Final Research for Master's Degree Assignment Sample

Introduction :The Impact of Limited Access to Clean Water and Sanitation Facilities on Public Health in Ethiopia: Challenges and Interventions

Sustainable Development Goal: Goal 6: Clean Water and Sanitation

Name of Low-income country:  Ethiopia

 Specific Area of Public Health Practice:  Access to Clean Water and Sanitation Facilities

The purpose of this research work is to evaluate the impact of limited access to clean water and sanitation facilities on public health in Ethiopia. Ethiopia is the second most populous country in Africa and is now recognised for robust economies, with an estimated financial growth of 6.4 per cent in FY of 2021/22 (The World Bank Group, 2023). According to data from the World Bank, approximately 60 million people in Ethiopia can now get easy access to basic drinking water, and the practice of open defecation has declined among the people to a considerable extent. However, despite this improvement, clean and safe drinking water is inaccessible to 60 million Ethiopians. This proportion accounts for 7 per cent of the global water crisis, Additionally, approximately 112 million Ethiopians are without access to basic sanitation facilities, where 22 million individuals are continuing open defecation (UNICEF, 2023).

A study supported by the Global Water Security and Sanitation Partnership (GWSP) indicated that lack of access to clean water and proper sanitation in Ethiopia correlate with a high prevalence rate of communicable diseases (60%) in the country (The World Bank Group, 2023). Therefore, in Ethiopia, water contamination remains a critical public health challenge, which is exacerbated by insufficient sanitation, and infrastructure, and it leads to the spread of diseases like diarrhoea and cholera. As per SDH or social Determinants of Health Theory, health outcomes are not just a result of individual choices or biological factors, rather it is shaped by social, economic, and environmental conditions (Woldemariam Merid et al. 2023). Considering the research topic and core concept of SDH theory, it can be stated that access to clean water and sanitation are an important determinant of health, as limited access to both components can lead to health inequalities, particularly in rural, and impoverished areas of Ethiopia.

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According to research by WHO (2019) the lack of proper sanitation facilities, and access to clean drinking water at schools contribute to a high rate of absenteeism and a reduced rate of educational opportunities for the children in Ethiopia. Additionally; more recent World Health Organization (2022) research has shown that, waterborne diseases are considered as the leading cause of morbidity and mortality among Ethiopian children under five years old. .

 . The issue related to adequate WASH is considered as a regional problem in many countries across the world, and it is most severe in low-to-middle-income countries like Ethiopia. the provision of water, sanitation and hygiene (WASH) facilities or framework plays an important role in reducing healthcare-acquired infection or HCAI Tilahun et al. (2020), UNICEF, reported that the extensive population growth and rapid urbanisation rate are now becoming a serious burden on the country’s water and sanitation facilities- “7” per cent of Ethiopians can have access to at least basic sanitation services (4 per cent in rural areas, and 20 per cent in urban areas) (UNICEF, 2023). On the other hand, poor health and hygiene practices, and a lack of knowledge about sanitation contribute to an increase in the rate of faecal contamination in the environment, which is considered as a major contributor to child mortality rate, illness, undernutrition, and stunting. In Ethiopia, approximately 60-80 per cent of health problems are positively associated with communicable diseases caused by unsafe water supply, unsanitary waste product disposal in open environments, and unhygienic environment Addressing Ethiopia's inadequate access to clean water and sanitation systems is important to improve public health. It needs targeted interventions, development of infrastructure, implementation of behaviour change and awareness programs in broader society, and policy set-up to ensure easy access to clean drinking water and appropriate sanitation facilities by every individual in the country (Woldemariam Merid et al. 2023). In such a scenario, the government has to take the initiative by setting up and implementing policy and regulative standards in line with the Sustainable Development Goal (SDG6) which can ensure substantial progress in reducing the burden due to waterborne diseases and improving overall public health Outcomes.

Systematic Literature Review

The purpose of this systematic literature review is to explore the impact of limited access to clean water and adequate sanitation facilities on public health outcomes in Ethiopia. Therefore, the review of this work will focus on the evaluation of health outcomes related to inadequate access to safe and clean water, and sanitation systems across the country. This review will also identify the factors that contribute to the specific problem and potential interventions that can be used at broader perspective to ensure overall improvement of public health outcomes.

Research question

Considering the purpose of this study, the research questions will be:

1. What is the specific impact of limited access to clean water and sanitation systems on public health outcomes in Ethiopia?
2. What interventions can be applied in society to address the issue and ensure effective health outcomes for Ethiopians?

