most assigned exposure via proxy of occupation of sanitation worker. We judged nearly all studies to have "high risk of bias" in exposure and outcome assessment. Despite these limitations, the consistency of the overall evidence suggests that sanitation workers are at increased risk of gastroenteritis and respiratory conditions, and may be at increased risk of musculoskeletal disorders and mental/social health conditions. The pooled odds ratio for hepatitis A--the only outcome deemed suitable for meta-analysis--was 2.09 (95% Predicted Interval: 1.39-3.00, 12 studies). There was conflicting evidence from studies of increased risk of mortality; only one study reported on injuries.

Conclusion: Despite a large number of studies, there is limited evidence to date of the health risks faced by sanitation workers, particularly among groups that may be at particular risk-- women, informal workers and those living in low-income countries. Nevertheless, the research to date provides suggestive evidence of elevated occupational risk among sanitation workers across a range of health condition. More research is needed to improve the current bodies of evidence for all included health outcomes to be able to quantify disease burden among this occupational group.

Keywords: Occupational exposures; Occupational health; Sanitation workers; Systematic review.

Copyright © 2021 The Authors. Published by Elsevier GmbH.. All rights reserved.

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PRISMA flow diagram summarizing study…

PRISMA flow diagram summarizing study selection.

Forest plot of odds ratios…

Forest plot of odds ratios of selected gastrointestinal conditions. [a] – [d]: The…

Odds ratios for studies on…

Odds ratios for studies on hepatitis A infection/seropositivity among sanitation workers. * Studies…

Forest plot of odds ratios of selected respiratory symptoms. [a] – [d]: The…

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Open Access

Peer-reviewed

Research Article

Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Children Without Worms, The Task Force for Global Health, Dhaka, Bangladesh, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Roles Data curation, Formal analysis, Methodology, Validation

Affiliation Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh

Roles Formal analysis, Investigation, Methodology, Validation, Writing – review & editing

Affiliation Institute of Education and Research, Dhaka University, Dhaka, Bangladesh

Roles Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing – original draft

• Ashraful Kabir, 
• Shuvo Roy, 
• Korima Begum, 
• Ariful Haq Kabir, 
• Md Shahgahan Miah

• Published: September 22, 2021
• https://doi.org/10.1371/journal.pone.0257663
• Reader Comments

Introduction

Improved hygiene and sanitation practices in educational settings are effective for the prevention of infections, controlling the transmission of pathogens, and promoting good health. Bangladesh has made remarkable advances in improving higher education in recent decades. Over a hundred universities were established to expand higher education facilities across the country. Hundreds of thousands of graduate students spend time in university settings during their studies. However, little is known about the sanitation and hygiene practice of the university-going population. This study aims to understand and uncover which factors influence students’ sanitation and hygiene behavior in university settings.

This study was conducted in a public university named Shahjalal University of Science and Technology located in a divisional city of Bangladesh. Based on the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we adopted an exploratory qualitative study design. We developed semi-structured interview guides entailing sanitation and hygiene behavior, access, and practice-related questions and tested their efficacy and clarity before use. We conducted seventeen in-depth interviews (IDIs), and four focus group discussions (FGDs, [6–8 participants per FGD]) with students, and seven key informant interviews (KIIs) with university staff. Thematic analysis was used to analyze the data. Triangulation of methods and participants was performed to achieve data validity.

Despite having reasonable awareness and knowledge, the sanitation and hygiene practices of the students were remarkably low. A broad array of interconnected factors influenced sanitation and hygiene behavior, as well as each other. Individual factors (gender, awareness, perception, and sense of health benefits), contextual factors (lack of cleanliness and maintenance, and the supply of sanitary products), socio-behavioural factors (norms, peer influence), and factors related to university infrastructure (shortage of female toilets, lack of monitoring and supervision of cleaning activities) emerged as the underpinning factors that determined the sanitation and hygiene behavior of the university going-population.

The results of this study suggest that despite the rapid expansion of on-campus university education, hygiene practices in public universities are remarkably poor due to a variety of dynamic and interconnected factors situated in different (individual, contextual, socio-phycological) levels. Therefore, multi-level interventions including regular supply of WASH-related materials and agents, promoting low-cost WASH interventions, improving quality cleaning services, close monitoring of cleaning activities, promoting good hygiene behavior at the individual level, and introducing gender-sensitive WASH infrastructure and construction may be beneficial to advance improved sanitation and hygiene practices among university students.

Citation: Kabir A, Roy S, Begum K, Kabir AH, Miah MS (2021) Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh. PLoS ONE 16(9): e0257663. https://doi.org/10.1371/journal.pone.0257663

Editor: Mary Hamer Hodges, Helen Keller International, SIERRA LEONE

Received: October 11, 2020; Accepted: September 7, 2021; Published: September 22, 2021

Copyright: © 2021 Kabir et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Interview and discussion guidelines are available in the Supporting Information files. Additional data cannot be made publicly available due to ethical restrictions regarding participant consent to data release. Interested parties may contact Mr. Jitu Mia ( [email protected] ), Assistant Administrative Officer, Departments of Anthropology, Shahjalal University of Science and Technology for further inquiries in this regard.

Funding: This study received no funding support to design, conduct, analyze, and report the findings. Although the first author (AK) had a consultant position with Children Without Worms, The Task Force for Global Health during the study time, that position did not play any role in this study. This study was conducted under a separate arrangement. Children Without Worms, The Task Force for Global Health provided support for this study via salary for AK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

Competing interests: The authors have read the journal’s policy and declare the following competing interests: AK received a salary from Children Without Worms, The Task Force for Global Health. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

The benefits of improved hygiene and sanitation are well-documented and largely recognized as an effective strategy for the prevention of infection and controlling the transmission of pathogens [ 1 , 2 ]. The promotion of good hygiene and sanitation practices is also well-recognized as a cost-effective, easy-to-practice, convenient, and useful public health measure to prevent and control the spread of infectious diseases and promote good health [ 3 , 4 ]. The importance of promoting appropriate sanitation and hygiene practices has been endorsed in many international policy documents and global commitments. The United Nations (UN) emphasized access to improved sanitation and good hygiene practices within the Sustainable Development Goals (SGD target 6), indicating that it is likely to achieve sustainable economic growth and a better future [ 5 , 6 ].

In recent years, Bangladesh has made overwhelming advances in economic development. The country maintained over six percent of Gross Domestic Product (GDP) over the last two decades and was positioned as the fastest-growing economy in the world [ 7 – 9 ]. Such economic growth enhances the government’s ability to substantially invest in the education sector (i.e., education stipend program, gender parity, geographical coverage), resulting in greater access to school attainment and boosting primary and secondary education [ 10 , 11 ]. Similar to the primary and secondary education sector, the government also took policy initiatives, such as the promulgation of the first Private University Act in 1992 and a 20-year Strategic Plan for Higher Education 2006–2026. The country has received technical and financial support from the World Bank since the 1990s to expand and meet the demands of higher education in Bangladesh [ 12 ]. The Private University Act of 1992 helped to expand higher education in the private sector, whereas the Strategic Plan for Higher Education 2006–2026 focused on the reformation of the entire higher education sector and is largely based on neoliberal policy doctrine [ 13 ]. The neoliberal policy shift has emphasized the need to expand technical and market-oriented knowledge [ 14 ]. This resulted in the establishment of many science- and technology-oriented new universities in older districts (which have a large population and land territory), headquarters, and townships [ 13 ]. According to the most recent statistics of the University Grants Commission (UGC)—the peak body charged with the higher education sector—as of 2020, the country has 148 universities [ 15 ]. The UGC’s latest annual report released in 2018 indicated that there are 136 functioning universities (out of 148, the rest are in the process of becoming operational). Of these, 47 are public (state-funded), and 107 are private (non-state-owned) [ 15 ]. Over the last decade, students’ enrolment in both public universities and their affiliated colleges and private universities has been increased by ten-fold [ 15 ]. Currently, 4,434,451 students are enrolled in a wide array of departments and schools. The share of female students’ enrolment in higher education institutes is around 38 percent [ 16 ]. Public universities largely provide on-campus residential facilities in university halls [ 17 ]. A high proportion of students stay on campus during their studies, which typically extend over a period of five to seven years. Despite the proven effectiveness of improved sanitation and hygiene practices in educational settings [ 18 ], there is evidence that maintaining good hygiene practices in low-income countries has a relatively low implementation rate [ 19 ]. Until recently, sanitation and hygiene practice-related studies in educational settings mainly focused on the school level (mostly in primary schools, ages six to eleven) in Bangladesh [ 20 – 22 ]. Few studies have reported the hygiene and sanitation behaviors of university students in the context of Bangladesh. Moreover, most of these studies have used quantitative methodological approach and focused on either the users’ perspective, such as students, or the suppliers’ perspective, such as access to facilities. This is insufficient to completely recognize and explore hygiene and sanitation related behaviour and practices. For example, few cross-sectional studies reported WASH-related descriptive statistics in university students [ 23 – 26 ]. Against this backdrop this paper uses a qualitative methodological approach to investigate hygiene and sanitation related behaviour and practices from a holistic perspective. Adopting a conceptual framework, this study recognizes and explains how and whether sanitation and hygiene practices among university students are influenced. This investigation will provide a total picture of factors associated with WASH-related processes and outcomes in a specific context. This pragmatic study will add information from the perspective of users and suppliers and contribute to the literature. Moreover, the study will inform the Water Sanitation and Hygiene (WASH)-related actions needed in public universities to improve sanitation and hygiene practices among university students.

Study time and setting

This study was conducted at Shahjalal University of Science and Technology (SUST) in Sylhet, a north-eastern city, approximately 240 km from Dhaka, the capital of Bangladesh. SUST is a public university established in 1986 to promote science and technology-oriented education and research. The campus has 320 acres of land [ 27 ]. The university supports residential facilities for students in five halls on campus. In addition, the university hires three privately-run halls for its female students outside the campus (in the central city). They are privately managed but aligned with a standard (i.e., WASH facility, security, physical space, etc.) set by the university. Students in these privately-operated halls pay higher rent compared to those who stay in the campus-based halls. In 2020, the university had approximately 11,000 students across seven schools, twenty-seven departments, and two institutes [ 27 ]. During their stay on campus, students usually move across different buildings and facilities, including academic buildings, libraries, residential halls, auditoriums, teacher-student center restaurants, cafeterias, and shops. There are several cafeterias, restaurants, and grocery stores that provide essential services for both campus-based students, off-campus students, and visitors. Among these, coffee shops are visited by thousands of students each day for breakfast, lunch, and dinner. There are also many mobile food vendors who prepare and sell various foods across campus [ 17 ].

Theoretical framework

We used the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) to inform our research [ 28 ]. This model offers an analytical and conceptual tool to explore and understand an array of factors that influence the use of water, sanitation, and hygiene dynamically in a resource-limited setting [ 29 ]. We, therefore, considered this model the best-suited in the current study setting that is characterized by constraints to the infrastructure required to promote better sanitation and hygiene practices. Based on this model, we developed a conceptual framework to analyze the data ( Fig 1 ). For this model, sanitation and hygiene practices are influenced by a broad range of factors at various levels. The individual-level factors include prior exposure and understanding of the importance of maintaining hygiene. The physical environmental factors refer to the availability of infrastructural facilities or shortages. Socio-behavioural factors are related to the psychological, and social determinants such as norms, beliefs, habits, self-efficacy that influence the adoption of sanitation and hygiene practices. Societal factors related to the institution focus on the polity and/or supply-related issues. The practice of sanitation and hygiene is the combined result of these factors, which are interconnected and influence each other.

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https://doi.org/10.1371/journal.pone.0257663.g001

Study population and sampling strategy

We conducted seventeen in-depth interviews (IDIs) and four focus group discussions (FGDs, [6–8 participants per FGD]) with both on-campus (students who stay in the halls) and off-campus students from various departments, and seven key informant interviews (KIIs) with university staff ( Table 1 ). We included undergraduate students based on eligibility criteria such as voluntary participation and completion of at least one year of study. We did not include students who did not have the capacity to provide informed consent or these who were doctoral students or enrolled in short-term courses (evening courses, short professional courses). Considering our study aims, we purposefully recruited the participants, which was used in qualitative studies the context of Bangladesh [ 30 , 31 ]. First, the interviewers approached potential students and shared the research aims, objectives, and expectations of the study. If the interviewee met all the criteria, they were approached to participate in the interview. During this process, we followed all steps described in the consent form, such as the subject matter of the study, participants’ rights, possible risks and benefits, the liberty of withdrawing from the interview at any point in time, confidentiality, anonymity, and additional information sources. We obtained the written consent of the participants before starting the interview. The interviews were audio-recorded. The number of interviews was determined based on the principle of data saturation; point of time, no new data, or dimension, or theme emerged [ 32 ]. Coordinated teamwork throughout had the strength of determining data redundancy, increasing data validity, and rigors. Multiple researchers concurrently conducted and analyzed interviews. After each interview day, the research team completed a debrief sheet to discuss the primary initial/axial codes. After two-thirds of the interviews were completed, the research team checked the independently developed codes and identified that no new information or codes were generated. Following a discussion and having reached a consensus, the research team decided to conduct a few more interviews to reach saturation of directional logic [ 33 ]. We stopped interviewing when the data was saturated. However, we considered the three basic principles of selecting a study participant: (i) maximum variation (we included participants from different years or semesters, disciplines, genders, and residences); (ii) iterative process (we re-interviewed two IDI participants and one KII participant to gather relatively accurate and nuanced data by verifying and cross-checking a few pieces of information); and (iii) reflexivity (assessed self-roles).

https://doi.org/10.1371/journal.pone.0257663.t001

Data collection procedure

The data collection team consisted of four members who were graduates in the fields of anthropology and public health. They had extensive expertise in qualitative research methods and the application of different techniques. The second and third authors conducted FGDs, while the first and last authors conducted IDI and KII. The fourth author coordinated the data collection activities with methodological feedback. The interviews were conducted in Bangla, the mother tongue of both the interviewees and interviewers. Semi-structured interview questionnaires and guides were developed and their appropriateness and clarity were tested at another educational institute. These question guides explored several aspects relating to the availability of sanitation and hygiene facilities, facilitators, and/or barriers, habits, infrastructure, supplies, maintenance, and so on. The interviewers first attempted to develop a good rapport with participants by asking about daily activities, preferences, and university-related lifestyles. We subsequently elicited detailed information about sanitation and hygiene-related issues. On average, the IDIs and KIIs took 40–55 minutes and the FGDs 80–100 minutes.

