Exploring Water,Sanitation,and Hygiene Status and Health Outcomes in Zimbabwe: A Scoping Review of Literature

Abstract

This scoping review aimed to explore the water, sanitation, and hygiene status in Zimbabwe and its influence on health outcomes. A systematic search of the literature published in English with an unrestricted search until 31 May 2024 was performed using predefined search strings with Boolean operators, including PubMed, EBSCO, SAGE, SpringerLink, Cochrane Library, ScienceDirect, Scopus, and Web of Science databases. A total of 655 records were identified, of which 20 peer-reviewed articles and 10 other records met the inclusion criteria. The inter-rater agreement for 20% of the dual screening achieved a κ-value of 0.85, indicating almost perfect agreement. Lack of access to adequate clean water, inadequate WASH infrastructure, and unhygienic conditions and practices are among the primary risk factors for diarrhoeal diseases and their associated outbreaks, as identified in several studies. These factors have been reported to play a significant role in recurrent outbreaks of cholera, typhoid, and diarrhoea in Zimbabwe. The lack of adequate WASH facilities in rural schools significantly impacts the management of menstrual hygiene waste. The review concludes that poor Water, Sanitation and Hygiene (WASH) has led to an array of adverse public health outcomes in Zimbabwe over the decades. Despite the existence of a comprehensive WASH policy framework, weak implementation, inadequate funding, poor governance and community participation, and unreliable WASH data monitoring systems largely contribute to the water and sanitation disease burden. Therefore, this review recommends investing in the Rural Water Information Management System (RWIMS) and other digital platforms to improve monitoring and surveillance. Achieving the desired health outcomes requires a fundamental shift in community knowledge, attitudes, and practice. Hence, this review recommends strong community capacity building to support community-led WASH initiatives. The review further recommends strengthening the whole-of-government approach to achieve universal access to WASH in Zimbabwe.

Keywords

water sanitation hygiene health outcomes sustainability Zimbabwe

Strengths and Limitations of the Study

✓ The scoping study included a broader variety of databases with a comprehensiveness rate of 96% or higher in the literature search, with the intention of maintaining a larger coverage.

✓ To examine the influence of WASH status on the health outcomes of various populations in Zimbabwe.

✓ This review focuses solely on research presenting findings on this topic of interest in Zimbabwe, perhaps limiting the generalisability of the study to different settings.

Introduction

Universal access to clean water, sanitation, and hygiene is a fundamental human right, as stated in the Sixth Sustainable Development Goal of the United Nations by 2030.¹ However, countries must overcome significant challenges to improve their health outcomes.^2,3 This scoping review explored the water, sanitation, and hygiene (WAin SH) status and its influence on health outcomes in Zimbabwe. WASH collectively refers to water, sanitation, and hygiene,¹ which are critical components for preventing communicable diseases linked to contaminated drinking water, inadequate sanitation, and poor hygiene^2,3 practices habits. Ensuring adequate access to safe water, proper sanitation facilities, and good hygiene behaviours directly reduces disease transmission and improves overall health outcomes.^1,4

In 2022, millions of people worldwide⁵ faced critical challenges accessing safe water, sanitation, and hygiene. During the same period, over 2 billion people⁵ lacked safely managed drinking water. Approximately 3.5 billion people⁵ lack access to safely managed sanitation facilities, and among this group, 419 million people⁵ still practise open defecation in 2022. Basic hygiene services were unavailable to 2 billion people,⁵ and 653 million⁵ had no hygiene facilities at all by 2022. Furthermore, 1.8 billion people⁵ collect drinking water from sources outside their homes, and in approximately two-thirds⁵ of these households, women are primarily responsible for collecting water. The number of people in the rural community without access to proper sanitation declined from 2.2 to 1.9 billion between 2015 and 2022. However, population growth and persistent WASH inequalities have kept the global population lacking adequate sanitation relatively constant at around 1.6 billion people during the same period. Globally, billions of vulnerable populations still lack access to basic WASH facilities and services, particularly in rural areas and developing countries.^2,6 The absence of basic services presents serious obstacles to optimal wellness, human population growth, and development. Progress must increase fourfold to achieve universal access by 2030, in line with Sustainable Development Goal 6, which aims to ensure the availability and sustainable management of clean water, proper sanitation, and hygiene.^6,7

Poverty, climate change, and limited financing are major drivers of WASH challenges,² resulting in diseases such as typhoid, cholera, bloody diarrhoea, acute diarrhoeal illnesses, malnutrition, and neglected tropical diseases, including intestinal worms, bilharzia, and trachoma across Africa.^2,7 These conditions contribute to millions of deaths and loss of millions of disability-adjusted life years (DALYs) each year, particularly in low- and middle-income countries (LMICs).⁷ WASH-related illnesses can decrease productivity and impose significant economic burdens on households and communities, highlighting the need for sustainable water, sanitation, and hygiene interventions.⁸ To address these challenges and ensure equitable, lasting improvements in WASH programmes, governments and stakeholders must sustain investments in infrastructure, enact legislative reforms, and actively engage communities.⁹ Zimbabwe is one of several African nations fighting to reduce the morbidity and mortality associated with waterborne and water-related illnesses.¹⁰ In pursuit of the transformative 2030 Agenda for Sustainable Development, like many other nations, Zimbabwe faces the pressing challenge of achieving Sustainable Development Goal 6 (SDG 6) to ensure access to clean water and sanitation.¹¹ Despite ongoing efforts by the government and stakeholders, the country continues to face significant challenges in WASH.¹² Zimbabwe had a total population of approximately 15.2 million,¹³ of whom 61% (9.26 million)¹³ resided in rural areas and 39% (5.92 million)¹³ in urban areas. Nationally, only 34.6%¹³ of the population has access to at least basic sanitation services, falling significantly short of the Sustainable Development Goal (SDG) 6 target of universal access to adequate and equitable sanitation by 2030.⁵ There are significant disparities between urban and rural areas, with 56%¹³ of the urban population having access to basic sanitation compared to only 36% in rural areas.¹³

In 2022, the country had an estimated 3.82 million households,¹³ comprising 2.80 million in rural areas and 1.02 million in urban areas.¹³ More than 30%¹³ of rural households rely on unimproved drinking water sources, indicating slow progress towards achieving universal access to safe and affordable drinking water (SDG 6.1).^5,11 Furthermore, 67.4% of rural households¹³ reported travelling 30 min or more to collect water, compared with 23.6% of urban households,¹³ highlighting the persistent burden of water collection in rural settings. Access to handwashing facilities also remained low, with only 26.8% of rural households¹³ having facilities with soap and water compared to 73.2% in urban areas.¹³ Poverty remains a major factor, as limited financial resources hinder access to WASH in rural areas.¹⁴ This scoping review examined the current state of Water, Sanitation, and Hygiene (WASH) and its impact on health outcomes in Zimbabwe. Aligned with its main objective, the review seeks to answer the overarching research question: “What is the impact of WASH status on health outcomes in Zimbabwe?” and utilises existing literature to address specific objectives and corresponding review questions, as detailed in Table 1.

Table 1.

Specific Objectives and the Corresponding Research Questions.

	Review objectives	Review questions
1	Extract and review previous studies on WASH Status and Health Outcomes in Zimbabwe from an unrestricted search back until May 31, 2024,	How many previous studies reported on WASH Status and Health Outcomes in Zimbabwe from an unrestricted search back until May 31, 2024,
2	Determine the progress that has been made in enhancing WASH conditions in Zimbabwe.	What progress has been made, and what challenges are faced in enhancing WASH conditions in Zimbabwe?
3	Document the trends of adverse health outcomes associated with poor WASH status in Zimbabwe.	What are the trends in adverse health outcomes due to inadequate WASH status in Zimbabwe?
4	Identify and analyse strategies or interventions proposed in the literature to enhance health outcomes in Zimbabwe.	What are the proposed WASH strategies or interventions in the literature?
4		Could they effectively address WASH issues in Zimbabwe and influence positive health outcomes?