The research question has been developed using the PICO framework (Population-intervention-comparison-outcome). In this review, population refers to the people living in deprived areas of Ethiopia with limited access to clean and safe water, and sanitation facilities. Intervention, in the PICO framework, refers to the effort that has to be taken to improve access to clean water and sanitation facilities. The comparison refers to the current state of limited access to clean water and sanitation facilities outcomes in public health and outcomes refers to the public health outcomes and overall health and well-being against related issues.

Aim and Objectives of the Systematic Literature Review

This systematic literature review aims to analyse and evaluate the existing literature and evidence on the impact of limited access to clean water and sanitation facilities on public health in Ethiopia. Therefore, the objectives of this review will be:

1. To identify the current scenario of sanitation facilities and access to clean water systems for communes in Ethiopia.
2. To evaluate the public health outcomes related to poor hygiene and sanitation facilities and limited access to clean water in Ethiopia.
3. To explore the factors that contribute to the identified issues in the country.
4. To identify and assess the effectiveness of intervention in improving the public health outcome by improving access to clean water and sanitation facilities.
5. To provide recommendations for regulative policies, programs, and interventions to address the identified public health issues.

In this research, the qualitative method will be carried out to develop a better understanding of the public health impact related to the identified issues and understand the effective public health implications to improve health outcomes and access to clean water and adequate sanitation service facilities.

Methodology

The purpose of this research work is to identify the impact of limited access to clean water and poor sanitation systems on public health in Ethiopia. To meet the aim and objectives of this research, a secondary qualitative study design has to be chosen. The justification for choosing a secondary qualitative research method for this proposed work can be linked to the idea that the chosen research method can allow the researcher to examine the existing studies, reports, and data related to the identified topic. This method can also provide a broad understanding of the issue by analysing diverse perspectives, uncovering the trends and identifying the key factors related to the previous research (Torres-Carrión et al. 2018). Additionally, this method can enable the researcher to contextualise the findings within Ethiopia's unique socio-economic, political and environmental conditions to evaluate the current status and impact of limited access to clean water and poor sanitation system on public health.

The search of the existing literature review for this proposed work will be based on the identified Sustainable Development Goal (SDG-6), in relevance to the public health scenario of low-income country Ethiopia and on specific areas of public health practice related to drinking water, sanitation system, and hygiene (WASH) (UNICEF, 2019). Therefore, the searched literature review will be based on the nature and scale of the WASH issue in Ethiopia, its impact on public health, and the gaps that need to be addressed to improve the overall scenario for ensuring public health outcomes. For this proposed work, a qualitative method or review of existing literatures has been selected as the data analysis method. According to Lame, (2019),this data analysis method offers a rigorous and structured approach to synthesise the existing articles, reviews, and literature on topics like ‘impact of limited access to clean water and poor sanitation system on public health in Ethiopia’. This method can also ensure a comprehensive evaluation by identifying, appraising, and analysing the relevant studies, minimising the bias, and providing a clear evidence-based understanding of the issue. Through the comprehensive analysis of literature, gaps in knowledge can also be identified, along with consistent patterns in findings which can lead to more reliable and comprehensive conclusions and recommendations for improving the water access and sanitation system. 

To carry out the search, online databases like PubMed, Web of Science, and Embase have been used along with the relevant grey literature sources (websites) like WHO, and NGO’s reports. To ensure the relevance of the literature for this proposed research work, a keyword search strategy has been used, which includes the combination of keywords and the use of vocabulary terms related to the research questions. Apart from keyword search, boolean operators (AND, OR) were also used to identify the keywords and find out the most relevant resources from online data sources to evaluate the impact of limited access to clean water and sanitation facilities in Ethiopia.

Based on the objectives, the keywords for the literature search will be:

1. Objective 1: “Sanitation”, “ Clean Water”, “Ethiopia”
2. Objective 2: “ Public health”, “ Outcome”, “ Poor Hygiene”, “Sanitation Facility”, “limited access”, “Clean Water”
3. Objective 3: “Contributing Factors”, “ Clean Water”, “Limited Access”, “Poor”, “ Sanitation”, “ Ethiopia”
4. Objective 4: “Intervention”, “Effectiveness”, “Improve”, “Public Health”
5. Objective 5: “Recommendation”, “Regulative Polices: “Intervention”, “Public Health”, “Issue”

Boolean search strategies for the objectives will be:

Table 1: Boolean Search

During the screening process, inclusion and exclusion criteria have been applied.

Table 2: Inclusion and Exclusion Criteria:

In this research, critical Appraisal Skills Programme (CASP) tool has been used to evaluate the qualitative studies. The narrative analysis method has been used as a data analysis technique to analyse and synthesise the included studies’ findings. This involved the extraction of relevant information from every selected study, summarising the key findings and identifying the common theme or patterns across the literature. For this proposed research, six existing literatures (sample size) have been collected from online database and the search has been carried out by using a PRISMA flow diagram.