Data analysis

Adopting this approach, we started to transcribe interviews immediately after completion. After transcribing the data, we translated it into English. We conducted a theme-based analysis following the thematic approach [ 30 , 34 ]. A stepwise procedure was followed [ 35 ]. First, all authors independently and repeatedly read the interviews to familiarize themselves with the content. Second, the primary codes were identified, namely, meaningful statements or information. Third, we searched for some clusters based on similarities in these codes. Finally, we identified four major themes to report the findings ( Fig 1 ). All authors independently prepared some codes and themes to check the similarities and dissimilarities among them. A thematic analysis approach enabled us to develop uncategorized themes, which is useful to explore and capture associated factors that influence sanitation and hygiene practices among students. However, one of the challenges of this approach was organizing and merging the codes/themes that appropriately capture participants’ comments and views. Any disagreements were resolved following a discussion or consensus. No text management software (i.e., Nvivo, Atlas-ti) was used to analyze the data.

This study received ethical approval from the institutional review board of Shahjalal University of Science and Technology. We developed consent forms for participants explaining issues related to confidentiality and anonymity, risk and harm, benefit and loss, additional information sources, and participants’ rights. We maintained all aspects described in the consent form, such as removing any personal identification during the analysis. All data were kept within the research teams. We obtained written consent from the participants.

The socio-demographic characteristics of the participants are presented in Table 2 . The mean age (mean ± standard deviation) of the IDI participants was 20.2 years (20.2±2.4) and 21.6 years for FGD participants (21.6±2.6). The highest number of participants was third-year students in the IDIs (7 out of 17) and FGDs (11 out of 29). The highest number of participants in the IDIs was female (9 out of 17) and from the Faculty of Social Sciences, whereas over half (15 out of 29) were male, and the majority were from the Faculty of Physical Sciences (8 out of 29) for FGD participants. The majority of the participants for both IDIs and FGDs were Muslim and came from rural households.

https://doi.org/10.1371/journal.pone.0257663.t002

Thematic analysis

We found that four key factors, namely, individual factors, socio-behavioural factors, contextual factors, and factors related to the university, determine sanitation and hygiene practices among students at the university ( Fig 1 ). Each of these major factors was further divided into sub-factors, as presented below. The data gathered from all sources revealed that students are substantially aware of the need for improved hygiene and sanitation; however, contextual and university-related factors jeopardize their practices.

Theme 1: Individual and structural factors

Our data revealed that sanitation and hygiene behavior was influenced by a wide array of individual factors, such as level of knowledge and awareness, past habits (developed through family education/orientation, and media exposure), privacy, gender, and the perceived benefits of improving sanitation and hygiene practices. A high proportion of participants were aware of the importance of using sanitary toilets and maintaining personal hygiene. The majority of participants said that they gained a good level of knowledge mostly from their families and schools, such as washing their hands with soap after defecation, and before and after eating, and by coming into contact with dirt throughout their childhoods. One participant stated the following:

" We normally learned many norms , such as ’hand wash behavior’ from our families . From childhood naturally , mom used to wash my hands after using toilets and obviously before eating food . I became used to washing my hands this way . " (A male student in an IDI)

A similar view was shared by another participant:

" From my childhood , my family members taught me how to wash my hands , use toilets , and maintain good hygiene . I think that was the base . I am now used to doing so . " (A male student in an IDI)

A parallel view was shared in the focus group discussions:

" From my childhood , my mother trained me how to wash my hands . She taught me about healthy sanitation behavior . Thus , I have adopted a sanitary and hygienic practice . " (A female student in an FGD)

Apart from family, exposure to media (i.e., TV programs, commercial advertisements, and school programs) was reported as a good source of knowledge about sanitation and hygiene habits. One participant explained:

" I have learned the primary lesson of ’sanitation and hygiene behavior’ from home . My mother taught me cleanliness , personal hygiene , and handwashing from early childhood . As I grew up , I have learned some additional sanitation stuff (i . e ., liquid soap , hand sanitizer , sanitary napkins) from my surroundings , television programs , school wash programs , and so on . " (A female student in an FGD)

More than two-thirds of participants said that they felt that using sanitary toilets and maintaining personal hygiene on campus largely depended on how much they allowed them to maintain their privacy. Students viewed toilets and washing facilities in campus buildings including academic buildings, libraries, residential halls, and auditorium buildings as safe places to use. However, female students expressed concern over not having a strict privacy policy. As a result, they emphasized the need to improve privacy issues within campus buildings in toilets and other sanitation facilities. One participant said:

"… We need privacy , and it’s really essential for females . " (A female student in an IDI)

A few students raised concerns about toilets located in places other than university buildings (i.e., located in shopping malls, cafes, restaurants). Toilets in commercial places might not always be safe for women and girls. Thus, the female students felt confident using the toilets and washing facilities in university buildings. Both the male and female participants reported that gender was an issue in toilet use. The participants mentioned that the number of toilets and sanitary facilities is inadequate across university buildings, and that it jeopardized maintaining improved sanitary and hygiene habits, especially for female students. One student reported:

" There are a lot of problems in campus bathrooms/toilets . We have to be in a queue to use the bathroom , and it’s quite normal for everyone in the hall . To be in a queue might be good in terms of maintaining discipline . But suppose , if you have an emergency and someone is already in the bathroom , then ? Sometimes things happen like you are in the toilets , and you suddenly discover that there is no water , then ? Sometimes you will see there is no soap , and toilets are left dirty and uncleaned—these types of things we know happen , but still we have to use this kind of dirty and unsafe latrines . " (A female student in an IDI)

Due to the long queues and the unusable conditions of the toilets, female students tended to hold their urine for a long time, which may affect their urinary system. One participant mentioned that holding urine for a long time may weaken the bladder and increase the risk of urinary tract infections:

" The tendency of holding urine among female students is very high . There are many reasons for this , including unusable toilet conditions , an insufficient number of toilets , and unhygienic toilets . I guess the incidence of urine infections may be high among female students and this could be linked to holding urine for a long time . " (A female student in an FGD)

Nearly two-third of IDI participants (11 out of 17) shared concerns about the barriers for maintaining menstrual hygiene both in the halls and other buildings. There was no proper arrangement to dispose of menstrual products in the toilets or washrooms. A vast majority of female participants reported that they usually fail to follow hygienic methods for managing menstrual waste. Toilets located in campus buildings were reported as unfriendly to female students as no waste disposal facilities exist except for the presence of a small basket in the toilet area. The following quotes explain the situation:

" The sanitation system of the campus is not female-friendly . Sometimes , the supply of water gets stopped for unknown reasons . There is no hand wash products or soap in any washroom . The only thing present is a small basket and a water pot in some toilets . There is no way to flush the toilets after use . There should be an emergency pad facility in the female washrooms , but unfortunately , we cannot see it . " (A female student in an FGD) " The scenario of women sanitation facilities on this campus is not good . If I have a period of unexpected time , I have to go to my room . And if I want to change pad , there is no dustbin or soap bar or sanitizer . " (A female student in an IDI)

This limitation was acknowledged by the one of the KII participants who said that the gender perspective related to hygiene and sanitation might have been overlooked over the years. The toilets do not seem gender friendly, especially in the academic buildings where no menstrual disposal materials are available. The participant said:

“ The condition is grossly poor . But this is worst in the academic buildings which are commonly used . Menstrual hygiene management facilities are poor in the academic buildings . ” (A house-tutor in a KII)

This view was reflected by another participant:

“ Overall the hygiene and sanitation facilities seem poor for female students . However , female students may relatively manage this inside the halls . But , this situation remains poor in academic buildings . ” (A tutor in a KII)

The majority of participants reported the perceived benefits of improved sanitation and hygiene practices, which act as a facilitating factor for the adoption of good hygiene habits. However, some female students reported that they carried personal hygiene products (i.e., hand sanitizer, toilet tissue). One participant reported:

" I carry my own sanitary and hand wash materials , so I used that . " (A female student in an IDI)

However, more than two-thirds of the participants reported that a negligible number of students carry personal hygiene materials with them. One participant mentioned:

" Carrying personal hygiene material has become a good strategy for coping with the situation , especially where the resources are limited . However , this is a recent trend and thus has not been widely practiced … it’s quite new in our culture . " (A female student in an FGD)

The majority of male students reported that they do not carry any sanitizer or any other means to maintain hygiene. One participant reported:

Maybe females and girls are more sensitive and have a good arrangement for carrying any materials. They usually carry a handbag where they easily keep such products. But it is very tough to carry this in the male school bags." (A male student in an FGD)

Theme 2: Socio-behavioural factors: Perceptions and beliefs

Mixed views were reported regarding the influence of friends and peers in promoting improved sanitation and hygiene habits. The majority of male participants acknowledged that they were neither motivated nor discouraged by their peers and friends in the adoption of sanitary and hygiene practices. In contrast, female participants said that they sometimes copied or followed what others were practicing. One of the female participants reported:

" I noticed that some of our friends were carrying personal hygiene products with them . I found that it is useful to carry a hand sanitizer or toilet tissue in my bag … I can use it if I feel so . " (A female student in an FGD)

Some participants stated that male students were found to urinate in open space mostly at roadsides and in alleyways across campus. In Bangladesh, males often urinate at roadsides or in alleyways; however, it is quite impossible for females to do the same. Unlike female students, male students seemed to have fewer concerns about maintaining hygiene at a personal level. One of the participants stated:

" I think male students do not think much about sanitation and hygiene issues . They get influenced by their surroundings … hygiene , sanitation , may remain concerned . " (A male student in an IDI)

A similar view was shared by a KII informant:

“ In our culture , females are more sensitive to maintaining their privacy which may help them adopt positive hygiene and sanitation habits . The social and cultural construction support the view that a male person can urinate by a roadside and in alleyways . ” (A tutor in a KII)

Theme 3: Contextual factors

Supply-side factors such as the improper maintenance of toilets, poorly managed services, a lack of cleanliness, unpleasant odors, lack of sanitary products (i.e., soap, hand wash agents, sanitizers, etc.) mostly appeared as constraining factors for the adoption of improved hygiene practice in university settings. The majority of students reported that the cleaning service was insufficient. The university authorities rarely supply soap and/or other sanitary materials. One of the participants stated:

" I cannot remember any scene that I saw any soap at the toilets … the authorities may not be concerned about the importance of providing this product . " (A male student in an FGD)

Additionally, most students reported that their proper hygiene practices are strongly impacted by how well the toilets are maintained and cleaned at the university. Almost all participants said that clogged toilets or dirt were frequently visible in the toilets. Some participants mentioned that the number of toilets was noticeably insufficient, thus creating pressure on the functioning ones. Therefore, regular maintenance of toilets and using sanitary cleaning materials are very critical to maintain cleanliness. However, the reality is, frustratingly, the opposite of this. One participant noted:

" Toilets are rarely cleaned with proper toilet cleaning products (chemicals) . Often , they use merely water and/or a small amount of chemical agent which might fail to kill germs , remove dirt , or clogs . " (A female student in an IDI)

Another student stated:

" To date , inadequate sanitation facilities remain the primary cause of unimproved sanitary and hygiene practices . The number of students is huge , so the authorities need to provide a good number of hand wash or soaps for the students and take care if they are finished or not . The authorities need to appoint more employees to do the cleaning . But I hardly noticed that all the mentioned actions were taking place in a timely manner . " (A female student in an IDI)

A similar view was expressed by another participant:

" The students are aware of the importance of good hygiene habits . But often , they fail to maintain it mostly because of the supply side . You rarely see any handwashing material readily available in the washrooms . How can a student maintain good handwashing practices after using the toilet ? " (A male student in an FGD)

However, a few KII participants explained why there is such a lack of or shortage in the cleaning workforce and university budget. Nevertheless, they acknowledged that there is a severe shortage of cleaning staff in almost all areas (halls and academic buildings). Thus, there are failures in the routine maintenance of sanitary activities and areas. One participant stated:

" We don’t have adequate budget support and a workforce to provide sanitary and hygiene support at the optimum level . I feel that this causes problems . Many of us acknowledge this shortage , but it is a very structural problem . " (A house tutor in a KII)

A similar view was shared by a cleaner:

" The number of cleaners is low . It sometimes causes problems in routinely maintaining cleaning activities . But I try to do my best . The cleaning products are supplied as per rules . " (A cleaning staff member in a KII)

Additionally, some participants reported that unstable water supply triggers the dirtiness or poor maintenance of toilets. On many occasions, the lack of a reliable water supply results in the improper flushing of toilets after use, which deteriorates the toilet hygiene condition. One participant stated:

" It’s prevalent that one leaves the toilet without proper flushing due to the lack of adequate water . This causes the toilet to be unusable for next users … thus deteriorating hygiene quality . " (A male student in an FGD)

Another participant noted:

" Bad odor is very common in the toilets because excreta are not properly flushed out . It is created when the toilet holes are not properly flushed out . Very often the reason is either a lack of stable water supply or a problem with the flushing system (the flushing system does not work for any reason . " (A male student in an IDI)

Theme 4: Factors related to the university

Access to toilets and handwashing facilities is restricted even further in the buildings around campus after office hours (8.00 am to 5.00 pm). Regular classes and administrative services are provided during this time; however, students remain on campus for longer periods of time for various reasons, such as library work, group assignments, social gatherings, and so on. During this time, they felt embarrassed as access to the toilets and hand wash facilities remain closed in and around campus. This situation becomes very problematic for female students as they need to go to the nearby halls or restaurants. However, a male student mentioned that it is not unusual for male students to urinate in an open place near a bush or building corner. One participant mentioned:

" A male student can manage his need by peeing at a roadside . But it creates a problem for female students . They either hold their needs for a long time or go to the nearby halls , which is embarrassing . "

The number of female toilets is noticeably low compared to male toilets, which causes female students to abstain from toilet use. The following participants explained the situation:

" In our academic building , there is only one common room for female students . And there are six departments in our academic building . So , for all the female students , there is only one common room . In this common room , we have only three toilets and one basin , which is usable , and the other is broken . This common room is open till 5 pm . But for male students , they have two washrooms available in this building . " (A female student) " In our academic building , there is only one common room for females , and it is being rebuilt . In the common room , there were three washrooms and two basins , but one basin was unusable . Two new washrooms have been built recently on the ground floor of the building . But I am not sure if these new washrooms are for male students . There are two washrooms for males and on the opposite side we have two washrooms for females also . " (Another female student)

Some participants mentioned that the lack of appropriate technology and poorly managed construction/repair work made it difficult for students to maintain good sanitary and hygiene practices. A few participants reported that the toilets often do not flush or stop properly, causing the toilet pans to become waterlogged. Some participants mentioned that the authorities (hall administrations, engineering office) do not check the toilets and talk to students about it.