Methods

Protocol Registration

The protocol for this scoping review was registered in BMJ Open (https://doi.org/10.1136/bmjopen-2023-082224) with an online issue publication on 19 August 2024. This protocol is available as an open-access article under the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) Licence.

Study Setting

Zimbabwe is a landlocked country located in south-central Africa, covering an area of 390,757 square kilometres (150 872 square miles). The country lies between the Zambezi and Limpopo Rivers, with the Zambezi River forming its northern border with Zambia and the Limpopo River marking its southern boundary with South Africa.¹⁵ Zimbabwe shares a border with Mozambique to the east and Botswana to the west.^16,17 The country lies between -19.015438° south latitude and 29.154857° east longitude¹⁵ and is entirely north of the Tropic of Capricorn.

Zimbabwe has three broad climatic regions: The Central Plateau, which covers most of the country and generally has a temperate climate. In contrast, low-lying areas, such as the Zambezi Valley, are warmer and drier, with hot summers.¹⁸ The Eastern Highlands are cooler, with significantly higher year-round rainfall.^18,19 However, the country experiences largely subtropical climatic conditions, characterised by a single rainy season that occurs from November to March.¹⁸ Rainfall becomes less reliable when moving from north to south and from east to west,¹⁵ contributing to water scarcity that affects the WASH status and health outcomes in the country. The period from August to October is typically hot and dry. Only 37% of the country receives adequate rainfall for agriculture.^18,20 The largest inland water body, Lake Kariba, lies along the Zambia-Zimbabwe border. The major rivers in Zimbabwe are the Zambezi, Limpopo, Sabi, and Runde. The country’s topographical features include the central watershed, which stretches from southwest to northeast, with elevations ranging from 1200 to 1500 m above sea level.^15,16

Zimbabwe is divided into 10 administrative provinces¹⁷: Bulawayo, Harare, Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Masvingo, Matabeleland North, Matabeleland South, and Midlands.^13,16 Harare, the capital city, serves as the main hub for administrative and commercial activities (Figure 1).^13,18,19 Zimbabwe’s population is estimated at approximately 15.8 million,^13,16 and the country is among several African countries working to reduce the burden of waterborne and water-related diseases.¹⁰

Figure 1.

Figure showing the study boundaries.

Study Design

A scoping review was employed because its methodology adheres to a pragmatic research perspective, highlighting the relevance of feasible and flexible approaches to meet the study objectives.²¹ This review is ideal because it is time-efficient and successfully answers the study questions. The scoping review methodically investigates key findings from previous studies and literature gaps relevant to a particular subject.²² In contrast to other types of reviews, this review is not limited to certain study designs, allowing for the incorporation of diverse results from qualitative and quantitative studies and policy documents.²² This wide approach provides a solid understanding of Zimbabwe’s WASH status and health outcomes (Table 1).

Data and Information Sources

In this review, records that satisfied the inclusion and exclusion criteria were sourced from the main databases (Table 2), including PubMed, SAGE, SpringerLink, Cochrane Library, ScienceDirect, Nature, Scopus, EBSCO, and Web of Science, and an unrestricted search for English-language publications was conducted until 31 May 2024. The chosen databases are reliable and span many fields, guaranteeing a variety of excellent sources and a thorough comprehension of Zimbabwe’s WASH situation and health achievements. Particular incidents, policy modifications, or environmental, socioeconomic, and political elements that may have previously occurred and impacted WASH status and health outcomes in Zimbabwe should be considered.

Table 2.

Inclusion and Exclusion Criteria.

Criteria	Inclusion	Exclusion	Rationale	Variables
Geographical focus	Studies conducted in Zimbabwe	Studies done exclusively in countries other than Zimbabwe	The focus is on Zimbabwe because it is among the LMIC in Sub-Saharan Africa (SSA)	a. WASH status 1. Water source (unimproved, improved, piped water), Water quality (faecal contamination, chemical parameters) 2. Sanitation facilities (unimproved, improved, sewerage, toilet facilities) 3. Hygiene practices (handwashing, water treatment, open defecation) 4. WASH access (distance, quantity, continuity of supply, disparities) in Zimbabwe b. WASH-related health and measurement outcomes WASH-related health outcomes, condition/disease Odds ratio, Relative risk and prevalence of Diarrhoea Respiratory infection Undernutrition/stunting Soil-transmitted helminths Schistosomiasis Trachoma Child growth, maternal health in Zimbabwe c. WASH policy, initiatives, strategies, programmes, interventions, and activities in Zimbabwe
Publication date	unrestricted search “until 31 May 2024”	. Studies conducted after 31 May 2024	There may be important historical context in older literature. It also strengthens the literature by aggregating and reviewing evidence on longitudinal trends in health outcomes, long-term milestones, and sustainability.
Language	Fully in English	Not or partially done in English	Avoidance of translation barrier to enhance ease of understanding and analysis
Data sources	1. Peer-reviewed articles published in reputable journals (Qualitative or quantitative or mixed). 2. Books, book chapters, and book reviews from well-established publishers that pertain to the topic. 3. Conference proceedings, theses, and abstracts published in respected peer-reviewed journals. 4. Grey literature found in reputable sources. 5. Official reports, such as those released by authoritative organisations like (WHO, UNICEF, MoHCC).	1. Newspaper articles 2. Opinion papers and commentaries 3. Articles from websites that lack peer review. 4. Content from social media platforms. 5. Research protocols.	The data sources to be included allows the review to be comprehensive, evidence-based, and representative of the existing knowledge on the topic, thereby enhancing the review’s reliability and credibility. The excluded sources compromise the fundamental principles of objectivity in this systematic review.
Health outcomes	1. Studies that examine WASH conditions, access, infrastructure, practices, or interventions 2. Studies that report on health outcomes (not limited only to diarrhoeal diseases, intestinal infections, child growth, and development)	Studies focussing only on WASH access or conditions without linking to health outcomes	Focussing on studies that link WASH access or conditions to health outcomes is essential because it addresses critical public health issues, informs targeted interventions, aligns with global health goals, and promotes evidence-based decision-making.
Measurement outcomes	All WASH-related measurement outcomes, such as prevalence, odds ratios (OR), and relative risk (RR)		These studies are useful in assessing the progress against Key performance indicators (KPIs)
Main electronic databases	Google Scholar, PUBMED, EBSCO, Cochran Library, Science Direct, Scopus, African Journals Online and Web of Science, GoZ, GLAAS, WHO/UNICEF, JMP websites	Literature from unofficial organisational websites.	The selected main electronic databases and official organisational websites augment the quality, reliability, and comprehensiveness of the sources included in the study.

Search Strategy

The search strategy for the review focussed on 3 key constructs: (i) WASH status, (ii) health outcomes related to WASH, and (iii) WASH interventions. Boolean operators (AND, OR) were applied systematically, with parentheses used to structure the search terms to ensure logical consistency. This approach allowed for the combination of multiple related terms within each construct while making “Zimbabwe” a mandatory term across all searches, as follows:

("Water, Sanitation, and Hygiene" OR "WASH" OR "Sanitation services" OR "Sanitation facilities" OR "WASH Infrastructure" OR "Water treatment" OR "Toilet facilities" OR "Sewage disposal" OR "Open defecation")

AND ("Health inequalities" OR "Health disparities" OR "Health determinants")

AND ("Hygiene-related diseases" OR "Sanitation-related diseases" OR "Water-borne diseases")

AND ("Hygiene practices" OR "Handwashing" OR "Personal hygiene")

AND ("Behaviour change" OR "Interventions" OR "WASH programs" OR "WASH initiatives" OR "Policy measures")

AND ("Health impacts" OR "Population health" OR "Child health" OR "Maternal health")

AND ("Household health")

AND ("Health Outcomes" OR "Health effects" OR "Health impacts" OR "Public health")

AND (Zimbabwe).