The justification for using the CASP tool for this proposed research is it can help the researcher to systematically evaluate every selected study along with the methodology, data validity and overall relevance of the study with set-up research questions (Long et al. 2020). This can ensure high-quality evidence and lead to a comprehensive conclusion that is relevant to the impact of limited clean water and sanitation systems on public health in Ethiopia. While the justification of the narrative analysis method for the chosen research work is it can allow the researcher to extract key information and interpret the result.

 According to Zeng et al. (2015), thequalitative method is also effective in exploring complex, and contextual issues like public health challenges, the impact of clean water accessibility and proper sanitation facilities on the health and well-being of people in a country like Ethiopia. 

A data extraction table was included in this proposal to record the key information for each study selected by PRISMA flow diagram, and inclusion and exclusion criteria. The table included details of the existing literatures including study authors, publication year, study design, sample size and key findings related to the study topic. The result of the review of literatures has to be presented below through narrative synthesis of studies selected by inclusion criteria. By summarising, and synthesising those findings, narrative analysis can provide a comprehensive understanding of the research area, by leading to a well-informed and comprehensive conclusion along with recommendations for future development and intervention.

For this proposed research method, the ethical consideration that has been followed are as per the Data Protection Act, 2010. It was ensured that the information collected from online data sources are valid and ethical. As per the University Policy, it was also ensured that all literature which provides information for this study have been acknowledged properly, and that information have been used for academic purposes. Privacy and confidentiality have been preserved by anonymising data to prevent identifying participants.

Findings and Discussion

Table 3: Data extraction/Data summary table

(Figure 2: The above table shows the relevant studies selected for this proposal)

(Source: created by author)

 Theme based analysis:

Theme 1: Current scenario of Sanitation facility and access to clean water system for communes in Ethiopia

Ethiopia’s population expansion and t rapid rate of urbanisation have put a huge burden on the country’s water and sanitation facilities despite significant advances. The Unicef.org (2023), report has shown that a basic level of sanitation services is accessible to 7 per cent of the population., whereas 60-80 per cent of the health problems or communicable diseases are due to unsafe water supply, unhygienic waste disposal facilities. Additionally, an estimated 50 per cent of consequences regarding undernutrition are caused due to poor hygiene practices, and lack of access to water supply and sanitation processes. According to the data published in both WHO (2019), and Novotný, and Mamo (2022), diarrhoea is the second leading cause of under-five mortality in Ethiopia, reporting an annual mortality rate of approximately 25,000 children every year. By considering the research of Belay & Andualem, (2022), it can be seen that the current scenario of poor sanitation and limited access to clean water in Ethiopia presents significant challenges. In this study, 16,650 households across Ethiopia have been used as a sample to study the effect of limited access to improved drinking water sources and sanitation systems on health and social outcomes, which represent that more than 40 per cent of the households in the country have the accessibility to very limited improved drinking water facility- the figure is high than the global average of 30 per cent yet lower than Kenya, Zambia, and Rwanda. The data published by WHO, approximates 60 million Ethiopians currently lack access to safe drinking water. Thereby contributing to 7 per cent of the global water crisis. Additionally, over 112 million people are living in the country without access to basic sanitation facilities, with 22 million continue the open defecation practice (The World Bank Group, 2023). Therefore, in Ethiopia., limited access to clean water and contamination of water remain critical health challenges, which are exacerbated by several determinant factors.

Theme 2: Public Health outcome related to poor sanitation facilities and limited access to clean water in Ethiopia

According to the GWSP, insufficient availability of clean water and proper sanitation systems in Ethiopia can be linked to more than 60 per cent of all communicable diseases in the country. Therefore, public health issues like surface water pollution, rapid growth of population, urbanisation and inadequate waste management, compound the problem. According to researchers, poor sanitation facilities and limited access to clean water have significant public health implications, which include an increased prevalence rate of waterborne diseases, along with diarrhoea,-( Diarrhoea increases the risk of undernutrition, and acute respiratory infections; it is among the leading causes of child death in Ethiopia,).

