Travis Yates Short-term WASH interventions in Jelena Allen Myriam Leandre Joseph emergency response Daniele Lantagne A systematic review February 2017 Systematic Water and sanitation Review 33 About 3ie The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, for whom, why and at what cost. We believe that better and policy- relevant evidence will help make development more effective and improve people’s lives. 3ie systematic reviews 3ie systematic reviews appraise and synthesise the available high-quality evidence on the effectiveness of social and economic development interventions in low- and middle-income countries. These reviews follow scientifically recognised review methods, and are peer-reviewed and quality assured according to internationally accepted standards. 3ie is providing leadership in demonstrating rigorous and innovative review methodologies, such as using theory-based approaches suited to inform policy and programming in the dynamic contexts and challenges of low- and middle-income countries. About this review Short-term WASH interventions in emergency response: a systematic review, was submitted in partial fulfilment of the requirements of grant SR7.1077 awarded under Systematic Review Window 7. This review is available on the 3ie website. 3ie is publishing this technical report as received from the authors; it has been formatted to 3ie style. 3ie will also publish a summary report of this review, designed for use by decision-makers, which is forthcoming. All content is the sole responsibility of the authors and does not represent the opinions of 3ie, its donors or its board of commissioners. Any errors are also the sole responsibility of the authors. Comments or queries should be directed to the corresponding author, Travis Yates, [email protected] Funding for this systematic review was provided by 3ie’s donors, which include UK aid, the Bill & Melinda Gates Foundation, Hewlett Foundation and 16 other 3ie members that provide institutional support. Suggested citation: Yates, T, Allen, J, Joseph, ML and Lantagne, D, 2017. Short- term WASH interventions in emergency response: a systematic review. 3ie Systematic Review 33. London: International Initiative for Impact Evaluation (3ie). 3ie systematic review executive editors: Edoardo Masset and Beryl Leach Production manager: Angel Kharya Assistant production manager: Akarsh Gupta Cover design: John F McGill © International Initiative for Impact Evaluation (3ie), 2017 Short-term WASH interventions in emergency response: a systematic review Travis Yates Tufts University Jelena Allen Consultant Myriam Leandre Joseph Consultant Daniele Lantagne Tufts University 3ie Systematic Review 33 February 2017 Summary Background Water, sanitation, and hygiene (WASH) interventions are needed in nearly all emergency contexts. From natural disasters to conflict zones and disease outbreaks, the aim of emergency WASH interventions is to reduce the risk of disease by providing safe water, reducing open defecation and promoting hygiene practices. There are increasing numbers of people affected by natural disasters and currently there are a record number of displaced persons in need. Despite regular use, emergency WASH strategies have a limited evidence-base. Delivering assistance is generally prioritized over research, which traditionally has led to ‘best practice’ rather than ‘evidence-based’ programming. Additionally, emergency WASH interventions are often adapted from development settings that may not be appropriate for the timeframe, scale and approach needed in emergency settings. An improved understanding of the efficacy and effectiveness of emergency WASH interventions is necessary to meet the increasing needs of populations impacted by emergencies. Objectives The objective of this review was to assess the outcomes and impacts of short-term emergency WASH interventions in low and middle-income countries (LMIC) through a systematic review process. Specific goals were to address five knowledge gaps in emergency WASH interventions: 1. What are the effects on use of service? 2. What are the effects on health-related outcomes? 3. What are the non-health related outcomes (i.e. psycho-social, quality of life, behaviour change)? 4. What are the programmatic barriers or facilitators to implementation? 