" I never heard that someone from the authorities talked with students and checked if the cleaning activities are properly maintained . " (A male student in an IDI)

Another participant stated:

" The toilets are not clean enough to use . Though the authorities have employed staff to clean the toilets of the academic buildings and residential halls , I don’t think they clean the toilets as required . There are bad odors in every toilet , and sometimes the toilets seem to be clogged also . As I stay in a residential hall , I have no other option than using these toilets . But I can’t maintain hygiene , and I am afraid for my health . I think it is about the monitoring and supervision of cleaning work . " (A female student in an IDI)

Using IBM-WASH model, this study aimed to explore and recognize how and which factors influence sanitary and hygiene practices among university students at a public university in Bangladesh. Data from multiple sources and participants identified a broad array of elements situated on different levels of the IBM-WASH model (i.e., individual, socio-behavioural, university, and contextual) that impact sanitation and hygiene practices. These factors are noticeably comparable and interconnected to each other.

In Bangladesh, few studies have examined sanitation and hygiene practices in educational settings. Those that are available tend to focus on primary and secondary schools [ 36 – 39 ]. Beyond the school-based WASH-related studies, few cross-sectional studies have focused on and determined the prevalence of handwashing attitudes, perceptions, and practices in university settings [ 23 , 25 ]. This shortage of information may limit the scope of comparing and contrasting our results with similar studies. Our findings revealed that university students were aware of and possessed adequate knowledge about sanitation and hygiene-related illnesses and health problems. This contrasts with several international studies in Turkey [ 40 ] and elsewhere [ 41 ]. The findings of this study revealed that students were aware of the importance of handwashing and possessed positive attitudes towards maintaining good hygiene practices despite structural barriers. These positive attitudes may be linked to WASH-related understanding gained at a pre-university age. Over the past two decades (2000–2020), there has been extensive school-based WASH-related interventions (i.e., hardware facilities such as latrine construction, tube-well installation, supplying handwashing products, cleaning materials, hygiene promotion messaging, IEC materials) in Bangladesh that familiarized and habituated students to adopt good hygiene practices [ 29 , 42 – 44 ]. A similar observation was noted in a recent study conducted in Dhaka University, the largest public university in Bangladesh. The study noted that hygiene and sanitation practices differed significantly by gender and socio-economic status; female students and students from nuclear families had better hygiene and sanitation practices compared to male students and students from joint families, where typically three or more generations living together in a single household [ 25 ]. Another reason is that university students may come from relatively middle and upper-middle class families with greater access to WASH information (i.e., media exposure) that helps them to adopt acceptable hygiene practices from their families [ 45 , 46 ]. Another reason may be that the majority of students (mostly born around the beginning of the current millennium) gained contemporary views on lifestyle as informed by (social) media. This is consistent with greater access to telecommunication media associated with economic growth in the last two decades, resulting in improvements in quality of life, particularly to the middle and upper-middle class population. Such views favored the adoption of enhanced sanitary and hygiene practices at personal and family levels. The adoption of enhanced hygiene practices became a symbol of politeness or standard courtesy.

However, our data showed that despite these positive habits related to individual level of WASH behaviors, the lack of contextual and socio-behavioural dimensions of WASH practices at the higher education institutions work as barrier for individuals not to maintain and foster these positive habits at the individual level. The data revealed that students noticeably failed to maintain improved sanitary and hygiene behavior at their university properly. The supply-side response substantially caused this failure, as noted in one study [ 36 ]. The university authorities lacked adequate support to monitor and supervise the management of cleaning activities at different levels, which might result in poor outcomes [ 36 ]. Similarly, the findings of this study also showed that an inadequate supply of cleaning products (soap, sanitizer, or other means) restricted the timely maintenance quality of sanitation facilities and arrangements across halls and other buildings at the University in Bangladesh. Conversely, the timely and regular supply of sanitary and hygiene material enhanced hygiene practices. A similar observation was noted in systematic reviews and control trials, as well as cross-sectional studies in several international settings [ 47 , 48 ].

One of the significant findings of this study is that the meaning of sanitation and hygiene was narrowly viewed by participants. Sex and gender sensitivity were largely ignored by the universities in the provision of sanitation-related supplies. The lack of gender sensitivity at the contextual level works as a barrier to improve and foster sanitation and hygienic practices at the individual level. This limitation jeopardized female students adopting improved hygienic behavior in and across campus buildings. Such a lack was noted in Bangladesh and elsewhere in previous studies where girls and women rarely had access to disposing of menstrual products or using cleaning agents [ 49 – 52 ]. Arranging a gender-friendly sanitation system was likely not seriously considered in construction plans. Structural constraints such as reliable water sources, timely managed services, and cleanliness appeared as an underlining barrier for adequate sanitation and hygiene practices. The absence of these factors significantly affected the female students as they are socially and culturally sensitive to using toilets in unfamiliar places (i.e., public toilets). They attempted to take an alternative strategy to cope with such a situation by holding their urine for a long time or tried to avoid drinking water. Due to the study design, our data do not enable us to determine how and whether the female students experienced any health problems caused by this practice. Another study reported that such a strategy negatively impacts girls’ and women’s health outcomes [ 53 – 55 ].

Our findings indicate that institutional-based higher education has expanded rapidly to align with the economic growth of the country in the past two decades. This economic growth might have created increasing demands on hygiene and sanitation facilities. To meet these increasing demands, the Government of Bangladesh announced a national goal known as “Sanitation for All by 2010” as a major policy initiative that facilitated multi-level programmatic supports at household levels [ 56 ]. To comply with this national goal, extensive programmatic interventions were implemented at the school level. The need to improve WASH facilities in higher educational institutions was therefore neglected, which resulted in poor facilities, management, and maintenance of WASH facilities. The current study advocates that WASH-related facilities and practices at universities need special focus to promote improved hygiene and sanitation practices in universities.

Limitation of the study

The findings of this research could not be generalized to those universities that offer fee-earning evening courses. This is because they earn money from professional degrees with high tuition fees and are intended to provide healthy facilities for their professional/executive students (i.e., the Business Faculty or Institute of Education and Research of Dhaka University or private universities). However, the situation of colleges under the National University may be worse than public universities. There are more than 2,200 colleges under the National University offering degrees. Our study is limited as we could not obtain interviews with high-level policy makers/administrators. The high-level policy makers/administrators had engaged with some pre-existing activities during the data collection period that might have focused on sanitation service provision and management in the university. Whilst we included participants from different years, semesters, disciplines, genders, and residences to maximize variation, we recognize that some students, such as those with hearing impairment or other physical/neurological disabilities, were not included in this research, and future research could consider this. However, we are confident that we sampled a diverse range of participants, ensured self-reflexivity, and applied an iterative process during the interviews. Careful consideration of these steps and the standard procedures of qualitative methods enabled us to generate valid evidence that might be generalizable to other public universities.

This study revealed that sanitation and hygiene practices in public universities are remarkably poor due to supply-side responses. Despite the remarkable increase in the number of universities and resource allocation, the promotion of improved sanitary and hygiene facilities has been overlooked over the years. Therefore, a multi-level promotional intervention focusing on provider responses is needed to advance an enhanced, need-oriented, and effective sanitary and hygiene system that can promote improved hygiene and sanitary practices among university students.

Suggested recommendations to improve hygiene and sanitation practices

• WASH-related materials and agents (i.e. supplying handwashing products, cleaning materials, washing equipment) should be regularly supplied to ensure quality cleaning services.
• A toilet cleaning checklist may be introduced to ensure quality cleaning services by cleaning professionals.
• WASH-related pictorials and key messages may be developed and displayed to promote good hygiene habits that remind the individual user to maintain good hygiene behavior.
• Regular monitoring and inspection of cleaning professionals and checking the toilet checklist to ensure quality services.
• Promote low-cost solutions such as soapy water or chlorine tablets/a tablet that has been proven effective in resource-limited settings should be introduced to minimize costs.
• Improve provision of toilets for female students. Consider gender perspectives in planning new infrastructure and construction. Low-cost menstrual hygiene-related disposal materials should be placed in existing buildings.

Supporting information

S1 file. guideline for in-depth interview..

https://doi.org/10.1371/journal.pone.0257663.s001

S2 File. Guideline for focus group discussion.

https://doi.org/10.1371/journal.pone.0257663.s002

S3 File. Guideline for key informant interview.

https://doi.org/10.1371/journal.pone.0257663.s003

Women's sanitation matters: Unpacking the conundrums associated with open defecation among women in Harper City, Liberia

• I. Baddianaah , G. K. Naazie , +1 author Paulina Terkper
• Published in Environmental Challenges 1 June 2024
• Environmental Science, Sociology

26 References

Determinants of open defecation among rural women in ghana: analysis of demographic and health surveys, we all share the blame: analyzing the root causes of flooding in african cities with specific reference to harper city, liberia, navigating access to golden lands: gender roles and constraints of women in artisanal and small‐scale mining operations in north‐western ghana, open defaecation by proxy: tackling the increase of disposable diapers in waste piles in informal settlements., condition of water, sanitation and hygiene (wash) in ghana's basic schools: empirical evidence from wa municipality, open defecation practice and its determinants among households in sub-saharan africa: pooled prevalence and multilevel analysis of 33 sub-saharan africa countries demographic and health survey, water, sanitation, and women's empowerment: a systematic review and qualitative metasynthesis, child defecation, feces disposal practices and associated factors in community-led total sanitation adopted districts in jimma zone, ethiopia, overcoming open defecation for healthier environment in case of pakistan, women’s experiences of defecating in the open: a qualitative study, related papers.

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Water sanitation and hygiene are critical to health, survival, and development. Many countries are challenged in providing adequate sanitation for their entire populations, leaving people at risk for water, sanitation, and hygiene (WASH)-related diseases. Throughout the world, an estimated 4.5 billion people lack access to safely managed sanitation  (WHO/UNICEF).

In the  Department of Environmental Health and Engineering , we are developing and evaluating strategies to ensure that water is safe to drink and use in our daily lives both locally and abroad.

Research Highlights

Protecting drinking water from aging infrastructure and climate change.

In cities across the U.S., water systems are under threat as aging infrastructure is being stressed by climate change. To better understand where we should apply public health resources, Abel Wolman Professor in Water and Public Health  Kellogg Schwab, PhD, MSPH , and assistant scientist  Natalie Exum, PhD ’16, MS , received funding from a  Bloomberg American Health Initiative  Spark Award to study what’s going on in the pipes—and what’s coming out of our faucets.  Learn more (video).

A Mobile Data Collection Platform Helps Reveal the Prevalence of a Neglected Tropical Disease

In sub-Saharan Africa, an estimated 200 million people are infected with the parasitic worms that cause schistosomiasis. Released by freshwater snails, the worms penetrate the skin of people who bathe in water contaminated by human sewage. The disease can cause liver damage, kidney failure, bladder cancer and infertility if left untreated. Working with the  Performance Monitoring and Accountability 2020 project ,  Natalie Exum, PhD ’16, MS , an assistant scientist in  Environmental Health and Engineering , is putting mobile technology in the hands of local data collectors to help determine the disease’s prevalence in Uganda.  Learn More.

An Assessment of Drinking Water in the Peruvian Amazon

The Peruvian Amazon, one of the world’s most biodiverse regions, is subject to pressure from climate change, deforestation, mining, and urbanization, with translational impacts on water quality, ecosystems, and human health. Shifts in the water cycle due to changes in climate or land use threaten ecosystem stability, food security, economic status, and human health. Recent surges in developmental activities, including logging, agriculture, petrochemical operations, and mining, have caused increases in deforestation and external impacts. These changes can expose humans to pathogens and contaminants (e.g., heavy metals and pesticides) causing acute and chronic illness and water-related, vector-borne disease (e.g., malaria).