The public health concern of making clean drinking water accessible and available the Ethiopian population is at high stake. Recent research by Alemayehu et al. (2023), showed that , “16.1” per cent of the Ethiopian households have limited access to clean water services which heightened the risks of waterborne diseases like typhoid, cholera, and diarrhoea out breaks. A study by Belay & Andualem (2022), stated that sanitation challenges include reliance on unimproved toilet facilities with increased rate of contamination of water sources. Cross-sectional research in urban areas of Ethiopia like Bishoftu town revealed that many households are lacking of proper infrastructure and facilities for accessing clean water supply and sanitation methods Lack of these basic infrastructure increases the risk of communicable diseases e.g cholera, and gastrointestinal disorders transmission. Derso Mengesha et al. (2023) mentioned that public health risks related to limited access to clean water, and proper sanitation facilities and practice are severe for vulnerable sections within the population like children. Therefore, addressing these challenges is critical to improving the health outcomes in Ethiopia.

Theme 3: Contributing factors to the current drinking water and sanitation system in Ethiopia

Considering the findings of existing literature , it can be stated that there are several factors related to poor clean water accessibility, and sanitation facilities in Ethiopia. For example, many researchers have suggested that inadequate infrastructure, poor maintenance, fast fast-paced urbanisation are the major causes of limited access to clean water and unimproved sanitation systems in Ethiopia. Alemayehu et al. (2023) summarised four major contributing factors to inadequate access to clean water supply. 1. geographic and demographic challenges like nomadic lifestyle in regions like Afar and other cities of Ethiopia hinder the development of permanent water facilities. 2., socioeconomic factors like lower wealth index across the country, specifically in rural areas have less face higher offs to limited access to improved drinking water compared to urban areas.

3. Governmental inefficiencies and inadequate performance of private contractors further can exacerbate the situation, as the quality and sustainability of water products are often compromised. This is indicated through the regional disparities and lack of strategic collaboration between Governmental, local, and state-level agencies to improve water accessibility in Ethiopia.

 On the other hand, Berihun et al. (2022), found that drinking water facilities and sanitation systems in Ethiopia are affected by several factors including quality monitoring and insufficient funding by the Government for WASH services in healthcare and public facilities. Behavioural factors like practising open defecation, misuse of handwashing materials, limited infrastructure of public toilets and the absence of WASH risk assessment plans in governmental facilities exacerbate the sustainable improvement of clean water access facilities and sanitation system in Ethiopia.

Theme 4: Effectiveness of intervention to improve the public health outcome by improving access to clean water and sanitation facilities in Ethiopia

Safe and accessible clean water services can generate beneficial outcomes for public health and the economy. Derso Mengesha et al., (2023), research mentioned that people with LAIDWS are vulnerable to various communicable diseases and other health-related problems. To overcome this issue, both governmental and non-governmental bodies should set out objectives for joint action and address the impact of limited access to clean water and lack of sanitation facilities in Ethiopia. Alemu et al. (2023) study addressed the association between safe water use, sanitation system and hygiene practices and the incidence of childhood diarrhoea and other communicable diseases in Ethiopia. The study states that proper WASH education and Health Extension Program have a positive impact on public health – as it helped the households regarding to increase awareness and change behavioural practices associated with the water treatment practice and use of latrines along with proper hand-washing facility. This study further revealed the positive health impact of WASH education in several regions of Ethiopia by increasing practices such as household latrine ownership, water treatment and safe storage practices.

 A meta-analysis by Wolf et al., (2022) found that WASH intervention and education on improved drinking water practice sanitation and handwashing practices with soap can significantly reduce diarrheal diseases among children in low-to-middle-income countries. In the case of Ethiopia, Alemu et al. (2023) have revealed the positive impact of WASH practice through the health Extension program. Through educational outreach, the program has had a positive impact on the health and well-being of people by promoting better water usage habits and increasing awareness about hygiene practices.

 Findings

Upon analysing the Data Extraction or Data Summary Table, and theme-based analysis, it can be stated that the studies selected by inclusion and exclusion criteria were synthesised and evidence gathered from those studies was analysed by using the thematic analysis method. The critical appraisal was conducted in the data extraction table to assess the strengths and weaknesses of the selected study by focusing on their findings. The data extraction table has provided a comprehensive overview of the probable impact of limited access to clean water and sanitation systems on the health and well-being of the population, of the country Ethiopia. Additionally, the thematic analysis also provided an in-depth idea about the challenges that Ethiopia has faced due to limited access to clean water and sanitation systems, and probable intervention strategies by which those challenges can be suppressed, and the well-being of people can be ensured.

The above findings underscore the importance of addressing the limited accessibility of clean water, and improper sanitation facilities in Ethiopia and its impact on public health within the context of SDG 6.