5. What is the cost-effectiveness? Methods A systematic review process was used to capture the available research in the emergency WASH sector from published and unpublished ‘grey’ literature. Published literature was searched with keyword strings in nine peer-reviewed databases. Grey literature, mostly held by non-governmental organizations that respond to WASH emergencies, was collected though website searching and direct solicitation. The scope of the review included populations affected by an emergency in a low or middle-income country and published between 1995-2016. Both quantitative and qualitative studies were eligible for inclusion. Studies were filtered independently by two reviewers by title, then abstract and full text. Biases were assessed and information was coded and double-screened for accuracy. i Results were grouped by intervention and summarized based on reported outcomes originating from different data sources through narrative synthesis. Themes common to each intervention were assessed and summarized within the scope of use, health and non-health factors from all three data sources. Evidence was assessed and summarized to appreciate bias, effect size, and consistency among additional factors. Results Through searching and solicitation, 15,026 documents were identified. In total, 106 studies with 114 unique evaluations were included in the review. Within the scope of WASH, 13 specific interventions were identified, including water source treatments, household water treatment, sanitation, hygiene promotion and environmental hygiene. Twelve of these interventions were found to be theoretically able to improve WASH conditions and reduce the risk of disease transmission. Outcomes varied by intervention and evaluation method; thus direct comparison between intervention and meta-analysis was not carried out. A summary of findings for each intervention is described in Table 1. Table 1: Summary of findings by intervention Intervention Summary of findings Saltwater Intrusion Evidence suggests that well pumping after a saltwater Cleaning intrusion was NOT effective. Seasonal rains reduce salinity naturally and faster than pumping. Well Disinfection Pot chlorination with pressed chlorine tablets can maintain free chlorine residual (FCR) for 3-4 days in a well; pot chlorination with powdered chlorine also had some success. (Inconsistent evaluation methods) Source Treatment – Bulk Water Treatment – Well-established treatment Large Scale methods (not evaluated) requires well-trained staff and regular monitoring. Water Trucking – A common activity in acute emergencies. FCR and microbiological contamination were inconsistent with limited evaluations. Source – Treatment Variation in reported, confirmed and effective use – Small-Scale context specific. (3 case studies). Speaking with Promoter and easy access to Dispenser associated with increased use. Household Water Reported use range: 1-84%, n=9. Confirmed use range: 1- Treatment – Chlorine 87%; n=11. Chlorine taste/smell, ease-of-use and Tablets familiarity influence use and acceptance. Household Water Reported use ranged: 6-88%; n=6. Confirmed use ranged: Treatment (HWT) – 1-69%; n=6. Familiarity of liquid chlorine was beneficial; Liquid Chlorine flexibility to be scaled-up from development projects. ii HWT – Flocculant/ Reported use ranged: 6-83%, n=3. Confirmed use ranged: Disinfectants 4-95%, n=6. Taste and ease of use varied, consistently preferred over other HWT options. HWT – Filtration Acute use (<3 months since emergency) ranged: 53- 100%, n=3, Sustained use (≥3 months since emergency) ranged: 0-96%, n=7, although effective use was lower. Improved taste consistent among populations. HWT – Other Limited evaluations and impact. Not widely used in acute emergency response, ease of use and community acceptance reported. Sanitation – Output- Positive health aspects. Driven Latrines: Targeting vulnerable populations increased use. Latrine alternatives: Reported use averaged: 59% (range: 8-91%); interventions promoting use in the home had higher rates of use. Ease of access, cleanliness and privacy are important non-health considerations. Hygiene Promotion Descriptions and documentation of disease or disease risk reductions. Personal communication and radio are preferred and trusted by the community. Community trust and ownership important factors. Hygiene Kits Reported use of contents is high. Quantity of materials and timeliness of distribution are key factors. Environmental Unclear reduction in disease transmission risk, yet high Hygiene community expectations of effectiveness. Chlorine concentration monitoring is necessary. WASH Package Anecdotal descriptions of disease reductions, behavior adjustments and psychosocial support; staffing and timing also important factors. State of evidence Interventions from 39 different countries were included, with Haiti as the most evaluated (22). Grey literature represented 50% of the included studies (57/114). The majority of studies (77%) had a high risk of bias. Interventions