A team of Hopkins researchers traveled to the Peruvian rainforest to conduct an assessment of the quality of drinking water utilized by some of these villages to gain understanding of the overall safety of available potable water sources as a first step towards developing a broader water research platform. This study generated an enhanced evaluation of the sources and types of drinking water contaminants in the Peruvian Amazon.  Learn more.

Associated Faculty

A current interest of Ball's is the development and application of appropriate and sustainable technologies for developing nations, with focus on water resources, drinking water, and sanitation. 

More Information

Natalie is the Senior Technical Advisor for Water, Sanitation and Hygiene (WASH) for PMA2020's mobile health data collection platform. She also leads the PMA2020 Schistosomiasis module in Uganda, which is providing a national assessment of the disease incidence throughout the country along with the WASH conditions of households to understand how to most effectively interrupt the transmission cycle. 

Ferraro's research focuses on behavioral economics and the design and evaluation of environmental programs in the private and public sector.

Harman's research group studies water flow and transport from soil to hillslope to watershed scales. Our work combines theory development, field work, experimental studies, and numerical modeling. The work is organized around two broad themes: flow and transport in the landscape; and structure and evolution of the critical zone.

Heaney is currently studying the health impacts of recreational beach activities, particularly waterbourne and other infectious diseases. A goal of his lab is to advance understanding of the health consequences of joint exposures to pathogens and toxicants in environmental and occupational contexts, including food animal production, drinking and recreational water, and municipal and industrial waste management. 

Hobbs' research interests in this area encompass stochastic electric power planning models, multi-objective and risk analysis, mathematical programming models of imperfect energy markets, environmental and energy systems analysis and economics, and ecosystem management.

Carsten investigates the fate of contaminants in the built and natural environment using state-of-the-art analytical chemistry techniques (e.g. high-resolution mass spectrometry) with the focus on identifying transformation products and understanding underlying mechanisms of transformation in the urban water cycle.

Schwab's current research projects involve investigating innovative water reuse treatment options as well as improving environmental detection methods for noroviruses (the leading cause of non-bacterial gastroenteritis worldwide). He is also working with Hopkins colleagues to integrate mobile data collection to assess family planning along with water, sanitation and hygiene around the world.

The focus of Dr. Sillé's research is understanding the effects of environmental exposures on the development and function of our immune system. Her major research directions are:

1. Understanding the long-term effects of early-life arsenic exposures on immunity and (infectious) disease risk. - Currently studying the interaction between arsenic and tuberculosis,

2. Establishing an integrated platform for immunotoxicity testing of early-life chemical exposures,

3. Investigating the effects early-life exposures on immunological memory and vaccine efficacy.

Stone has studied chemical reactions at nanoparticle/water interfaces for more than 25 years. Synthetic chemicals directly added to environmental media merit special attention, i.e. chemicals used in agriculture, animal production, forestry, and aquaculture, as large volumes of water are used for cooling, paper-making, and water supply. He researches how natural constituents found in such waters interact with treatment chemicals. 

*Denotes faculty who are accepting PhD students.

Goal 6: Ensure access to water and sanitation for all

Access to safe water, sanitation and hygiene is the most basic human need for health and well-being. Billions of people will lack access to these basic services in 2030 unless progress quadruples. Demand for water is rising owing to rapid population growth, urbanization and increasing water needs from agriculture, industry, and energy sectors.

The demand for water has outpaced population growth, and half the world’s population is already experiencing severe water scarcity at least one month a year. Water scarcity is projected to increase with the rise of global temperatures as a result of climate change.

Investments in infrastructure and sanitation facilities; protection and restoration of water- related ecosystems; and hygiene education are among the steps necessary to ensure universal access to safe and affordable drinking water for all by 2030, and improving water-use efficiency is one key to reducing water stress.

There has been positive progress. Between 2015 and 2022, the proportion of the world’s population with access to safely managed drinking water increased from 69 per cent to 73 per cent.

Access to water, sanitation and hygiene is a human right. To get back on track, key strategies include increasing sector-wide investment and capacity-building, promoting innovation and evidence-based action, enhancing cross-sectoral coordination and cooperation among all stakeholders, and adopting a more integrated and holistic approach to water management.

Water is essential not only to health, but also to poverty reduction, food security, peace and human rights, ecosystems and education.

Nevertheless, countries face growing challenges linked to water scarcity, water pollution, degraded water-related ecosystems and cooperation over transboundary water basins.

What are the challenges?

In 2022, 2.2 billion people still lacked safely managed drinking water, including 703 million without a basic water service; 3.5 billion people lacked safely managed sanitation, including 1.5 billion without basic sanitation services; and 2 billion lacked a basic handwashing facility, including 653 million with no handwashing facility at all.

By managing our water sustainably, we are also able to better manage our production of food and energy and contribute to decent work and economic growth. Moreover, we can preserve our water ecosystems, their biodiversity, and take action on climate change.

Are water and climate change linked?

Water availability is becoming less predictable in many places. In some regions, droughts are exacerbating water scarcity and thereby negatively impacting people’s health and productivity and threatening sustainable development and biodiversity worldwide.

Ensuring that everyone has access to sustainable water and sanitation services is a critical climate change mitigation strategy for the years ahead.

Without better infrastructure and management, millions of people will continue to die every year from water-related diseases such as malaria and diarrhoea, and there will be further losses in biodiversity and ecosystem resilience, undermining prosperity and efforts towards a more sustainable

What can we do?

Civil society organizations should work to keep governments accountable, invest in water research and development, and promote the inclusion of women, youth and indigenous communities in water resources governance.

Generating awareness of these roles and turn- ing them into action will lead to win-win results and increased sustainability and integrity for both human and ecological systems.

You can also get involved in the World Water Day and World Toilet Day campaigns that aim to provide information and inspiration to take action on hygiene issues.

Facts and figures

Goal 6 targets.

• Despite great progress, billions of people still lack access to safe drinking water, sanitation and hygiene. Achieving universal coverage by 2030 will require a substantial increase in current global rates of progress: sixfold for drinking water, fivefold for sanitation and threefold for hygiene.
• Water use efficiency has risen by 9 per cent, but water stress and water scarcity remain a concern in many parts of the world. In 2020, 2.4 billion people lived in water-stressed countries. The challenges are compounded by conflicts and climate change.
• Key strategies to get Goal 6 back on track include increasing sector-wide investment and capacity-building, promoting innovation and evidence- based action, enhancing cross-sectoral coordination and cooperation among all stakeholders, and adopting a more integrated and holistic approach to water management.
• Only 0.5 per cent of water on Earth is useable and available freshwater – Wake up to the looming water crisis, report warns | World Meteorological Organization
• Limiting global warming to 1.5°C compared to 2°C would approximately halve the proportion of the world population expected to suffer water scarcity, although there is considerable variability between regions. Chapter 8: Water Cycle Changes (p. 1063)
• The global urban population facing water scarcity is projected to double from 930 million in 2016 to 1.7–2.4 billion people in 2050. Imminent risk of a global water crisis, warns the UN World Water Development Report 2023 | UNESCO
• Despite progress, 2.2 billion people still lacked safely managed drinking water services, 3.5 billion lacked safely managed sanitation services, and 2.0 billion lacked basic hygiene services in 2022
• Surface water bodies, such as lakes, rivers, and reservoirs, are undergoing rapid global changes, with one in five river basins showing high fluctuations in surface water levels in the past 5 years
• Water pollution poses a significant challenge to human health and the environment in many countries.

Source: The Sustainable Development Goals Report 2023

6.1 By 2030, achieve universal and equitable access to safe and affordable drinking water for all

6.2  By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

6.3  By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally

6.4  By 2030, substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity

6.5  By 2030, implement integrated water resources management at all levels, including through transboundary cooperation as appropriate

6.6  By 2020, protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers and lakes

6.A  By 2030, expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programmes, including water harvesting, desalination, water efficiency, wastewater treatment, recycling and reuse technologies

6.B  Support and strengthen the participation of local communities in improving water and sanitation management

World Water Assessment Programme

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Water Action Decade

Fast Facts: Clean Water and Sanitation

Infographic: Clean Water and Sanitation

Water Action Decade, 2018-2028

40 per cent shortfall in freshwater resources by 2030 coupled with a rising world population has the world careening towards a global water crisis. Recognizing the growing challenge of water scarcity the UN General Assembly launched the Water Action Decade on 22 March 2018, to mobilize action that will help transform how we manage water.

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Sanitation, Urban Environment and the Politics of Public Health in Late Imperial Moscow

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Preeti Jajodia

Dmitry Mikhel

Thanks to the opening of archives and the forging of exchanges between Russian and Western scholars interested in the history of medicine, it is now possible to write new forms of social and political history in the Soviet medical field. Using the lenses of critical social histories of healthcare and medical science, and looking at both new material from Russian archives and interviews with those who experienced the Soviet health system, the contributors to this volume explore the ways experts and the Soviet state radically reshaped medical provision after the Revolution of 1917. Soviet Medicine presents the work of an international group of leading scholars. Twelve essays—treating subjects that span the 74-year history of the Soviet Union—cover such diverse topics as how epidemiologists handled plague on the Soviet borderlands in the revolutionary era, how venereologists fighting sexually transmitted disease struggled to preserve the patient’s right to secrecy, and how Soviet forensic experts falsified the evidence of the Katyn Forest massacre of 1940. This important volume demonstrates the crucial role played by medical science, practice, and culture in the shaping of a modern Soviet Union and illustrates how the study of Soviet medical history can benefit historians of medicine, science, the Soviet Union, and social and gender historians.

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In the second half of the 19th century olfactory perception and related ideas of sensibility were at the centre of public discussion, together with a broader problem of public health and urban sanitation. The explanatory model of miasmatic theory converted the olfactory dimension of routine into a series of symptoms which should be noticed, interpreted correctly and followed with sanitary measures. At the brink of a new bacteriological era in natural science, the sanitary approach to pathogeny brought about a reconsideration of the idea of sensibility and paved the way for the new sensory regimes which would emerge after Pasteur and Koch's discoveries had spread in the Western world. Since the cholera years of the 1820s, epidemics had reshaped key concepts of medicine (such as illness, health, contagion etc.) and thus were not only milestones for medical debates and sanitary congresses, but also influenced personal and public practices and perceptions. The paper describes discourses and practices called into being by the last plague of the pre-bacterial era, and traces conflicts it provoked.

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Download a branded Cambridge Journals Online toolbar (for IE 7 only). What is this? ... Add Cambridge Journals Online as a search option in your browser toolbar. What is this? ... The Hazards of Urban Life in Late Stalinist Russia: Health, Hygiene, and Living Standards, 1943–1953. By Donald Filtzer. Cambridge: Cambridge University Press, 2010. Pp. Xxx, 379. $110.00, cloth. ... The Hazards of Urban Life in Late Stalinist Russia: Health, Hygiene, and Living Standards, 1943–1953. By Donald Filtzer. Cambridge: Cambridge University Press, ...

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Greening the food supply chain: Developing sustainable food systems through interdisciplinary collaboration

by University of Connecticut

Sustainability is a hot topic in just about every field that engages with the environment, including agriculture. An interdisciplinary group of researchers in UConn's College of Agriculture, Health and Natural Resources has published a paper outlining the current state of sustainable food production research in the Journal of Agriculture and Food Research .

The group includes Yangchao Luo, associate professor of nutritional sciences; Zhenlei Xiao, associate professor-in-residence of nutritional sciences; and Abhinav Upadhyay, assistant professor of animal science. Bai Qu, Luo's Ph.D. student, is the lead author on the paper.

Sustainable food production focuses on creating food systems that are environmentally sound, economically viable, and socially equitable.

"It focuses on the entire food supply chain, from farm to table, ensuring that each step is sustainable, minimizes waste, and reduces the carbon footprint," Luo says.

The paper outlines the key features of sustainable food production including environmental stewardship , economic vitality, innovation and adaptation, and social responsibility.

The paper also reviews green technologies like urban agriculture , food nanotechnology, and plant-based foods, all of which play a role in reducing the negative impacts of food production.

"This is not a new concept, but I think with the development of emergent technology, a lot of things are going on now, it is very important to revisit this concept," Luo says.

This publication provides a holistic and interdisciplinary perspective on the topic.

"Sustainable food production is a very collaborative topic," Luo says. "You cannot do everything on your own."

Sustainable food production encompasses the concept of a circular economy in which the waste from one process or product can be reused elsewhere.

"People have not cared about the waste generated, the impact to the environment, whether it's sustainable or not," Luo says. "People are pretty much profit driven. Now we have to change the whole concept or else the entire agricultural industry cannot be sustainable."

This paper reflects the College and UConn's broader commitment to sustainability, Luo explains.

"There's many things in the College and at the University, campus-wide, that flow into this area that really inspire me to dive deeper into this topic," Luo says.

Luo, co-chair for CAHNR's committee for sustainable agriculture and food production, is currently working with a group of students to develop an organic poultry feed additive made from microalgae.

"You cannot think about sustainable agriculture from a single discipline," Luo says. "It has to be highly collective and collaborative from all three areas—society, environment, and community health. You have to connect all three angles together."

Provided by University of Connecticut

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Call for papers: Generating stronger evidence to inform policy and practice: natural experiments on built environments, health behaviours and chronic diseases

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https://doi.org/10.24095/hpcdp.44.6.11

Recommended Attribution

This call for papers in the HPCDP Journal licensed under a Creative Commons Attribution 4.0 International license

Guest editors: Dr. Stephanie Prince Ware (Public Health Agency of Canada), Dr. Gavin McCormack (University of Calgary)

HPCDP Journal Editors: Robert Geneau and Margaret de Groh (Public Health Agency of Canada)

Where we work, learn, play, eat and live has important implications for health. The built environment has been associated with the development of chronic disease, and with health behaviours often seen as critical pathways for this relationship. Footnote 1 Footnote 2 Built environments refer to components of the physical environment that are human-made or human-modified and include structures and buildings, recreation facilities, green spaces and parks, transportation systems and community design.