Minor syntax adjustments were made for individual databases, such as PubMed, Scopus, and Web of Science, to accommodate differences in search functionalities while maintaining the core structure and conceptual integrity of the search strategy. In this comprehensive review, EndNote was used to efficiently organise, store, and cite references.²³ The titles and abstracts of publications retrieved from databases in response to search queries were loaded into Rayyan, a cloud-based platform designed to help reviewers collaborate more efficiently. This tool helps locate and organise appropriate sources for scoping reviews.^24,25 The integration of these tools results in a more effective and coordinated scoping review process.

Screening Process

This study adopted a two-step screening process to identify relevant literature. This multistage approach is crucial because systematic searches often generate large volumes of potentially relevant studies.²² In the initial phase, 2 independent reviewers screened the titles and abstracts of all articles retrieved through a systematic search. One reviewer screened all entries, whereas the other independently screened 20% of the records screened. Articles were included in the next stage if their titles and abstracts met the predefined inclusion criteria (Table 2). The second stage involved a thorough review of the full-text articles. This two-step process aligns with established methods for enhancing the rigour of literature reviews. This study used Cohen’s kappa coefficient for inter-rater reliability (IRR). A citation-mining approach was used to ensure comprehensive literature identification. The reference lists of the included studies were examined using EndNote and Rayyan to identify potentially relevant sources that may have been missed during the initial search. Backward and forward citation chaining was conducted for all included studies to identify any additional relevant literature.

Strategies for Enhancing Rigour

The assessment of study quality was based on the established Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension (PRISMA-ScR) criteria to ensure a comprehensive evaluation of the included studies. The results were analysed descriptively, and the review adhered to the PRISMA-ScR for the scoping review checklist, which guided the reporting process (using the main website: https://www.equator-network.org/).

Data Extraction

Data extraction is a vital prerequisite because it enables the analysis, summarisation, and interpretation of evidence.^26,27 The PRISMA-ScR framework also guided the extraction of structured data in response to the identified variables from the specific review questions and objectives listed in Tables 1 and 2. These variables included information about the study context (including study population, design, and setting/location in Zimbabwe), WASH interventions from policy to activities, and all WASH-related health outcomes beyond diarrhoeal conditions/diseases.

Analysis and Synthesis

Given the limited number of previous studies and variations in interventions and health outcome measures, a meta-analysis was not feasible. Therefore, the results were analysed using a mixed-methods approach. The quantitative analysis focussed on identifying patterns, relationships, and trends between WASH-related variables and health outcomes in the extracted data. Qualitative analysis, guided by thematic analysis aligned with the research objectives and questions (Table 1), was used to further explore and interpret the findings. Data charting was employed to streamline the data synthesis and enhance accessibility for analysis and interpretation. Conclusions were drawn directly from the collected and analysed evidence, ensuring that they directly addressed the research objectives.

Results

General Characteristics

The studies included in this review spanned a range of methodologies, including spatial analysis, cross-sectional surveys, clinical trials, and qualitative studies, covering urban and rural settings. A total of 655 data searches were conducted for the papers, as shown in Figure 2. Of the identified articles, 20 peer-reviewed and 10 national policy/strategy/survey report documents met the inclusion criteria for this review. Backward and forward citation chaining was performed on all the included studies to identify any additional relevant literature. However, this process did not yield any studies that met the inclusion criteria. The inter-rater agreement for the 20% dual screening was κ = 0.85, indicating almost perfect agreement. A brief of the 10 policy documents and survey reports included in the review focussed on improving sanitation and hygiene practices, ensuring access to clean water and proper sanitation for all citizens, emphasising sustainable water management and access to clean water for everyone, and strategic government planning to reduce the disease burden, foster sustainable economic growth, and improve infrastructure and services.

Figure 2.

PRISMA flow diagram showing steps followed to select articles.

The distribution and focus of the studies revealed that out of 20 articles, the majority 16 of the studies were observational in nature, indicating a strong emphasis on understanding real-world contexts and behaviours related to WASH interventions and their health impacts (Table 3). The distribution of these articles in the context of rural and urban settings revealed that they were equally represented, and this balanced approach allowed for a comprehensive understanding of how WASH conditions and health outcomes differ across environments. The distribution of the articles showed that 11 studies were conducted at the household level, 8 at the community level, and 1 at the individual level, contributing to valuable information that could inform targeted interventions aimed at improving WASH status and health outcomes (Table 3).

Table 3.

Summary of Studies Used in the Review.