Considering the findings of the existing literature used in this work for systematic review purposes has significantly addressed the challenges and opportunities for intervention related to the specific issues in Ethiopia (Takele et al. 2019). Considering all the findings, it can be stated that rapid urbanisation, and population growth, limited funding to WASH facilities, limited infrastructure of water supply and latrines in many households restrict the people of Ethiopia from accessing clean water and using proper sanitation facilities (Girma et al. 2024). One of the most pressing public health outcomes associated with these issues is the high prevalence of waterborne diseases, including diarrheal diseases, typhoid, cholera and other communicable disorders (Azage et al. 2018). Every literature used for this study has referred to the fact that vulnerable populations, specifically children in Ethiopia are affected heavily by under-or-malnutrition and other severe health outcomes due to frequent exposure to contaminated water and poor sanitation conditions. In many research, interventions like the Health Extension Program, and WASH education are being identified with which a significant change has been implemented in Ethiopia. As per many research, WASH interventions have significantly reduced the incidence of diarrhoeal diseases, particularly among children (Desye et al. 2022; Derso et al. 2020).

Literature gap:

Upon analysing the above findings, it can be stated that despite the valuable insights towards the subject matter, this research has limitations, due to the availability of limited studies on specific topics linked with SDG for Ethiopia.

Additionally, this research has to explore the effectiveness and feasibility of interventions, considering the country’s unique socio-economic, and cultural scenario, and healthcare-related infrastructure (Kwami et al. 2019). The findings suggest that despite the efforts to achieve SDG-6, ensuring universal access to clean water and sanitation by 2030, progress remains slow in low-to-middle-income countries like Ethiopia (Janus and Karps, 2019). Challenges such as poverty, inadequate infrastructure and governmental funding, and limited resources hinder the efforts and make the target unlikely to be met without significant acceleration (Usman et al. 2016). Additionally, the pursuit of SDG 6 has a profound impact on other sustainable developmental goals, like SDG 3 and SDG 1. The interconnectedness of the SDGs highlights the need for a holistic approach to tackle the underlying determinants of health, such as poverty, inequality, and environmental sustainability (Tilahun et al. 2020). As a whole, considering the topic of research in reference to Ethiopia, it can be stated that achieving SDG 6 will not only improve public health outcomes,

Recommendation

Based on the identified issues and discussion in Ethiopia about sustainable development goal 6, the following recommendations can be suggested:

1. Increase the financial support: The increase in financial support is important including development assistance, innovative financing, and public-private partnerships to address the resource constraints. Additionally, with proper financial support, the health infrastructure of Ethiopia can be improved, through which the people of the country can access essential services, which ensure the public health outcome (Guo et al. 2017).
2. Strengthening the health system: improvement in healthcare infrastructure is essential for Ethiopia to address communicable diseases and diseases caused by contaminated water and the use of poor sanitation practices. A proper health infrastructure can also aware people of the importance of WASH facilities or how to maintain sanitation and hygiene along with the use of clean water (Li et al. 2017).
3. Address the sociocultural barrier: to address the limited accessibility of clean water and improper sanitation systems in different regions of Ethiopia, the address of socio-cultural barrier. It can help the government to address the disparities in different socio-economic regions of Ethiopia, which can further add value to the initiative of reducing the gap and providing equal access to clean water and sanitation facilities to the people regardless of their income, and societal values (Aiemjoy et al. 2017).
4. Multisectoral collaboration: multisectoral collaboration between government, civil society, academics, and private sectors can help in tackling issues like poverty, inequality, and gender disparities. This multisectoral collaboration can also help the government to provide effective healthcare facilities to prevent communicable disease spread among the population of the country by addressing the inadequate access to clean water and a proper sanitation system.

Conclusion

The purpose of this research was to identify the impact of limited access to clean water and improper sanitation systems on public health outcomes in Ethiopia. This objective has been linked to sustainable development goal 6, where it has been mentioned that it is a human right to access clean water and proper sanitation by 2030. However, in this study, different existing literature and studies have been accessed and evaluated thoroughly, which referred to poor infrastructure of water supply, limited access to clean water, and improper sanitation systems by the majority of the household population in Ethiopia. This study also highlighted the public health impact of these issues, where it has been mentioned that diarrheal diseases are now becoming a major cause of childhood mortality death in Ethiopia, along with malnutrition. These conditions are exacerbated due to limited access to clean water, contamination of water, and poor sanitation practice. However, in this study, focus has been given to intervention plans like WASH education and Health extension Programs through which, the government are trying to make people aware of proper sanitation practice water treatment and storage of clean water practice. In this research, several recommendations like improvement of multisectoral collaboration, development of the health infrastructure of Ethiopia, and strengthening the financial stability of this country have been suggested mentioned to improve the addressed challenges and public health outcome.

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Casey Bennett   7 years | PhD

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