Natural experiments are interventions that occur without a researcher’s ability to manipulate the intervention or exposure to the intervention. Footnote 3 Footnote 4 Natural experiments offer the opportunity to evaluate the effects of “naturally occurring” interventions such as changes to the built environment (e.g. creation of a new bike path, park improvements, infrastructure changes to schools or workplaces, construction of a new recreation facility or grocery store) on health behaviours and chronic disease risk. Natural experiments are often more practical for investigating the health impacts of environmental interventions when compared to traditional experimental studies (e.g. randomized controlled trials). Compared to cross-sectional studies, natural experiments provide a means to generate rigorous evidence to better establish causality, as well as to understand the implementation of interventions in “real-world” scenarios.

This special issue answers the 2017 Canadian Public Health Officer annual report’s call to further evaluate the health impacts of community design features in Canada. Footnote 5 This special issue resonates with the expanding scholarly and policy-oriented interest in the utility of natural experiments as a critical tool in advancing the body of evidence and for informing interventions to improve public and population health. Footnote 6 Footnote 7 Specifically, the objective of this special issue on natural experiments is to provide timely evidence to further understand the effectiveness of built environment interventions on health behaviours and chronic disease prevention in a Canadian context.

Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice is seeking relevant topical research articles that present new findings or synthesize/review existing evidence on natural experiments of the built environment (or related policies) that influence health behaviours with implications for chronic disease prevention in Canada.

Relevant topic areas include, but are not limited to:

• Built environments, including community or neighbourhoods, workplaces, schools, transportation infrastructure, home environments, recreation environments, parks, playgrounds, green spaces, public open spaces, natural environments and seniors’ residences.
• All health-related behaviours, including physical activity, sedentary behaviour, sleep, food consumption, smoking and substance use.
• Chronic diseases and health-related outcomes, including body mass index, fitness, blood pressure, blood lipids, blood sugar, injuries, falls, mental health, stress, depression, anxiety, Alzheimer's disease, dementia, obesity, metabolic syndrome, cardiovascular disease, cancer, diabetes and lung disease.

International submissions will be considered if they include Canadian data, results (e.g. as part of multi-country studies or global comparisons) and/or evidence-based discussion of implications for community or population health in Canada.

Consult the Journal’s website for information on article types and detailed  submission guidelines for authors . Kindly refer to this call for papers in your cover letter.

All manuscripts should be submitted using the Journal’s  ScholarOne Manuscripts  online system. Pre-submission inquiries and questions about suitability or scope can be directed to  [email protected] .

Submission deadline: November 30, 2024

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• Introduction
• Conclusions
• Article Information

Estimated incidence per 100 000 person-years at age 60 years is shown by birth year (1908-1983). All curves are on the log 10 scale. These and additional curves are shown in eFigure 11 in Supplement 1 . Tick marks on the x-axis indicate start years for consecutive social generations: 1928-1945, Silent Generation; 1946-1964, Baby Boomers; 1965-1980, Generation X. Shaded areas indicate 95% CIs.

Estimated incidence per 100 000 person-years at age 60 years is shown by birth year (1908-1983). All curves are on the log 10 scale. These and additional curves are shown in eFigure 13 in Supplement 1 . Tick marks on the x-axis indicate start years for consecutive social generations: 1928-1945, Silent Generation; 1946-1964, Baby Boomers; 1965-1980, Generation X. Shaded areas indicate 95% CIs.

Gen X indicates Generation X. Shaded areas indicate 95% CIs.

Fitted cohort pattern curves by cancer site are adjusted for race and ethnicity as described in the Methods, plotted on a natural log scale, and sorted from largest (top) to smallest (bottom). IRR indicates incidence rate ratio; NHL, non-Hodgkins lymphoma.

Arrow plots indicate magnitude and direction of change from older to younger generations. Corresponding percentage changes and 95% CIs are also graphed in eFigure 19 in Supplement 1 .

eMethods. Statistical Methods

eTable 1. Organ-Specific Site Code Used in the Classification of Cancer Sites Using SEER*Stat 8.4.0

eTable 2. Age-Standardized Incidence Rates and Cancer Cases by Sex, Race and Ethnicity, United States, 35-84 Years Old, 1992-2018

eFigure 1. Observed Rates in Females

eFigure 2. APC Fitted Values in Females

eFigure 3. Observed Rates in Males

eFigure 4. APC Fitted Values in Males

eFigure 5. Lack of Fit (LOF) in Females

eFigure 6. Lack of Fit (LOF) in Males

eFigure 7. Higher-Order Deviations vs Lack of Fit (LOF) in Females

eFigure 8. Higher-Order Deviations vs Lack of Fit (LOF) in Males

eFigure 9. Local Drifts in Females

eFigure 10. Local Drifts in Males

eFigure 11. Fitted Cohort Patterns (FCPs) by Cancer Site, Race, and Ethnicity: Females

eFigure 12. Estimated Annual Percentage Change (EAPC) of the Fitted Cohort Pattern (FCP): Females

eFigure 13. Fitted Cohort Patterns (FCPs) by Cancer Site, Race, and Ethnicity: Males

eFigure 14. Estimated Annual Percentage Change (EAPC) of the Fitted Cohort Pattern (FCP): Males

eFigure 15. Average Incidence at Age 60: Generation X vs Baby Boomers

eFigure 16. Average Incidence at Age 60: Baby Boomers vs the Silent Generation

eFigure 17. Average Incidence at Age 60: Silent vs Greatest Generations

eFigure 18. Site-Adjusted Cancer Incidence Rate Ratios (IRRs) for Non-Hispanic Black, Hispanic, and Asian or Pacific Islander vs Non-Hispanic White by Sex and Social Generation

eFigure 19. Percent Changes in Incidence of Leading Cancers at Age 60 Years per 100 000 Person-Years in Successive Generations

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Rosenberg PS , Miranda-Filho A. Cancer Incidence Trends in Successive Social Generations in the US. JAMA Netw Open. 2024;7(6):e2415731. doi:10.1001/jamanetworkopen.2024.15731

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Cancer Incidence Trends in Successive Social Generations in the US

• 1 Division of Cancer Epidemiology and Genetics, Biostatistics Branch, National Cancer Institute, Rockville, Maryland

Question   Is cancer incidence in successive social generations in the US slowing or growing?

Findings   In this cohort study of 3.8 million patients with cancer ascertained by the Surveillance, Epidemiology, and End Results Program, members of Generation X born between 1965 and 1980 have been experiencing larger per-capita increases in the incidence of leading cancers combined than any prior generation born between 1908 and 1964.

Meaning   These findings suggest that based on current trajectories, cancer incidence in the US might remain high for decades.

Importance   The incidence of some cancers in the US is increasing in younger age groups, but underlying trends in cancer patterns by birth year remain unclear.

Objective   To estimate cancer incidence trends in successive social generations.

Design, Setting, and Participants   In this cohort study, incident invasive cancers were ascertained from the Surveillance, Epidemiology, and End Results (SEER) program’s 13-registry database (November 2020 submission, accessed August 14, 2023). Invasive cancers diagnosed at ages 35 to 84 years during 1992 to 2018 within 152 strata were defined by cancer site, sex, and race and ethnicity.

Exposure   Invasive cancer.

Main Outcome and Measures   Stratum-specific semiparametric age-period-cohort (SAGE) models were fitted and incidence per 100 000 person-years at the reference age of 60 years was calculated for single-year birth cohorts from 1908 through 1983 (fitted cohort patterns [FCPs]). The FCPs and FCP incidence rate ratios (IRRs) were compared by site for Generation X (born between 1965 and 1980) and Baby Boomers (born between 1946 and 1964).

Results   A total of 3.8 million individuals with invasive cancer (51.0% male; 8.6% Asian or Pacific Islander, 9.5% Hispanic, 10.4% non-Hispanic Black, and 71.5% non-Hispanic White) were included in the analysis. In Generation X vs Baby Boomers, FCP IRRs among women increased significantly for thyroid (2.76; 95% CI, 2.41-3.15), kidney (1.99; 95% CI, 1.70-2.32), rectal (1.84; 95% CI, 1.52-2.22), corpus uterine (1.75; 95% CI, 1.40-2.18), colon (1.56; 95% CI, 1.27-1.92), and pancreatic (1.39; 95% CI, 1.07-1.80) cancers; non-Hodgkins lymphoma (1.40; 95% CI, 1.08-1.82); and leukemia (1.27; 95% CI, 1.03-1.58). Among men, IRRs increased for thyroid (2.16; 95% CI, 1.87-2.50), kidney (2.14; 95% CI, 1.86-2.46), rectal (1.80; 95% CI, 1.52-2.12), colon (1.60; 95% CI, 1.32-1.94), and prostate (1.25; 95% CI, 1.03-1.52) cancers and leukemia (1.34; 95% CI, 1.08-1.66). Lung (IRR, 0.60; 95% CI, 0.50-0.72) and cervical (IRR, 0.71; 95% CI, 0.57-0.89) cancer incidence decreased among women, and lung (IRR, 0.51; 95% CI, 0.43-0.60), liver (IRR, 0.76; 95% CI, 0.63-0.91), and gallbladder (IRR, 0.85; 95% CI, 0.72-1.00) cancer and non-Hodgkins lymphoma (IRR, 0.75; 95% CI, 0.61-0.93) incidence decreased among men. For all cancers combined, FCPs were higher in Generation X than for Baby Boomers because gaining cancers numerically overtook falling cancers in all groups except Asian or Pacific Islander men.

Conclusions and Relevance   In this model-based cohort analysis of incident invasive cancer in the general population, decreases in lung and cervical cancers in Generation X may be offset by gains at other sites. Generation X may be experiencing larger per-capita increases in the incidence of leading cancers than any prior generation born in 1908 through 1964. On current trajectories, cancer incidence could remain high for decades.

Is cancer incidence in the US—ie, the number of newly diagnosed cases per capita per year—slowing or growing? Notably, while the incidence of certain cancers is declining, 1 others are increasing in younger age groups (aged <50 years). 2 These temporal patterns encompass a diversity of neoplasms and vary over time by demographic factors, including age, sex, and race and ethnicity. A more fundamental question is: are we collectively experiencing lower cancer incidence as we age than the generation of our parents?

Analyses that focus on birth years and social generations can provide insights into cancer prevention and health care accessibility and highlight persistent demographic and socioeconomic inequalities that span generations. Nevertheless, tracking the history of cancer in the US is challenging because cancers evolve over the lifetimes of individuals, 3 yet the observational period of contemporary cancer registries spans at most a few decades. 4 Hence, we must reconstruct the longitudinal history of cancer in the population from a time-limited series of cross-sectional observations. To understand the overarching trends, it is imperative to assemble these snapshots into a cohesive longitudinal narrative for a variety of cancer types in diverse demographic groups.

With the use of new statistical methods, 5 , 6 we can now obtain single-year reconstructions of cancer incidence by age, period, and birth cohort with unprecedented precision. Our goal is to model the shifting landscape of cancer from one birth year to the next for leading cancers in men and women by race and ethnicity. From this ensemble, we hope to glean insights into the overall trajectory of cancer in the US from the Greatest Generation (born from 1908 through 1927) through Generation X (born from 1965 through 1980).

Our cohort study was based on publicly available, deidentified data and, therefore, the National Cancer Institute institutional review board determined it exempt from review and informed consent. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We collected case and person-years at risk data from the Surveillance, Epidemiology, and End Results (SEER) program’s 13-registery database using SEER*Stat, version 8.4.0. Data ascertained for the November 2020 submission were retrieved on August 14, 2023 (eTable 1 in Supplement 1 ). Using these data, we assembled 152 rate matrix Lexis diagrams 7 covering 50 single years of age (35-84 years) and 27 calendar years (1992-2018), spanning 76 single-year birth cohorts (1908-1983) for 21 leading invasive cancers in women and men within 4 racial and ethnic categories: Asian or Pacific Islander, Hispanic, non-Hispanic Black, and non-Hispanic White. The definitions of race and ethnicity follow the criteria established by the SEER program. 8 In brief, the SEER program uses an algorithm to recode detailed race and origin variables in the SEER incidence data. The 21 leading invasive cancers were esophageal, stomach, gallbladder, liver, pancreatic, colon, rectal, kidney, bladder, leukemia, non-Hodgkin lymphoma (NHL), myeloma, brain and central nervous system (hereafter, brain), thyroid, lung, melanoma of skin (hereafter, melanoma), breast, ovarian, corpus uterine (hereafter, corpus), cervix uterine (hereafter, cervical), and prostate (eTable 2 in Supplement 1 ).

We analyzed each Lexis diagram using semiparametric age-period-cohort (SAGE) analysis. 6 The basic idea is to denoise the observed Lexis diagrams upfront by using a contemporary nonparametric procedure, 5 then fit the new age-period-cohort (APC) model to the smoothed Lexis diagrams. 9 The new APC model contains parameters that describe how expected rates vary as a function of birth cohort, accounting for age and calendar period effects. We used the model parameters to estimate the fitted cohort pattern (FCP). The FCP estimates the absolute incidence of a cancer at an arbitrary reference age (here, 60 years) for each birth year in the Lexis diagram. 9 Additional details are provided in the eMethods in Supplement 1 .

To further characterize FCP features, we fitted Joinpoint models 10 to the FCPs, allowing up to 5 segments, each with 10 or more birth years. We also computed mean FCPs and corresponding variances for the following social generations: Greatest Generation (1908-1927), Silent Generation (1928-1945), Baby Boomers (1946-1964), and Generation X (1965-1980). We had too few data points to produce estimates for Millennials (1981-1996).