Author	Aim	Setting	Level	Study design	Study time frame	Population characteristics	WASH status	Main findings (health outcomes)	Proposed WASH strategies or interventions in literature
Joseph et al²⁸	Estimating spatially disaggregated probability of severe COVID-19 and the impact of handwashing interventions: The case of Zimbabwe	Rural and urban	Individuals	Spatial analysis, interventional	2020-2023	Population at risk of severe COVID-19	The lowest and highest cluster-level handwashing risk estimates in Zimbabwe were 0.036 and 0.923, respectively. Hand washing risk ranged from 0.25 in Bulawayo to 0.69 in Mberengwa at the district level.	The likelihood of severe disease at the district level was estimated to range between 0.026 and 0.033, with Makonde, Mutasa, and Marondera expected to have the highest probabilities.	Handwashing has been encouraged during the pandemic to reduce the likelihood of spreading the infection from one individual to another
Gondo and Kolawole²⁹	Household water access and COVID-19 in Karoi Town Council (KTC) in Zimbabwe	Urban	Households	Cross-sectional	2020-2022	Residents of Karoi Town	Inadequate water supply, with 75% of households located more than 500 m from a water source. High costs made access difficult for low-income households. Old, dilapidated pipes, vandalism, theft of metres, illegal connections, and leaks from urban farming further disrupted supply. Additionally, high seepage and low rainfall.	The results showed that households had knowledge on the importance of water availability and hygiene in relation to COVID-19 prevention, leading to an intensified high demand for water and consequently water shortage in the area.	KTC and ZINWA need to improve on its water infrastructure and enhance the subsidisation of improved water access during and post-COVID-19 pandemic
Deshpande et al⁸	Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000 to 2017	Urban	Households	Geospatial analysis, Descriptive, Bayesian geostatistical model	2000-2017	Low-income and middle-income country populations	Over 253 000 people in Harare lacked access to sewage and septic sanitation systems. In 2017, 46.3% of people have access to septic or sewer sanitation.	Increased child diarrhoeal mortality and NTDs	Guide targeting of disease prevention efforts, particularly vaccines and interventions for nutrition, child health and NTDs, to the communities with the lowest access.
Rogawski McQuade et al³⁰	Impact of Water Quality, Sanitation, Handwashing, and Nutritional Interventions on Enteric Infections in Rural Zimbabwe: The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial	Rural	Community	Clinical trial	2010-2015	Infants in rural Zimbabwe	Water, sanitation, and hygiene (WASH) and infant and young child feeding (IYCF) interventions on enteric infections in the Sanitation Hygiene Infant Nutrition Efficacy	WASH interventions decreased the number of parasites detected (difference in number compared to non-WASH arms, −0.07 [95% confidence interval, −0.14 to −0.02]), but had no statistically significant effects on bacteria, viruses, or the prevalence and quantity of individual enteropathogenesis after accounting for multiple comparisons.	Improved pit latrine, hand-washing stations, liquid soap, point-of-use water chlorination, and clean play space) did not prevent enteric infections. Transformative WASH interventions are needed that are more efficacious in interrupting faecal–oral microbial transmission in children living in highly contaminated environments.
Gough et al³¹	Effects of improved water, sanitation, and hygiene and improved complementary feeding on environmental enteric dysfunction in children in rural Zimbabwe: A cluster randomised controlled trial	Rural	Community	Cluster-randomised controlled trial	2020	Children in rural Zimbabwe	The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial was a 2 × 2 factorial cluster-randomised trial of improved IYCF and improved WASH on child stunting and anaemia at 18 months of age.	The WASH intervention decreased plasma IGF-1 at 3 months (β: 0.89, 95% CI:0.81, 0.98) and plasma kynurenine at 12 months (β: 0.92, 95% CI: 0.87, 0.97), and increased plasma IGF-1 at 18 months (β: 1.15, 95% CI: 1.05, 1.25), but these small WASH effects did not translate into improved growth.	Transformative WASH interventions are required to prevent or ameliorate EED in low-income settings.
Chandna et al³²	Effects of improved complementary feeding and improved water, sanitation and hygiene on early child development among HIV-exposed children: substudy of a cluster randomised trial in rural Zimbabwe	Rural	Community	Sub study, cluster-randomised trial	2019	HIV-exposed children in rural Zimbabwe	WASH (pit latrine, 2 hand-washing stations, liquid soap, chlorine, play space, hygiene counselling; 53 clusters) or IYCF + WASH (53 clusters).	Children randomised to combined IYCF + WASH had higher total MDAT scores (Mean difference + 4.6; 95% CI 1.9 to 7.2) and MacArthur Bates vocabulary scores (+8.5 words; 95% CI 3.7 to 13.3), but there was no evidence of effects from IYCF or WASH alone.	Combining IYCF and WASH interventions significantly improved motor, language and cognitive development in HIV-exposed children
Bagamian et al³³	Heterogeneity in enterotoxigenic Escherichia coli and shigella infections in children under 5 years of age from 11 African countries: a subnational approach quantifying risk, mortality, morbidity, and stunting	Urban	Community	Cross-sectional, Subnational	2019	Children under 5 years in 11 African countries	Children in low-income households had limited access to improved water and sanitation, with rates of 0% and 9.7% in Mozambique and Zimbabwe, respectively.	The majority of ETEC and Shigella mortality markers showed the highest heterogeneity in Zimbabwe. Zimbabwe was among five sub-nationals with an increase in diarrhoeal mortality from 2000 to 2015 in Africa.	To find key populations that would be targeted for WASH programmes and enteric vaccinations, as well as to select communities for additional research.
Mutsaka-Makuvaza et al³⁴	Knowledge, perceptions and practices regarding schistosomiasis among women living in a highly endemic rural district in Zimbabwe: implications on infections among preschool-aged children	Rural	Community	Qualitative study	2019)	Women in highly endemic rural district in Zimbabwe	knowledge, perceptions and practices and socio-demographic characteristics.	Schistosomiasis was known to 93.7% of the population, with 97.7% comprehending transmission and 87.5% knowing preventative strategies. Women over 30 were more likely to identify chronic schistosomiasis-related infertility (OR: 1.7, 95% CI: 0.9-3.0).	disease control efforts should consider socio-demographic factors, which may influence the knowledge, perceptions and practices of occupants in a given setting.
Midzi et al³⁵	Knowledge attitudes and practices of grade three primary school children in relation to schistosomiasis, soil transmitted helminthiasis and malaria in Zimbabwe	Urban	Households	Descriptive cross-sectional survey	2011	Grade 3 children	33% Of individuals never wore shoes, and 62% did not use soap before eating or after using a toilet. There were no running water points in any of the schools, nor soap to wash hands after using toilets.	The study identified a significant frequency of parasites: S. haematobium (77.8%), S. Manson (33.3%), hookworms (29.6%), and P. falciparum (48.1%). Past reports that malaria and schistosomiasis were significant illnesses (P = .042 and .001, respectively).	Health awareness campaigns by means of educational institutions to the most vulnerable students
Tshuma et al³⁶	An Analysis of Factors Influencing Household Water, Sanitation, and Hygiene (WASH) Experiences during Flood Hazards in Tsholotsho District Using a Seemingly Unrelated Regression (SUR) Model	Rural	Community	Seemingly unrelated regression model	2022	Households in Tsholotsho District	Surface and ground water contamination, pit latrine collapse, and contamination of household items. Borehole and well collapsed and increased water salinity. Water points become inaccessible. Open defecation also increases when sanitation facilities are damaged	Water- and hygiene-related disease outbreaks	To monitor the state of the water supply and infrastructure. To consider implementing more WASH programmes, increasing access to safe and clean drinking water, and increasing the level of education of communities.
Lampard-Scotford et al³⁷	Knowledge, attitudes, practices and behaviours (KAPB) around water, sanitation and hygiene (WASH) in villagers exposed to schistosomiasis in Zimbabwe	Rural	Households	A cross-sectional study using qualitative approaches	2022	Villagers exposed to schistosomiasis	WASH coverage indicated that 60.62% had access to toilets and 48% to boreholes. However, 16% of adults and 36% of children with toilet access continued to practise open defecation.	The prevalence of schistosomiasis was 42.4%, with 13% of infections linked to open defecation and 27% to the use of river water.	The use of context relevant behavioural theories and interventions is required to influence prioritisation and subsequent adherence to WASH facilities.
Kanda et al³⁸	Contamination of soil around an abandoned gold mine tailings dam with trace elements in a small town, northeastern Zimbabwe	Rural	Community	Health risk assessment study	2015	Individuals in NE Zimbabwe	Health risk exposure of the local population (adults and children) through ingestion and dermal exposure to heavy metals contaminated water	The local populace was at medium to high risk of developing cancer due to arsenic exposure.	Providing constant piped water supplies, re-vegetating the tailings dam, and redirecting surface tailings outflow to a containment pond.
Maponga et al³⁹	Risk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study	Urban	Households	Case-control study	2011	Residents in Kadoma City	Unhygienic personal and household practices, handwashing in a single bowl, littering, inadequate water supply, non-functional boreholes, and sewer blockages.	Independent protective factors included exclusive breastfeeding for 6 months (AOR = 0.44), using municipal water (AOR = 0.38), using aqua tablets (AOR = 0.49), and storing water in closed containers (AOR = 0.24).	Key measures include providing safe water, promoting handwashing, exclusive breastfeeding, good hygiene, distributing water purification tablets, water trucking, repairing boreholes, unblocking sewers, and health education on personal hygiene.
Gundry et al⁴⁰	Child dysentery in the Limpopo Valley: a cohort study of water, sanitation, and hygiene risk factors	Rural	Households	Cohort study	2009	Children aged 12 to 24 months in the Limpopo Valley	Faecal contamination of source water., indicated by Escherichia coli counts of 10+ cfu/100 ml, increased risk by 2.9 (1.5-5.7), Unimproved groundwaters 47 (50%) and Pit latrines 19 (20%).	Children drinking from non-standpipe sources had a 3.8 times higher risk (95% CI: 1.5-9.8, P = .005) compared to those using standpipes.	A water and sanitation policy could reduce disease by prioritising safer sources like standpipes. For higher-risk sources, water treatment at the source or household level should be implemented.
Ndlovu and Bhala⁴¹	Menstrual hygiene – A salient hazard in rural schools: A case of Masvingo district of Zimbabwe	Rural + Urban	Community	Qualitative and employed methodologies of document analysis	2015	Female students in rural schools	Infrastructure that is not girl-friendly, restricted availability to menstrual hygiene products as a result of poverty, and improper handling and disposal procedures, non-involvement of men in MHM issues,	Low class participation, difficulty concentrating, limited interactions with peers and teachers, low self-esteem, anxiety, and feelings of discrimination.	Advocating for government support in establishing a policy framework, providing education and training, building girl-friendly sanitary facilities, and promoting local production of reusable menstrual pads (RUMPs).
Ayling et al⁴²	A stitch in time: The importance of water and sanitation services (WSS) infrastructure maintenance for cholera risk. A geospatial analysis in Harare, Zimbabwe	Urban	Households	Case study	2018	Individuals affected by Cholera in Harare	The pipelined water network became contaminated as a result of sewer bursts; from December 2017 to December 2018, there were 24 713 sewer burst location reports and 7179 water network breakage complaints.	Cholera risk indicators included, poverty, sewer burst density, and sanitation risk. 46 people died as a result of the 93% (9755) of the nearly 10 000 cases.	The maintenance of improved water and sanitation infrastructure is crucial for ensuring its functionality and longevity. Regular upkeep prevents system failures, promotes public health, and enhances the reliability of water supply and sanitation services
Moyo et al⁴³	Risk factors for contracting watery diarrhoea in Mzilikazi, Bulawayo City, Zimbabwe, 2020: A case control study	Urban	Households	Unmatched case-control study.	2020	Residents affected by the cholera outbreak	Old water and sewer reticulation infrastructure in highly populated urban settings, Faecal coliforms were detected in water samples, and Shigella flexneri was found in 2 of 13 stool specimens. Residents used decommissioned boreholes due to water rationing. Dirty toilets (29%) and improper water storage (34%) were common, along with sewer blockages.	82% of the people who presented with watery diarrhoea were children under 5 years of age.	Health education on home water treatment, distribution of water storage containers, and Aquatabs.
Imanishi et al⁴⁴	Household Water Treatment Uptake during a Public Health Response to a Large Typhoid Fever Outbreak in Harare, Zimbabwe	Urban	Households	Survey	2011-2012	Households affected by the typhoid outbreak	Disruption of the municipal water supply, boreholes the main alternative source of water.	42 Confirmed cases of typhoid fever were reported in Harare, with 54% female. Two patients died, and 1788 (43%) were hospitalised.	Increasing community education and access to products to improve drinking water quality and household hygiene.
Maruta et al⁴⁵	Water safety and associated public health impacts in upcoming and informal urban settlements in Zimbabwe: case of Amsterdam Park in Harare	Urban	Households	A descriptive case study	2021	Amsterdam Park households’ residents	Water contamination was mostly caused by seepage from an adjacent cemetery, unlined septic tanks, and open home waste dumps. Drinking water had more than recommended levels of ammonia, E. coli, and turbidity.	The most prevalent conditions were diarrhoea and stomach pain. Diarrhoea, typhoid, and cholera outbreaks are experienced more frequently by residents.	Supporting the development of Amsterdam Park to meet public health standards under the Public Health Act and advance Sustainable Development Goals 3 and 6.
Dembedza et al⁴⁶	Water, Sanitation, and Hygiene practices in areas affected by Cyclone Idai in Zimbabwe	Urban + Rural	Households	A descriptive case study	2024	Buhera, Chimanimani and Chipinge districts in Manicaland Province	Cyclone damaged infrastructure such as toilets and sewage systems, leading to poor sanitation practices. In Buhera, Chimanimani, and Chipinge, the most common toilets were open defecation (38.2%), pit latrines with a slab (33.9%), and pit latrines without a slab (39.5%), respectively.	Inadequate access to sanitary facilities and clean water made pre-existing health issues worse and raised the risk of disease epidemics.	Immediate and coordinated emergency response efforts to restore clean water sources, provide access to sanitation facilities, and promote good hygiene practices in affected communities.

Water, Sanitation, and Hygiene Status in Zimbabwe

Inadequate WASH Infrastructure and Limited Services

WASH infrastructure and services in Zimbabwe encounter considerable obstacles.^{8,29,36,42,43,45,47} While numerous rural communities continue to depend on unsafe practices such as open defaecation,²⁹ a previous study conducted in the Masvingo district revealed that the upkeep of Blair Ventilated Improved Pit Latrines (BVIPs) is inadequate, highlighting that even when toilets are available, inadequate maintenance can result in unsafe waste management and associated health hazards for households that utilise them.⁴¹ In urban areas, residents often lack access to adequate sanitation and solid waste services because of ageing and deteriorating sewer infrastructure. Factors such as vandalism, metre theft, illegal connections, leaks, and pressure from urban agriculture further compromise water supply and sanitation delivery.^{8,29,37,39,43} Zimbabwe’s National Health Strategy (2021-2025) highlights that the availability of safe water and sanitation facilities remains a huge challenge in the country. Despite these persistent challenges, the Zimbabwe National Sanitation and Hygiene Policy emphasises the need to provide sufficient and sustainable WASH facilities nationwide. This policy framework aims to address infrastructure gaps, promote hygiene practices and sanitation services to enhance public health and achieve national and global sustainable development goals.

Water, Sanitation, and Hygiene (WASH) Intervention Inequities

Gender-sensitive WASH interventions remain a significant challenge, particularly in rural areas.^{8,32
-35,37,41,43} Additionally, several records shown in the WASH equity framework (Table 4) further revealed that rural areas and low-income households had limited access to improved water and sanitation.^{29,33,35,37,46} The lack of basic WASH infrastructure that accommodates girls’ needs has emerged as a critical issue, especially in schools. Facilities frequently lack functional locks, sufficient lighting, and menstrual hygiene support, including inadequate access to water, disposal options, and hygiene materials. These gaps expose girls to health risks, safety and privacy concerns, and discomfort, contributing to increased absenteeism and negatively impacting their overall well-being and school performance.^37,41 A previous study conducted in Shamva District in Mashonaland Central Province and Mutare District in Manicaland Province highlighted that the lack of adequate facilities contributed to poor hygiene practices among students, with 62% not using soap before eating or after using the toilet.³⁵ However, school WASH programmes are critical for promoting health and hygiene among children.^35,37,41 Inclusive policies that address the specific needs of vulnerable populations are critical for improving WASH outcomes.³⁶

Table 4.

Water, Sanitation and Hygiene (WASH) Equity Framework in Zimbabwe.

Equity dimension	Indicator	Group A	Group B	Gap	Source
Water access/service	Proportion of persons accessing improved sources of drinking water	Rural: 67%	Urban: 97%	−30% pp gap	ZIMSTAT, ICF⁴⁸
	Proportion using basic drinking water services	Rural: 51%	Urban: 92%	−41%	ZIMSTAT, UNICEF⁴⁹
	Proportion of household members in households using an appropriate water treatment method	Rural:7%	Urban:16%	−9% H/H gap	ZIMSTAT, UNICEF⁴⁹
	Proportion of persons with water on premises	Rural: 19%	Urban: 71%	−52% pp gap	ZIMSTAT, ICF⁴⁸
	Proportion of household population with drinking water source not accessible	Rural: 9%	Urban: 2	7% H/H gap	ZIMSTAT, UNICEF⁴⁹
	Proportion of persons obtaining water in more than 30 min	Rural: 41%	Urban: 9%	32% pp gap	ZIMSTAT, ICF⁴⁸
	Average time spent collecting water per day up to 3 h	Rural: 27%	Urban:4%	23%-time gap	ZIMSTAT, UNICEF⁴⁹
Water quality	Proportion of household population with E. coli in source water	Rural: 71%	Urban: 32%	39% H/H gap	ZIMSTAT, UNICEF⁴⁹
Water quality	Proportion of household population with E. coli in household drinking water	Rural: 94%	Urban: 61%	33% H/H gap	ZIMSTAT, UNICEF⁴⁹
Gender and Social Inclusion (GESI)	Percentage of persons usually collecting drinking water in the rural areas	Male: 16%	Female: 84%	−68% age gap	ZIMSTAT, UNICEF⁴⁹
Gender and Social Inclusion (GESI)	Percentage of persons usually collecting drinking water in the urban areas	Male: 21%	Female: 79%	−58% age gap	ZIMSTAT, UNICEF⁴⁹
Sanitation	Proportion of persons with improved sanitation	Rural:35%	Urban:52%	−17% pp gap	ZIMSTAT, ICF⁴⁸
	Proportion of H/H using improved sanitation	Rural: 55%	Urban: 98%	−43 H/H gap	ZIMSTAT, UNICEF⁴⁹
	Proportion of children used toilet/latrines	Rural: 7%	Urban: 13%	−5% children gap	ZIMSTAT, ICF⁴⁸
	Proportion of houses with hand washing facilities	Rural: 63%	Urban: 94%	−31% pp gap	ZIMSTAT¹³
	Proportion of households practising open defecation.	Rural: 29%	Urban: 3%	26% H/H gap	MoHCC⁵⁰, MoHCC⁵¹
	Proportion of institutions with disability-sensitive sanitation facilities	Data not available	Data not available	Evidence gap	-
Poverty quintiles	Children’s wealth quintiles	Poorest: 23%	Richest: 16%	6% gap	ZIMSTAT, UNICEF⁴⁹
	Proportion of multidimensionally child poverty	Rural: 69%	Urban: 38%	31% pp gap	UNICEF⁵²
	Proportion of households in the highest wealth quintiles	Rural: Two (2) highest quintiles 14%	Urban: Two (2) highest quintiles 100%	86% gap	ZIMSTAT, ICF⁴⁸
	Proportion distribution of the household population in the poorest wealth quintile	Rural: two lowest quintiles 0.4%	Urban: two lowest quintiles 58%	−57% gap	ZIMSTAT, UNICEF⁴⁹
Child health	Prevalence of diarrhoea among children under 5 years of age	Male: 18%	Female:15%	3% gap	ZIMSTAT, ICF⁴⁸
Child health	Percentage of children (0-59 months) with diarrhoea in the last 2 weeks	Rural: 71%	Urban: 29	42% gap	ZIMSTAT, UNICEF⁴⁹