To compare and contrast mean FCP values across generations, we fitted log-linear models to the generational differences in site-specific FCPs among men and women separately for the Silent vs Greatest Generations, Baby Boomers vs the Silent Generation, and Generation X vs Baby Boomers. We adjusted for race and ethnicity with non-Hispanic White as the reference group and weighted the data inversely with the estimated variance of each difference.

The SEER registries do not record the parents’ birth year for each cancer case. However, on average, the parents of Generation X are Baby Boomers and members of the Silent Generation, and the parents of Baby Boomers are members of the Silent and Greatest Generations. To see this assumption, subtract 20 through 29 years (mean maternal age at birth during our study period 11 ) from the end points of each generation, yielding 1917-1944 for Baby Boomers, which straddles the Greatest and Silent Generations (eg, 1917-1927 and 1928-1944, respectively), and 1936-1960 for Generation X, which straddles the Silent Generation and Baby Boomers (eg, 1936-1945 and 1946-1960, respectively). Similarly, the proxy parents of the Millennial generation (1981-1996) straddle the Baby Boomers and Generation X (eg, 1952-1964 and 1965-1976, respectively). In our study, we make no adjustments for multiple testing.

In total, we analyzed 3.8 million cases of incident cancer occurring over 521 million person-years (eTable 2 in Supplement 1 ). Overall, 51.0% of individuals were male (compared with 49.0% female) and 71.5% were non-Hispanic White (compared with 8.6% Asian or Pacific Islander, 9.5% Hispanic, and 10.4% non-Hispanic Black).

The SAGE analysis produced optimally smoothed single-year estimates of incidence for 80 female strata (observed Lexis diagrams, eFigure 1 in Supplement 1 ; smoothed APC fitted rates, eFigure 2 in Supplement 1 ) and 72 male strata (observed, eFigure 3 in Supplement 1 ; smoothed, eFigure 4 in Supplement 1 ). For the majority, lack of fit (LOF) (females, eFigure 5 in Supplement 1 ; males, eFigure 6 in Supplement 1 ) was negligible or small relative to the corresponding annual fluctuations (females, eFigure 7 in Supplement 1 ; males, eFigure 8 in Supplement 1 ). The most prominent LOF was observed for liver, rectal, and brain cancers and melanoma in females and liver, brain, thyroid, and prostate cancers in males. Time trends by age (local drifts) were significant in all strata (females, eFigure 9 in Supplement 1 ; males, eFigure 10 in Supplement 1 ). As shown previously, 6 LOF had little effect on the local drifts for the Lexis diagrams included in our study. Hence, the model fits appear adequate. 6

eFigure 11 in Supplement 1 presents FCPs by cancer site for women by race and ethnicity. Six of these FCPs, including pancreatic, colon, kidney, thyroid, lung, and cervical, are also shown in Figure 1 A through F, respectively. The statistical efficiency of the SAGE analysis yielded partially or fully nonoverlapping curves within most FCPs; the conclusions below were obtain by visual inspection.

Differences by race and ethnicity strongly depended on birth cohort. There were marked declines in cervical FCPs across all racial and ethnic groups. Incidence rates were highest among the Greatest Generation in non-Hispanic Black women for esophageal, pancreatic, and colon cancers and myeloma; in Hispanic women for gallbladder cancer; in Asian or Pacific Islander women for stomach and liver cancers; and in non-Hispanic White women for bladder, breast, ovarian, and corpus cancers and leukemia, NHL, and melanoma. Patterns by race and ethnicity were similar for the Silent Generation. Patterns changed with the Baby Boomers. Notable changes included convergence of esophageal cancers in non-Hispanic Black and non-Hispanic White women; steep declines for stomach cancer in Asian or Pacific Islander women; and steep increases in corpus cancer for Asian or Pacific Islander, Hispanic, and non-Hispanic Black women. In Generation X women, the FCPs consistently increased for liver, colon, rectal, kidney, thyroid, and corpus cancers ( Figure 1 ; eFigure 11 in Supplement 1 ). Estimates of the corresponding estimated annual percentage changes (EAPCs) of the FCPs obtained by Joinpoint analysis are shown in eFigure 12 in Supplement 1 .

eFigure 13 in Supplement 1 presents FCPs by cancer site for men. Six of these FCPs, including pancreatic, colon, kidney, thyroid, lung, and prostate, are also shown in Figure 2 A through F, respectively. For thyroid cancer, increases by cohort were slower in Asian or Pacific Islander, Hispanic, and non-Hispanic Black men compared with women, and peak incidence for lung cancer occurred earlier in men compared with women. The FCPs for prostate cancer were parallel across racial and ethnic groups, being highest in non-Hispanic Black and lowest in Asian or Pacific Islander men. In Generation X men, the FCPs were consistently increasing for colon, rectal, kidney, and thyroid cancers ( Figure 2 ; eFigure 13 in Supplement 1 ). eFigure 14 in Supplement 1 provides the corresponding estimated EAPCs.

Figure 3 presents the sum of the cancer site–specific FCPs (20 sites in women and 18 in men) by sex and race and ethnicity. Among men, incidence at age 60 years declined through the Greatest and Silent Generations in all 4 racial and ethnic groups. Subsequently, incidence increased for the Baby Boomers. Except for Asian or Pacific Islander men, incidence continued to increase in Generation X.

In contrast, among women, incidence was comparatively stable among members of the Greatest and Silent Generations and then increased beginning with the Baby Boomers for non-Hispanic White individuals ( Figure 3 A), then the Silent Generation for Hispanic and Asian or Pacific Islander ( Figure 3 C and D) and Generation X for non-Hispanic Black individuals ( Figure 3 B). Within each racial and ethnic group, the large male excess in the Greatest Generation diminished in subsequent generations. By Generation X, Hispanic and non-Hispanic White women had a similar incidence to their male counterparts ( Figure 3 A and C), and Asian or Pacific Islander women had a higher incidence compared with their male counterparts ( Figure 3 D). In the non-Hispanic Black group, the male excess persisted.

eFigure 15 in Supplement 1 presents arrow plots of mean FCP values by cancer site for Generation X vs Baby Boomers stratified by sex and race and ethnicity. Within each stratum, the FCP for Generation X was higher than the corresponding FCP for Baby Boomers at some sites and lower at others. Similar heterogeneity was observed in arrow plots of Baby Boomers vs the Silent Generation (eFigure 16 in Supplement 1 ) and the Silent vs Greatest Generations (eFigure 17 in Supplement 1 ).

To synthesize these data, we estimated FCP incidence rate ratios (IRRs) by fitting log-linear models to the estimated FCPs in eFigures 15 to 17 in Supplement 1 . For example, for Generation X vs Baby Boomer women, we synthesized the 80 arrows shown in panels eFigure 15A to D in Supplement 1 . Each arrow, which is indexed by site and race and ethnicity, contributed 1 difference or IRR to the modeled data. The estimated variances of the differences were used as weights.

Figure 4 presents forest plots of the site-specific IRRs between successive social generations adjusted for race and ethnicity in women and men. Point estimates are shown for non-Hispanic White individuals. Estimates for other racial and ethnic groups are similar (eFigure 18 in Supplement 1 ). Site-specific IRRs varied markedly by generation except for the brain.

The incidence of many cancers increased significantly in members of Generation X vs Baby Boomers ( Figure 4 ). Among women, increases were observed for the following cancers: thyroid (IRR, 2.76, 95% CI, 2.41-3.15), kidney (IRR, 1.99; 95% CI, 1.70-2.32), rectal (IRR, 1.84; 95% CI, 1.52-2.22), corpus (IRR, 1.75; 95% CI, 1.40-2.18), colon (IRR, 1.56; 95% CI, 1.27-1.92), NHL (IRR, 1.40, 95% CI 1.08-1.82), pancreatic (IRR, 1.39; 95% CI, 1.07-1.80), and leukemia (IRR, 1.27; 95% CI, 1.03-1.58). Among men, increases were observed for the following cancers: thyroid (IRR, 2.16; 95% CI, 1.87-2.50), kidney (IRR, 2.14; 95% CI, 1.86-2.46), rectal (IRR, 1.80; 95% CI, 1.52-2.12), colon (IRR, 1.60; 95% CI, 1.32-1.94), leukemia (IRR, 1.34; 95% CI, 1.08-1.66), and prostate (IRR, 1.25; 95% CI, 1.03-1.52). Other cancers decreased, including lung (IRR, 0.60; 95% CI, 0.50-0.72) and cervical (IRR, 0.71; 95% CI, 0.57-0.89) among women and lung (IRR, 0.51; 95% CI, 0.43-0.60), NHL (IRR, 0.75; 95% CI, 0.61-0.93), liver (IRR, 0.76; 95% CI, 0.63-0.91), and gallbladder (IRR, 0.85; 95% CI, 0.72-1.00) among men.

Figure 5 summarizes incidence at age 60 years for leading cancers combined, averaged over birth years within successive generations. eFigure 19 in Supplement 1 plots the corresponding percentage changes. Comparing the Silent vs Greatest Generations ( Figure 5 A), combined incidence decreased significantly in both sexes and all 4 racial and ethnic groups. The decreases were greater for men compared with women. For example, incidence decreased by 41.0% (95% CI, −43.9% to −38.1%) in non-Hispanic White men vs 5.6% (95% CI, −6.6% to −4.6%) in non-Hispanic White women. In contrast, comparing Baby Boomers with the Silent Generation ( Figure 5 B), combined incidence had a mixed pattern, decreasing in some groups, eg, by 5.4% (95% CI, −6.1% to −4.8%) and 10.6% (95% CI, −11.6% to −9.5%), respectively, in non-Hispanic White women and men, but increasing in others, eg, by 13.0% (95% CI, 11.1%-14.9%) among Hispanic women.

Comparing Generation X with Baby Boomers ( Figure 5 C), combined incidence increased in all groups except for Asian or Pacific Islander men. The increases ranged from 5.5% (95% CI, 1.4%-9.7%) in non-Hispanic Black women to 28.0% (95% CI, 23.5%-32.5%) in Hispanic women. The increases ranged from 10.4% (95% CI, 0.7%-20.1%) in Hispanic men to 13.7% (95% CI, 2.4%-24.9%) in non-Hispanic White men. The increase among non-Hispanic Black men was 13.7% (95% CI, −1.9% to 29.2%). Incidence decreased by 8.2% (95% CI, −15.6% to −0.9%) among Asian or Pacific Islander men. Except for Asian or Pacific Islander men, these increases were larger than any observed in prior social generations (eg, point estimates in Figure 5 C are larger than corresponding point estimates in Figure 5 A and B). In absolute terms, non-Hispanic Black men in Generation X had the highest combined incidence at 1561 cases per 100 000 person-years (95% CI, 1493-1629 cases per 100 000 person-years), while Asian or Pacific Islander men had the lowest at 519 cases per 100 000 person-years (95% CI, 474-563 cases per 100 000 person-years).

Male Baby Boomers had a lower combined incidence than their proxy parents (Greatest and Silent Generation birth cohorts from 1917 to 1944) ( Figure 5 D), with the greatest reduction of 28.8% (95% CI, −31.0 to −26.7%) in non-Hispanic Black men. The decreases among men were statistically significant in the other 3 racial and ethnic groups (Asian or Pacific Islander, −16.8% [95% CI, −19.5% to −14.2%]; Hispanic, −11.3% [95% CI, −14.0% to −8.6%]; non-Hispanic White, −20.8% [95% CI, −21.9% to −19.7%]). Female Baby Boomers had a mixed pattern: non-Hispanic White women, 7.0% lower (95% CI, −7.7% to −6.3%); essentially unchanged in non-Hispanic Black women, 0.7% higher (95% CI, −1.3% to 2.7%); Hispanic women, 12.1% higher (95% CI, 9.8%-14.4%); Asian or Pacific Islander women, 7.7% higher (95% CI, 5.4%-10.0%).

In contrast, members of Generation X had a higher combined incidence than their proxy parents (Silent Generation and Baby Boomers birth cohorts from 1936 to 1960) ( Figure 5 E) in all demographic groups except for Asian or Pacific Islander men. These increases were statistically significant in all 4 racial and ethnic groups among women (Asian or Pacific Islander, 20.1% [95% CI, 15.7%-24.4%]; Hispanic, 34.9% [95% CI, 29.8%-40.0%]; non-Hispanic Black, 6.1% [95% CI, 1.7%-10.5%]; non-Hispanic White, 15.1% [95% CI, 13.1%-17.2%]) and in Hispanic (14.1%; 95% CI, 3.6%-24.5%) and non-Hispanic White (11.9%; 95% CI, 0.7%-23.0%) men. Similarly, the proxy parents of the Millennials (Baby Boomer and Generation X birth cohorts from 1952 to 1976) also had higher cancer incidence than the proxy parents of Generation X in all demographic groups except Asian or Pacific Islander males ( Figure 5 F). The increases were statistically significant in Asian or Pacific Islander (11.1%; 95% CI, 8.9%-13.2%), Hispanic (17.8%; 95% CI, 15.4%-20.2%), and non-Hispanic White (4.5%; 95% CI, 3.6%-5.5%) women and in Hispanic (9.0%; 95% CI, 4.1%-14.0%) and non-Hispanic White (4.7%; 95% CI, 0.4%-9.0%) men.

In this cohort study, we asked whether we, collectively, are experiencing lower cancer incidence as we age than our parents. Using SAGE analysis, we were able to reconstruct the cancer experience of social generations from the Greatest Generation through Generation X and use selected birth years from the 2 preceding social generations as a proxy for the corresponding parental generation. To arrive at an overall conclusion, we used a simple summary measure: the incidence of leading cancers combined (20 sites in women and 18 sites in men).