Inadequate WASH Knowledge and Unsanitary Practices

Unsanitary practices at both the personal and household levels, including handwashing in a single basin, littering, and open defaecation, are prevalent issues.^37,39,40,43 Faecal contamination of source water was evidenced by Escherichia coli counts exceeding 10 CFU/100 ml.⁴⁰ Hygiene promotion was essential for improving health outcomes, yet many communities lacked effective education on hygiene practices. A previous study indicated that individuals did not adhere to hygienic practices because of cultural beliefs and a lack of facilities.³⁹ Several studies have indicated a significant gap in community knowledge of WASH practices, particularly regarding schistosomiasis and other neglected tropical diseases.^34,35,37 Research on women’s knowledge, attitudes, and practices regarding schistosomiasis has indicated that while awareness is high, misconceptions about transmission and prevention persist. The article highlighted that demographic factors influence women’s knowledge and practices, with uneducated women being more likely to be exposed to unsafe water sources.³⁴

Contaminated Drinking Water Sources

The studies revealed that water contamination was exacerbated by seepage from nearby cemeteries, unlined septic tanks, open waste dumps, open defaecation, and sewer bursts.^29,42,45 Poor source water quality was evidenced by Escherichia coli counts exceeding 10 colony-forming units (CFU) per 100 ml.⁴⁰ In a previous study, the results showed that groundwater had higher concentrations of contaminants during the dry season than during the wet season because of trace elements near abandoned mines.³⁸ The geo-accumulation and contamination degree indices revealed significant to severe soil contamination by cadmium (Cd), chromium (Cr), and copper (Cu) within a 10-m radius of the tailings dam. The analysis showed that contamination was most pronounced near the dam, reflecting the immediate environmental impact at the site.³⁸

Adverse Effects of Climate Vulnerability

The impact of natural disasters such as Cyclone Idai, on Water, Sanitation, and Hygiene (WASH) services in Zimbabwe has underscored the vulnerability of communities to health risks associated with inadequate access to clean water and sanitation facilities. Water, Sanitation, and Hygiene (WASH) practices are frequently influenced by severe and recurrent natural disasters. The aftermath of Cyclone Idai resulted in widespread damage to water supply systems, leaving many communities without access to clean drinking water. Cyclones also cause extensive damage to sanitation infrastructure, including latrines and sewage systems.⁴⁶ Floods cause extensive damage to water supply systems, leading to shortages of clean water and an increased risk of contamination.³⁶ According to international standards, an contrast, low rainfall significantly strains WASH services, leading to water challenges, and compromised hygiene.²⁹

Governance and Financial Constraints

Effective governance and a robust policy framework are essential for the successful implementation of WASH programmes in Zimbabwe.^29,53 While few studies provide an oblique reference to the Zimbabwe WASH policy in the context of Sustainable Development Goal Six (6) in Zimbabwe, the ongoing challenges within the Water, Sanitation, and Hygiene (WASH) sector suggest a weakened policy framework and its operationalisation.⁵³ A person is entitled to 50 L²⁹ of water from an improved source each day, according to international standards. Additionally, the Zimbabwe National Water Policy states that water for domestic use should be available in amounts of at least 25 L/day²⁹ for each individual. This means that a household should not spend more than 5% of its monthly income on water services.²⁹ However, the studies revealed that residents had become victims of the Zimbabwe National Water Authority (ZINWA), receiving exorbitant monthly water bills despite going weeks without tap water,^29,53 which exposed governance constraints and financial mismanagement in the provision of water services.²⁹ Technology that can be utilised to enhance WASH services is still not widely funded in Zimbabwe.^36,41 Limited funding for the Rural Water Information Management System (RWIMS) has weakened real-time data-driven water infrastructure and quality monitoring.³⁶ Some studies also recommended that the government commission review the current multi-stakeholder platform to align its governance structure with the 2013 national constitution and WASH policy framework.⁵³

Interventions should strike a balance between capital and operational spending while addressing key issues identified in the studies to reduce Non-Revenue Water (NRW). Capital expenditures (Capex), such as investing in the RWMIS, implementing transparent and subsidised smart metring billing systems, rehabilitating assets, and installing modern infrastructure with support from the government and private sector, can help reduce billing disputes and high-water costs. These investments provide long-term benefits.^28,29,42 Operational expenditure (Opex) activities, including regular inspections of water supply and sanitation systems, prompt leak repairs, ongoing data analysis, and the use of Key Performance Indicators (KPIs), as well as quick responses to RWMIS failures and routine staff training, can lead to a more sustainable and fair water supply system. Furthermore, community involvement in reporting damage, marking underground pipes, prohibiting farming near water lines, and enforcing laws against vandalism are essential protective measures. Good management of Capex and Opex allows utilities to reinvest savings from reduced water losses, which improves the financial stability, reliability, and sustainability of the water system.^28,29,42

Schools should adopt Standard Operating Procedures (SOPs) for menstrual hygiene-friendly WASH facilities. These procedures include providing private and secure toilets with locks and good lighting, a reliable water supply for washing and cleaning, and proper disposal methods, such as covered bins or incinerators, for menstrual waste. Schools should also provide access to hygiene materials and designated changing areas. These procedures highlight the need for regular maintenance and cleanliness. By implementing these SOPs, schools can create a safe, inclusive, and supportive learning environment that respects girls’ dignity while improving their attendance and academic performance.^35,37,41

Discussion

This review collectively and consistently highlights the multifaceted relationship between unsafe Water, Sanitation, and Hygiene (WASH) and a range of adverse public health outcomes in Zimbabwe. The review indicates that poor infrastructure, rapid urbanisation, climate change,³⁶ environmental stress, cultural barriers, inadequate financing, and ineffective governance contribute to poor WASH in Zimbabwe. The evidence provided by the reviewed literature suggests that prolonged unsafe water, sanitation, and hygiene (WASH) were driven by a combination of these key challenges over several decades in the country. Several studies have further revealed that human behaviours characterised by unhygienic households and personal practices, tied with knowledge gaps, increase the risk of adverse health outcomes.