For Baby Boomers (1946-1964) vs their proxy parents (1917-1944), the answer was yes for men (ie, progress) and mixed for women ( Figure 5 D). For Generation X (1965-1980) vs their proxy parents (1936-1960), the answer was no in all groups except for Asian or Pacific Islander males ( Figure 5 E).

The increases in cancer incidence in members of Generation X vs their proxy parents were substantial, especially among Hispanic women (a 34.9% increase) and men (a 14.1% increase). In contrast, the corresponding increases among non-Hispanic White women and men were 15.1% and 11.9%, respectively. We obtained similar results when we compared the Generation X to Baby Boomer social generations ( Figure 5 C). Furthermore, between the Greatest Generation and Generation X, the historical male cancer excess narrowed (non-Hispanic Black and non-Hispanic White men), declined to parity (Hispanic men), or reversed (Asian or Pacific Islander men) ( Figure 3 ).

Our conclusions are more concerning than previously reported increases in cancer incidence in younger age groups. 2 , 12 Those results, based on local drifts, describe the slope of the FCP curve in consecutive blocks of P birth years, where P is the total number of calendar years in the analysis (eg, P  = 19 in Sung et al 2 ; P  = 27 in our analyses). 9 For this reason, local drifts provide lagging and conservative indicators of changes from one birth year to the next. Furthermore, using SAGE analysis, we were able to estimate absolute FCP values for single-year birth cohorts and consecutive changes in incidence per birth year vs the 10-year overlapping cohort relative risks reported by Sung et al. 2

The substantial increases we identified in Generation X vs both the Baby Boomers and their proxy parents surprised us. Numerous preventable causes of cancer have been identified. 13 Cancer control initiatives have led to substantial declines in tobacco consumption. 14 Screening is well accepted for precancerous lesions of the colon, rectum, cervix, uterus, and breast. 15 However, other suspected carcinogenic exposures are increasing. 16 - 18

Unfortunately, as shown in our detailed comparative analysis of Generation X vs Baby Boomers, gaining cancers have numerically overtaken falling cancers. Among Generation X women, statistically significant declines in lung and cervical cancers have been overtaken by significant increases in thyroid, kidney, rectal, corpus, colon, pancreatic, and ovarian cancer and NHL and leukemia ( Figure 4 C). Among Generation X men, declines in lung, liver, and gallbladder cancers and NHL have been overtaken by gains in thyroid, kidney, rectal, colon, and prostate cancers and leukemia ( Figure 4 F).

Some portion of these increases can be attributed to rising obesity rates 19 and increasingly sedentary lifestyles. 20 - 23 Another portion might be explained by changes in cancer registry policies and International Statistical Classification of Diseases and Related Health Problems, 10th Revision (World Health Organization) classifications, 24 leading to inclusion of relatively indolent lesions in more recent periods that might not have been diagnosed as cancer in earlier periods. Furthermore, radiologic diagnoses have become more common following widespread deployment of sophisticated medical imaging technologies, 25 especially for thyroid 26 , 27 and kidney 28 , 29 cancers. We chose not to exclude any leading cancer site from our summaries because our granular estimates are freely available (eFigures 15-17 in Supplement 1 ).

Our results beg the question of what the cancer experience may be like among the 72 million Millennials (1981-1996) when they enter their 40s, 50s, and 60s. On one hand, our analysis shows that the proxy parents of the Millennials are experiencing as much or more cancer than the proxy parents of Generation X ( Figure 5 F). This increase is concerning because of shared cancer-predisposing lifestyle factors and exposures. On the other hand, thanks to the global investment in cancer research, there are tremendous opportunities to prospectively reduce the Millennials’ future cancer burden.

The American Cancer Society, 30 Centers for Disease Control and Prevention, 31 and World Health Organization 13 advocate a series of preventive actions to diminish cancer risks. These include reducing tobacco and alcohol use, increasing physical activity, improving dietary habits, and promoting breastfeeding. These recommendations can also reduce heart disease 32 and cognitive decline. 33

Unfortunately, universal implementation of these recommendations in the US is a work in progress. The Black-to-White cancer mortality gap narrowed following passage of the Patient Protection and Affordable Care Act. 34 , 35 However, income inequality, 36 underinsurance, 37 - 39 food swamps and deserts, 40 , 41 deficits in the built environment, 42 and other factors make it difficult for everyone to eat healthy and stay active. 30 Taken together, these findings indicate that for many people in the US, a healthy lifestyle remains, to various degrees, an unattainable privilege rather than a fundamental right. The extent to which lifestyle disparities explain rising generational cancer rates in our data and falling life expectancies in other studies 43 is unclear and, in our view, merits further study.

Our study has 2 major limitations. First, the numbers of less common cancers in the SEER 13-registry database among Asian or Pacific Islander, Hispanic, and non-Hispanic Black men and women are limited, especially for esophageal and gallbladder cancers and melanoma. Second, our conclusions derive from modeling. Even so, we believe that our detailed analysis of 3.8 million individuals with invasive cancers in 152 distinct strata mitigated many potential biases. Furthermore, at most cancer sites, the birth cohort effects were substantial, and the LOF was relatively small. For this reason, we believe that it is appropriate to draw conclusions from our FCP estimates. However, it is important to appreciate that the FCP incorporates backward projection for older cohorts and forward projection for younger cohorts; in other words, it is very much a model-based quantity.

The models in this cohort study suggest that Generation X is experiencing larger per-capita increases in the incidence of leading cancers combined than any prior generation born from 1908 through 1964. In addition, the rate of leading cancers appears to be as high or higher in the proxy parents of the Millennials than the proxy parents of Generation X. Therefore, if the Millennials’ cancer experience follows the estimated trajectory of their proxy parents, cancer incidence in the US could remain unacceptably high for decades to come.

Accepted for Publication: April 8, 2024.

Published: June 10, 2024. doi:10.1001/jamanetworkopen.2024.15731

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Rosenberg PS et al. JAMA Network Open .

Corresponding Author: Philip S. Rosenberg, PhD, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NCI Shady Grove, Room 7E-130, 9609 Medical Center Dr, Bethesda, MD 20892 ( [email protected] ).

Author Contributions: Drs Rosenberg and Miranda-Filho had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: Miranda-Filho.

Supervision: Rosenberg.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics, National Cancer Institute (Drs Rosenberg and Miranda-Filho) and through an appointment to the National Cancer Institute Oak Ridge Institute for Science and Education Research Participation Program under contract DE-SC0014554 from the Department of Energy (Dr Miranda-Filho).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation of the manuscript. The Division of Cancer Epidemiology and Genetics, National Cancer Institute, reviewed and approved the manuscript and approved the decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Ultra-processed plant-based food has been linked to heart disease and early death — but a simple swap could boost your health

• Plant-based diets have been linked to lower blood pressure and slower aging. 
• But the plant-based ultra-processed food category is growing. 
• Plant-based UPFs increased the risk of heart disease, while whole foods lowered it, in a new study.

Eating a plant-based diet is associated with a lower risk of heart problems and a longer life.

But plant-based foods that are ultra-processed, like vegan nuggets or potato chips, can increase the risk of cardiovascular disease and early death, according to a new study .

There is a simple swap, however, that could boost your health.

People who switch out plant-based processed foods with whole foods, such as fruits and vegetables, have been found to have lower blood pressure and a reduced risk of diabetes . They may also age slower .

In recent years, highly-processed plant-based meat alternatives have become popular. In 2023, the plant-based market was worth $8.1 billion, according to the Good Food Institute.

Ultra-processed foods (UFPs) make up around 73% of the US food supply, according to a 2024 research paper by Northeastern University's Network Science Institute, which hasn't been peer-reviewed. Eating a diet high in UPFs has been linked to health conditions, including cancer, type 2 diabetes, and obesity.

To understand the impact that eating plant-based products and UPFs had on cardiovascular risk, researchers analyzed data from a UK Biobank longitudinal study.

Related stories

They looked at data from more than 118,000 people between the ages of 40 and 69 who answered questions about their diet. This information was later linked to hospital and mortality records to monitor cardiovascular risk factors.

The study, published Monday in The Lancet Regional Health Europe, found that plant-based UPF consumption was associated with a 5% increased risk of cardiovascular disease and a 12% higher risk of early death.

However, replacing plant-based UPFs with non-UPF plant-based foods was associated with a 7% lower risk of cardiovascular disease and 15% lower risk of dying from cardiovascular disease, the study said.

In light of their findings, the authors recommended that dietary guidelines should emphasize not only limiting meat and animal products, but also the need to avoid UPFs in general.

"A higher intake of plant-sourced foods may only bring about better cardiovascular health outcomes when largely based on minimally processed foods while a higher intake of plant-sourced UPF may have detrimental effects on health," the study said.

Baked goods, snacks, and soda made up the majority of plant-based UPFs

Although meat alternatives were included, processed baked goods were the main foods considered plant-based UPFs, Duane Mellor, dietitian and spokesperson for the British Dietetic Association and Honorary Academic Fellow at Aston University, said.

These included packaged bread, pastries, cake, cookies, potato chips, and sugar-sweetened beverages,

Fake meat made up 0.5% of all ultra-processed foods consumed by participants in the study.

"It is important to emphasize that just because a food or drink is technically plant-based, it does not mean it is healthy," he said.

Tom Sanders, Professor emeritus of Nutrition and Dietetics, King's College London, said: "As a nutritionist, I find the term "plant-based ultra-processed food" confusing and not helpful in formulating dietary advice to the public." Cake, soda, and cookies are unhealthy whether they're made industrially or at home, he added.

Watch: How to spot ultra-processed foods we mistake for healthy

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Indonesian university boosts Asia’s public health programmes through research training

Growing up in Bangladesh where several infectious diseases transmitted by helminths (worms) take a large health toll, Tilak Chandra Nath has always been fascinated with the challenges of addressing diseases of poverty.

After graduating as a biologist, Ezra Valido’s interest in infectious diseases took him to work in a rural, poor community in the eastern Philippines, where he headed public health programmes on tuberculosis, measles, dengue and chikungunya.

Valido’s community was devastated in 2013 by Typhoon Haiyan, one of the most powerful tropical cyclones ever recorded. From that, he gained experience working in the aftermath of a disaster, including how to prevent waterborne diseases and sanitation-related illnesses.

As a TDR-supported fellow, also at UGM in 2017, Valido’s research project focused on how willing people were to take doses of the dengue vaccine in poor communities in the Philippines’ Quezon City. His initial plan was to focus on how the vaccines were rolled out. But this had to be shelved after community and media outrage based on misinformation about the vaccine led the government to cancel its vaccination plans.

TDR’s postgraduate training programme on implementation research

Both Nath and Valido were part of a special postgraduate training programme focused on implementation research, based at UGM’s Faculty of Medicine, Public Health and Nursing, located in Yogyakarta. 

The programme, involving students from both WHO’s South-East Asia and Western Pacific Regions, is supported by TDR, a global programme for research on diseases of poverty ,   hosted by the World Health Organization (WHO) in Geneva, and co-sponsored by the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), WHO and the World Bank.

UGM is part of TDR’s global postgraduate training scheme network , developed over the past eight years to boost the skills of future research leaders.  

The initiative focuses on building students’ skills in implementation research, a fast-growing field that supports the identification of system bottlenecks to delivering health services and approaches to addressing them. It is particularly useful in low- and middle–income countries where many health interventions do not reach those who need them the most.

One of the two partner institutions in Asia Pacific is UGM, where the initiative is co-ordinated by Professor Yodi Mahendradhata, Dean of Research and Development at the Faculty of Medicine, Public Health and Nursing. 

Involved from the start

Mahendradhata is proud of the fact that UGM was involved from the start - back in 2015 – in  TDR’s fellowship scheme as well as in the parallel development of course content for implementation research. So he feels considerable ownership over how it has evolved.

“It wasn’t just about receiving the tools and the toolkits, but being involved very early on in the development of the implementation research course, and that is what we particularly appreciate from TDR,” said Mahendradhata. “We learned a lot from participating in the development process, and that gives us a sense of ownership.”

His university has also developed and piloted lessons on implementation research as a part of a TDR-supported Massive Open Online Course (MOOC) , enabling researchers in places like Nepal and Myanmar to participate in virtual training, with UGM as the hub.

Critical and relevant

Valido is sanguine about how he had to shift the focus of his research on a new dengue vaccine from examining the standard parameters of mass rollout to focusing on the vaccine’s  acceptability in one city, Quezon, the biggest city in the Philippines.

Sanofi Pasteur’s Dengvaxia vaccine was approved in the Philippines in December 2015 , and the government started to roll it out to primary school children in 2016. However, in late 2017, Sanofi issued a statement reporting that, in rare cases, the vaccine could increase the risk of severe dengue illness in children who had never had the disease if they contracted the virus after being vaccinated. A public outcry followed , and the health department suspended the vaccine programme soon afterwards.

“While we were conducting the research, an update on the vaccine information caused a media frenzy which eventually led to its suspension and eventual cancellation,” he says. “We had to change the research and eventually looked at the change in the acceptability of the vaccine pre- and post-controversy.”

“The programme teaches you to be critical and relevant, and I had to change my research to remain relevant,” Valido says.“At the time, the Philippines was the only country implementing mass dengue vaccination in schools.”

Dengvaxia has since been approved in a number of countries, including the US – but only for people clinically proven to have had dengue in the past.

Valido enjoyed the opportunity to dissect the Filippino government’s plans for the vaccine’s implementation, focusing on “strategic actions, context and health system thinking.” 

New insights into managing parasitic diseases

Meanwhile, Nath’s research into parasitic diseases gave him new insights into how they can be both managed and prevented.

“In developed countries, most parasitic diseases have been either eradicated or controlled, but the scenario is quite different in lower-income countries, where many diseases remain a serious constraint to public health safety,” says Nath.

“Through the TDR training programme,” he says, “I learned to investigate the problems in preventing these diseases in greater detail and pave the way to find an implementable solution for policy-makers to mitigate the burden.”

Preparing for the future

Following his studies at UGM, Nath continued his research training, completing a PhD in Medicine from the Chungbuk National University, in Korea, in the area of One Health.  He is now an Associate Professor in the Department of Parasitology at Sylhet Agricultural University in Bangladesh.

 In a sense he has come full-circle - bringing knowledge amassed through years of study abroad back to his home country to ponder issues that he wondered about since his youth.  

“I am now actively engaged with helminthiasis elimination and biobanking of parasites projects,” says Nath, who is currently also the director of Bangladesh’s Parasite Resource Bank, where he is investigating the interactions between human, animal, and environmental parasites, following the One Health approach. 

Meanwhile, Valido is working on the biomedical aspects of infectious diseases as a post-doctoral researcher at Swiss Paraplegic Research, where he is exploring the interaction of microbiomes and the spinal cord. He started this work while completing his PhD in Health Sciences at the University of Lucerne in Switzerland. 

Few scientists understand the biomedical aspects of infectious diseases and “the complexity of public health designs to improve health programmes, guide health policies and identify key health infrastructure,” Valido observes. The TDR training helped him to build that interdisciplinary skill set.

This is the first article in a series on TDR’s research capacity strengthening programme - building skills of public health researchers, implementers, health practitioners and policy-makers in the fast-developing field of implementation research for improving uptake of effective health interventions.

TDR’s postgraduate training scheme

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• v.6(Suppl 1); 2015 Aug

Water and sanitation hygiene knowledge, attitude, and practices among household members living in rural setting of India

Anjana kuberan.

1 Final Year MBBS Student, Saveetha Young Medical Researchers Group, Faculty of Medicine, Saveetha Medical College and Hospital, Saveetha University, Saveetha Nagar, Chennai, Tamil Nadu, India

2 Student, Operations Research in Population Health, Foundation of Healthcare Technologies Society, New Delhi, India

Awnish Kumar Singh

3 Department of Public Health, Foundation of Healthcare Technologies Society, New Delhi, India

Jyoti Bala Kasav

Satish prasad, krishna mohan surapaneni.

4 Department of Biochemistry, Saveetha Medical College & Hospital, Faculty of Medicine, Saveetha University, Saveetha Nagar, Chennai, Tamil Nadu, India

5 Research Affiliate, Foundation of Healthcare Technologies Society, New Delhi, India

Vandana Upadhyay

Ashish joshi.

6 Department of Public Health, CUNY School of Public Health, New York, USA

Background:

Rural population in developing countries face water, sanitation, and hygiene-related health issues. To objectively highlight these issues, we studied the knowledge, attitude, and practices-related to drinking water and sanitation facilities among the rural population of Chennai, India.

Materials and Methods:

A cross-sectional study was designed involving individuals over 18 years of age living in Thandalam village, Chennai, India. Basic information about sociodemographic profile and existing drinking water and sanitation related knowledge, attitude, and practices was collected using a modified version of previously validated questionnaire and analyzed.

Forty-five percent of the participants were not following any methods of water treatment and among them half of the participants felt that water available to them was clean and did not require any additional treatment. Twenty-five percent of the participants surveyed did not have access to toilets inside their household.

Conclusion:

There is a need for intervention to educate individuals about drinking water treatment methods, sanitation, and hand washing practices.

INTRODUCTION

The effects of poor sanitation seep into every aspect of life — health, nutrition, development, economy, dignity and empowerment.[ 1 ] With a little less than a year left to achieve the millennium development goals, 2.5 billion people are still devoid of improved sanitation facility.[ 2 , 3 ] The sanitation target 7C (target 7C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation) to reach 75% of global coverage by 2015 from the present 63% is likely to be missed.[ 4 ] Globally, water and sanitation hygiene practice are responsible for 90% of diarrhea-related mortality, which is much higher than combined mortality from malaria and HIV/AIDS.[ 5 , 6 , 7 ] Although piped water facility in the rural regions almost doubled in past two decades, there are still 171 million people in rural regions who use surface water as the primary source of water.[ 8 ] Despite limited improvement in drinking water facilities in rural regions, the trend of the sanitation is still on a slow track, with 66% of the total rural population not having toilet facilities.[ 9 ]

Limited access to safe drinking water and poor sanitation can lead to under nutrition, water borne diseases, gastro-enteropathy along with diarrhea and dysentery. These problems are predominant among preschool children in the developing countries.[ 10 , 11 ] Although majority of water borne infections could be treated using antibiotics, the persisting burden of water borne infectious disease and increasing antibiotic resistance has created dual pressure on public health professionals, pharmaceutical industry and policy makers. Interventions for reducing the proportion of people with limited access to clean drinking water can lead to significant economic benefits,[ 11 ] which can help in achieving sustainable development.[ 12 ]

Although government agencies are providing the infrastructural support to improve sanitation condition in the developing countries, nevertheless there is a need for collateral personal hygiene and sanitary education to achieve improved outcomes.[ 2 , 3 , 13 ]

Many communicable diseases can be effectively managed by improving the sanitation, hygiene and water usage practices.[ 14 , 15 , 16 , 17 , 18 ] However, infrastructure development and policies alone are adequate to fill the existing gap of knowledge and practice of drinking water and sanitation. Nevertheless for effective reduction of effects from poor water and sanitation practices there is a need for understanding the present scenario and the affect of currently existing interventions in the rural settings. Hence, the objective of this study was to understand the knowledge, attitude, and practices related to drinking water and sanitation facilities among the rural population of Chennai, India.

MATERIALS AND METHODS

A cross-sectional study was designed during September 2013 in the rural setting, Chennai, India. Thandalam village, Chennai, India was selected as study site. 100 households were selected randomly and one member from each household was enrolled as participant. Efforts were made to contact head of the family and in case of his unavailability next immediate available resident was contacted for the interview. The participants had to be over 18 years of age and residing in rural areas. Participants were informed about the study objectives and those eligible and giving a written informed consent were enrolled in this study. Individuals who were mentally or physically challenged were excluded from participating in the study. The study protocol was approved by the Institutional Review Board (IRB) of the Foundation of Healthcare Technologies Society (FHTS), New Delhi (IRB#FHTS/006/2013). Confidentiality of all the participants was maintained by assigning unique code to each of the participants.

Data collection tools

A modified questionnaire was prepared from the existing validated tools. It consisted of following content.

Sociodemographic characteristics

Information was gathered about age (years), gender, educational status (no formal education, primary [1-5 th grade], middle [6-8 th grade], high school [9-10 th grade], intermediate [11-12 th ] or equivalent, graduate or postgraduate), marital status (single/married/divorce or separated/widow), annual household income, type of family (joint, nuclear, broken, extended), number of family members, and occupation status (professional, semi-profession, clerical, shop owner, farmer, skilled worker, semi-skilled worker, unskilled, unemployed).[ 19 ]

Water facility and related issues

Information was gathered about the various sources of drinking water, individuals that were responsible for fetching water in household, periods of water shortage, distance of water source from household, water supply timings and water storage practices.

Water treatment and storage practices

Information was gathered about participant's attitudes toward water treatment practices. Water safety, effects of unsafe drinking water on health, and the practices that were adopted to make water safe to drink related topics were included.

Sanitation and related health issues

Information was gathered about toilet facilities, hand washing, waste disposal facilities and quantity of water being used in the house for various purposes (drinking, cooking, and ablutions, washing clothes, house cleaning, and miscellaneous). Additional information was sought regarding any diarrheal episode has occurred in the family in past 3 months.

Additional information was gathered through open-ended questions about challenges faced by the participants to fetch water, their satisfaction toward existing water and sanitation facilities.

Statistical analysis

Descriptive analysis was performed using univariate statistics to report means and standard deviations (SDs) for the continuous variables and frequency distribution for the categorical variables. All analysis was performed using SPSS version 16 (SPSS Inc., Chicago, USA).

The average age of participants was 39 years (SD = 9.7), Majority of them were females (71%), 74% of them were married and 68% of them were living in nuclear families with average family size of 4 (SD = 2). Thirty-six percent of the participants had intermediate (12 th grade) or above level of education. Half of the participants were unemployed with average annual household income of Indian National Rupee 89,175 (SD = 13,179) [ Table 1 ]. The major sources of water procurement were public tap/stand pipe (42%) and tube well/borehole (37%). Sixteen percent of the participants were dependent on private water supply. Figure 1 presents the source of water utilized for different activities. Daily consumption of water for various activities varied considerably [ Figure 2 ]. Ninety-five percent of the participant's fetched water within premises and majority of them (81%) required <5 min for fetching water from the water outlet. Majority of the participants (85%) fetching water were women in the age group of 15-60 years. Majority of the participants (98%) reported meeting the daily need of water quantity. Nineteen percent of the participants reported water shortage twice in a year with average shortage period of 2-3 days (25%). Seventeen percent of the participants indicated July-September as water shortage months while 14% suggested April-June. Half of the participants (53%) reported morning and evening supply of water with uncleanliness (26%) as one of the predominant problem [ Table 2 ].

Sociodemographic characteristics of the participants

Source of water used for different daily activities by individuals living in Thandalam village of Chennai, India

Quantity of water (L) required for various activities by individuals living in Thandalam village of Chennai, India

Existing water facilities and associated issues in Thandalam village of Chennai, India as reported by the participants

Majority of the participants (95%) perceived that the quality of water being used was safe, 71% of the participants agreed that quality of water can affect health status, 75% of them stored drinking water in wide mouth closed container and most of them cleaned water container daily (70%). Forty-five percent of the participants were not following any methods of water treatment and among them half of the participants felt that water was already clean and did not require any additional treatment. Half of the participants (51%) agreed that unsafe drinking water can cause general fever, whereas 22%, 18%, and 16% of the participants reported common cold, diarrhea, and vomiting respectively as potential consequence of drinking unsafe water. Water supply timing was the biggest challenge faced by the majority (94%) of the participants [ Table 3 ]. Twenty-five percent of the participants did not have access to toilets inside the households. Seventy-nine percent of the participants had access to septic tank type of toilets. The majority of the participants agreed that hand should be washed before and after meals, while only 32% felt that hand should be washed after defecation. Results showed that 17% of the participants used plain water or water with ash to clean their hands while majority of the participants washed their hands to prevent infection (82%) or for hygiene maintenance (76%). Forty-seven percent of the participants reported that they discharge their waste in open drainage [ Table 4 ]. Sixty-two percent of the participants desired for filter water and 38% of them desired for boiled and safe water facilities from the suppliers. Most of them had reported improper sanitary facilities and stressed on the need of sanitary education [ Table 5 ].

Perceptions and practices-related to drinking water storage and safety among the study participants

Existing sanitation facilities and related practices followed by the participants

Challenges and suggestions for water, sanitation and hygiene

Water is one of the precious natural resource and is essential element of our life. Clean water and optimum sanitation facilities can prevent the occurrence of various infectious diseases and help in curbing the associated morbidity and mortality. The current study was conducted in rural setting of India to understand the existing water and sanitation facilities, perceptions and practices. Majority of the participants used public tap/stand pipe for water procurement and most of them had water supply inside their household premises. Females of age between 15 and 60 years were the primary responsible person for fetching water, which is consistent with previous report.[ 20 ] Most of the participants were consuming 151-200 L of water daily for cleaning and washing and ≤100 L of water for drinking, cooking and ablutions. Most of the participants reported that their daily needs of water quantity were met by the current supply.

About one in five of the participants reported water shortage twice in a year with average shortage period of 2-3 days. A previous study on water quality of groundwater resources showed that the water quality index of bore well, dug well and hand pump declined in postmonsoon season[ 21 ] which may account for water shortage. In addition, impurity in supplied water was one of the predominant problems, reported by one-fourth of the participants while the majority of the participants felt that the quality of water being used was safe. Majority of the participants were aware of the effects on health due to quality of water and half of them agreed that the consumption of unsafe drinking water may lead to one or more infectious diseases. Despite the knowledge 45% of the participants were not following any methods of water treatment and among them half of the participants felt that water is already clean, hence no further treatment was necessary.

One-fourth of the total participants were devoid of toilets facilities inside their households; leaving them with the options of using community toilets, open defecation or sharing the toilets with other households which in turn promotes the increase in incidence of water-borne disease. Although, the majority of the participants knew and reported hand washing before and after meals only one in three participants felt that hand should be washed after defecation. It was also observed that few of the participants used plain water for hand washing after defecation. This is again consistent with the previous report.[ 22 ] This kind of practice may give rise to diseases of the feco-oral route and increase the financial burden in terms of hospital admissions and associated medical expenses. School attendance of children would be affected as their role changes from studying to care provider for an elderly sick person in the family; in addition to children falling ill due to similar hand washing practices.

On assessing the need of water, sanitation, and hygiene; most of the participants desired for filter water and 38% of them desired for boiled and safe water facilities form the suppliers. Most of the participants stressed on the need of sanitary education. Nevertheless, there are some limitations associated with our study. First it included smaller sample size and the study design was cross-sectional. Further the study was limited to one geographical location; hence, the results of the study should not be generalized. However, our study does identify the need for intervention program to educate the population regarding sanitation, water treatment methods, and hand washing practices. There is also a need for developing cost effective water testing devices to record seasonal variations in water quality in rural areas.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgment

We would like to thank all our study participants for giving their valuable time out of their busy schedules to participate in the study and provided valuable information.