This review identifies key equity dimensions of water access/service, water quality,⁴⁹ sanitation,^50,51 gender roles,⁴⁹ and poverty quintiles.^48,49 The lack of girl-friendly WASH infrastructure in rural schools constrains menstrual hygiene waste,⁴¹ suggesting gender and educational disparities between institutions. The review further reflects that rural-urban disparities remain a major concern in the WASH landscape in Zimbabwe.⁴⁸ Despite concerted efforts and the implementation of WASH interventions, low-income households,³³ and vulnerable individuals, such as people with disabilities, continue to face significantly greater challenges in accessing basic sanitation and improved water supply. This situation implies limited progress towards equitable access to WASH in Zimbabwe

The recurrent WASH-attributable diseases from the reviewed articles include increased prevalence of diarrhoeal diseases, persistent enteric infections, and outbreaks (ETEC, Shigella, typhoid, and cholera),^{33,36,39,43
-45} and higher burdens of neglected tropical diseases (schistosomiasis and STH),^8,34,35 coupled with the risk of malnutrition. Likewise, the cumulative negative health impacts were reported to be most prevalent among children under 5 years old,^8,43 poor households, and rural areas due to these water and sanitation-related preventable illnesses. Therefore, the reviewed articles and records suggest that decades of inadequate water, sanitation, and hygiene (WASH) infrastructure and services have contributed to numerous negative public health outcomes in Zimbabwe.

Overall, the studies reviewed provide a solid foundation to conclude that despite numerous WASH initiatives and interventions, improving various health outcomes in Zimbabwe still faces substantial obstacles. Therefore, the present study recommends improvements in water infrastructure, water supply management, sanitary facilities, and community-led WASH practices to improve health outcomes in Zimbabwe’s rural areas. Achieving the desired health outcomes related to WASH requires a fundamental shift in the community’s knowledge, attitudes, practices, and behaviours (KAPB). Funding the Rural Water Information Management System (RWIMS) is crucial for monitoring the water supply infrastructure, interventions, and activities in Zimbabwe. However, the reviewed articles and other records call for urgent policy action, and there is a lack of discussion on how to implement these policies effectively. Future research should focus on the barriers to policy implementation and strategies for overcoming them.

Strengths and Limitations

A key strength of this review is its longitudinal timeframe, which enables the assessment of both short- and long-term impacts of WASH interventions on health outcomes. This provided a comprehensive understanding of the temporal dynamics. Furthermore, the scope of this review extends beyond diarrhoeal diseases and encompasses a broader range of WASH-related health outcomes. This holistic approach contributes to a more comprehensive understanding of the subject matter. The reliability of this study was enhanced by rigorous searches across highly comprehensive databases. Although focussing on Zimbabwe enhances the contextual relevance of this study, it may limit the generalisability of the findings to other settings. Furthermore, the heterogeneity observed across studies in terms of interventions, populations, and outcome measures poses significant challenges. This variability can hinder the seamless integration of findings into broader contexts.

Footnotes

Acknowledgements

Not applicable.

Author Note

SB holds an MSc in Public Health degree from the Universitas Indonesia and an MSc in Biostatistics and Epidemiology degree from the Midlands State University of Zimbabwe. The author is the District Environmental Health Officer for the Zvishavane District within the Ministry of Health and Childcare in Zimbabwe. VN holds an MSc in Public Health from the University of Zimbabwe. The author works as the Environmental Health Director of Zimbabwe’s Ministry of Health and Child Care. WNN is a PhD in Public Health and an Associate Professor and Acting Head of School of Public Health in the Faculty of Health Sciences at the University of Botswana.

ORCID iD

Wilfred Njabulo Nunu

Ethical Considerations

Ethical approval was obtained from Universitas Indonesia (Ket26/UN2.F10.D11/PPM.00.02/2024), the Zimbabwe Medical Research Council (MRCZ/B/2629), and the Ministry of Health and Child Care.

Consent for Publication

Not applicable.

Author Contributions

SB, WNN, and VN conceptualised the research idea. SB, WNN and VN conducted a literature search, performed data extraction, and drafted the manuscript. WNN provided visualisation. WNN supervised the manuscript writing process. All the authors have read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Not applicable.

Human and Animal Rights

Not applicable.

Patient and Public Involvement

None.

References

Sara

Euphrasia

David

, et al Water, sanitation and hygiene (WASH): the evolution of a global health and development sector. BMJ Glob Health. 2024;9(10):e015367.

Okesanya

Eshun

Ukoaka

, et al Water, sanitation, and hygiene (WASH) practices in Africa: exploring the effects on public health and sustainable development plans. Trop Med Health. 2024;52(1):68.

Wolf

Johnston

Ambelu

, et al Burden of disease attributable to unsafe drinking water, sanitation, and hygiene in domestic settings: a global analysis for selected adverse health outcomes. Lancet. 2023;401(10393):2060-2071.

Zyoud

. Water, sanitation, and hygiene global research: evolution, trends, and knowledge structure. Environ Sci Pollut Res Int. 2023;30(56):119532-119548.

World Health Organisation. The-Sustainable Development Goals Report. 2024: 20-21. Accessed July 25, 2025. https://unstats.un.org/sdgs/report/2024/The-Sustainable-Development-Goals-Report-2024.pdf

Gordon

Boisson

Johnston

Trouba

Cumming

. Unsafe water, sanitation and hygiene: a persistent health burden. Bull World Health Organ. 2023;101(9):551-551a.

Kishore

Venkatesh

Verma

Walia

. Water, sanitation, and hygiene: a global imperative for health. Indian Journal of Community Health. 2023;35(3):367-371.

Deshpande

Miller-Petrie

Lindstedt

, et al Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17. Lancet Glob Health. 2020;8(9):e1162-e1185.

Merid

Alem

Chilot

, et al Impact of access to improved water and sanitation on diarrhea reduction among rural under-five children in low and middle-income countries: a propensity score matched analysis. Trop Med Health. 2023;51(1):36.

10.

Garatsa

Mohammadnezhad

Kostrzynska

Nwankwo

Hagan

. Risk factors of diarrhoea among under-five children in Zimbabwe: a systematic review. 2023. https://dx-doi-org.web.bisu.edu.cn/10.34297/AJBSR.2023.19.002591

11.

World Health Organisation. Evaluation Report for DFAT-WHO water, sanitation and hygiene (WASH) Evaluation across the Asia Pacific 2018-2022. Final Report. 2023. Accessed August 13, 2025. https://cdn.who.int/media/docs/default-source/evaluation-office/dfat-who-wash-evaluation-report-final-for-dfat.pdf?sfvrsn=c9f45932_3&download=true

12.

United Nations Development Programme. Zimbabwe United Nations sustainable development cooperation. 2023. Accessed July 25, 2025. https://www.undp.org/zimbabwe/publications/zimbabwe-united-nations-sustainable-development-cooperation-framework-2022-2026

13.

ZIMSTAT. Zimbabwe 2022 population and housing census report. 2022: 85-94. Accessed 25 July, 2025. https://www.zimstat.co.zw/wp-content/uploads/Census/Zimbabwe_2022_PHC_Gender_thematic_FINAL_DRAFT_Jan_25.pdf

14.

UNICEF. Zimbabwe humanitarian situation: multi-hazard situation report. 2024: 1-10. Accessed July 25, 2025. https://www.unicef.org/documents/zimbabwe-humanitarian-situation-report-multi-hazard-01-january-30-june-2024

15.

Sande

Zimba

Mberikunashe

Tangwena

Chimusoro

. Progress towards malaria elimination in Zimbabwe with special reference to the period 2003–2015. Malar J. 2017;16(1):295.

16.

Gavi

Tapera

Mberikunashe

Kanyangarara

. Malaria incidence and mortality in Zimbabwe during the COVID-19 pandemic: analysis of routine surveillance data. Malar J. 2021;20(1):233.

17.

Betera

Wispriyono

Nunu

, et al Malaria severity in the Elimination Continuum: A retrospective cohort study between Beitbridge and lupane Districts in Zimbabwe, 2021-2023. Int J Environ Res Public Health. 2024;21(7):877.

18.

Mwadzingeni

Mugandani

Mafongoya

. Assessing vulnerability to climate change in smallholder irrigation schemes of Zimbabwe. Sustainability. 2021;13(18):10023.

19.

Nyahunda

Tirivangasi

. Barriers to effective climate change management in Zimbabwe’s rural communities. In: African Handbook of Climate Change Adaptation. Springer; 2021:2405-2431.

20.

Manzeke-Kangara

Muwaniki

Siziba

Chamboko

Mtambanengwe

Wedekind

. Evolution of agricultural extension in Zimbabwe: Emerging Technologies, training needs and future possibilities. S Afr J Agric Ext. 2024;52:21-55.

21.

Kelly

Cordeiro

. Three principles of pragmatism for research on organizational processes. Methodol Innov. 2020;13(2):2059799120937242.

22.

Kazi

Chowdhury

Turin

. Conducting comprehensive scoping reviews to systematically capture the landscape of a subject matter. Popul Med. 2021;3:1-9.

23.

Vijai

Natarajan

Elayaraja

. Citation Tools and reference management software for academic writing. SSRN Electron J. 2019;586-595.

24.

Valizadeh

Moassefi

Nakhostin-Ansari

, et al Abstract screening using the automated tool Rayyan: results of effectiveness in three diagnostic test accuracy systematic reviews. BMC Med Res Methodol. 2022;22(1):160.

25.

Johnson

Phillips

. Rayyan for systematic reviews. J Electron Resour Librarian. 2018;30(1):46-48.

26.

Behera

Samant

Dehury

. Assessment of water, sanitation, and hygiene in south-East Asia: a systematic review. J Clin Diagn Res. 2022;16(10):IE01-IE06.

27.

Ramesh

Blanchet

Ensink

Roberts

. Evidence on the effectiveness of water, sanitation, and hygiene (WASH) interventions on health outcomes in humanitarian crises: a systematic review. PLoS One. 2015;10(9):e0124688.

28.

Joseph

Milusheva

Sturrock

Mapako

Ayling

Hoo

. Estimating spatially disaggregated probability of severe COVID-19 and the impact of handwashing interventions: the case of Zimbabwe. PLoS One. 2023;18(11):5.

29.

Gondo

Kolawole

. Household water access and COVID-19 in Karoi town, Zimbabwe. Sci Afr. 2022;16:2.

30.

Rogawski McQuade

Platts-Mills

Gratz

, et al Impact of water quality, sanitation, handwashing, and nutritional interventions on enteric infections in rural Zimbabwe: the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial. J Infect Dis. 2020;221(8):1379-1386.

31.

Gough

Moulton

Mutasa

, et al Effects of improved water, sanitation, and hygiene and improved complementary feeding on environmental enteric dysfunction in children in rural Zimbabwe: a cluster-randomized controlled trial. PLoS Negl Trop Dis. 2020;14(2):1-29.

32.

Chandna

Ntozini

Evans

, et al Effects of improved complementary feeding and improved water, sanitation and hygiene on early child development among HIV-exposed children: substudy of a cluster randomised trial in rural Zimbabwe. BMJ Glob Health. 2020;5(1):1-15.

33.

Bagamian

Anderson

IV Muhib

, et al Heterogeneity in enterotoxigenic Escherichia coli and shigella infections in children under 5 years of age from 11 African countries: a subnational approach quantifying risk, mortality, morbidity, and stunting. Lancet Glob Health. 2019;8(1):e101-e112.

34.

Mutsaka-Makuvaza

Matsena-Zingoni

Tshuma

, et al Knowledge, perceptions and practices regarding schistosomiasis among women living in a highly endemic rural district in Zimbabwe: implications on infections among preschool-aged children. Parasit Vectors. 2019;12(1):458.

35.

Midzi

Mtapuri-Zinyowera

Mapingure

, et al Knowledge attitudes and practices of grade three primary schoolchildren in relation to schistosomiasis, soil transmitted helminthiasis and malaria in Zimbabwe. BMC Infect Dis. 2011;11:2-9.

36.

Tshuma

Belle

Ncube

. An analysis of factors influencing household water, sanitation, and hygiene (WASH) experiences during flood hazards in Tsholotsho district using a seemingly unrelated regression (SUR) model. Water. 2023;15(2):371.

37.

Lampard-Scotford

Pfavayi

Kasambala

, et al Knowledge, attitudes, practices and behaviours (KAPB) around water, sanitation and hygiene (WASH) in villagers exposed to schistosomiasis in Zimbabwe. PLOS Water. 2022;1:4.

38.

Kanda

Ncube

Gadaga

Dudu

Makumbe

Nyamadzawo

. Contamination of soil around an abandoned gold mine tailings dam with trace elements in a small town, northeastern Zimbabwe. Int J Glob Environ Issues. 2019;18:283-455.

39.

Maponga

Chirundu

Gombe

Tshimanga

Shambira

Takundwa

. Risk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study. BMC Infect Dis. 2013;13:3-8.

40.

Gundry

Wright

Conroy

, et al Child dysentery in the Limpopo Valley: a cohort study of water, sanitation and hygiene risk factors. J Water Health. 2009;7(2):259-266.

41.

Ndlovu

Bhala

. Menstrual hygiene - a salient hazard in rural schools: a case of Masvingo district of Zimbabwe. Jamba. 2016;8(2):2-7.

42.

Ayling

Milusheva

Maidei Kashangura

Hoo

Sturrock

Joseph

. A stitch in time: the importance of water and sanitation services (WSS) infrastructure maintenance for cholera risk. A geospatial analysis in Harare, Zimbabwe. PLoS Negl Trop Dis. 2023;17(6):2.

43.

Moyo

Juru

Sibanda

, et al Risk factors for contracting watery diarrhoea in Mzilikazi, Bulawayo City, Zimbabwe, 2020: a case control study. Pan Afr Med J. 2022;41:145.

44.

Imanishi

Kweza

Slayton

, et al Household water treatment uptake during a public health response to a large typhoid fever outbreak in Harare, Zimbabwe. Am J Trop Med Hyg. 2014;90(5):945-954.

45.

Maruta

Matsa

Mupepi

Dzawanda

. Water safety and associated public health impacts in upcoming and informal urban settlements in Zimbabwe: case of Amsterdam Park in Harare. Sustain Water Resour Manag. 2023;9(5):138.

46.

Dembedza

Chopera

Macheka

. Water, sanitation and hygiene practices in areas affected by cyclone Idai in Zimbabwe. J Water Sanit Hyg Dev. 2024;14(7):532-542.

47.

Kanda

Ncube

Voyi

. Drivers and barriers to sustained use of Blair ventilated improved pit latrine after nearly four decades in rural Zimbabwe. PLoS One. 2022;17(4):3.

48.

ZIMSTAT, ICF. Zimbabwe demographic and health survey 2015: final report. 2016:19-183. Accessed July 25, 2025. https://dhsprogram.com/pubs/pdf/FR322/FR322.pdf

49.

ZIMSTAT, UNICEF. Zimbabwe Multiple Indicator Cluster Survey 2019, Survey Findings Report. ZIMSTAT and UNICEF; 2019:27-295.

50.

MoHCC. Zimbabwe Livelihoods Assessment Committee (ZimLAC) Rural Livelihoods Assessment Report. MoHCC; 2024:86-93.

51.

MoHCC. Zimbabwe Livelihoods Assessment Committee (ZimLAC) Urban Livelihoods Assessment. MoHCC; 2024:103-104.

52.

UNICEF. The Child Poverty in Zimbabwe: A Multiple Overlapping Deprivation Analysis of Multiple Indicator Cluster Survey 2019. UNICEF; 2021:11-55.

53.

Dhoba

. Strengthening water, sanitation and hygiene governance: a critical review of Zimbabwe’s WASH sector institutional arrangements. H2Open J. 2022;5(2):248-263.