Background

The United Nations’ Sustainable Development Goal 6 (SDG 6) emphasises the need for universal access to clean water, sanitation and hygiene (WASH) to ensure human well-being as a fundamental human right for sustainable development.1–5 WASH refers to water, sanitation and hygiene which are essential for health and well-being.6 It encompasses access to clean portable drinking water, safe sanitation facilities and good hygiene practices that are meant to improve health outcomes and minimise the spread of communicable diseases associated with unsafe drinking water, poor sanitation and unsafe hygienic practices.7 8 Millions of people worldwide still lack access to clean water for drinking and sanitary facilities.9–11

In 2022, there were still 2.2 billion people without access to safely managed drinking water, including 703 million people lacking a basic water service. Those lacking access to safely managed sanitation were 3.5 billion, and 2 billion lacked a basic handwashing facility at home with soap and water, including 653 million without one at all.11 12 This condition has made people worldwide vulnerable to a wide range of public health and environmental challenges, which has hindered socioeconomic growth.13 Every day, about 1000 children under the age of 5 die globally as a result of unsafe WASH.12 14 15

The availability of safe drinking water is still a serious problem worldwide, particularly in rural regions, where, according to UNICEF, 80% of people lack access to better water systems.2 16 In rural and underdeveloped areas, one-third of the world’s population lacks access to bacteria-free drinking water.17 Since 2016, more than 70% of countries have explicitly outlined legal or policy procedures for involving local communities in managing water resources and providing rural residence access to clean drinking water. Current global rates of progress in access to clean drinking water, sanitation and hygiene should be accelerated three to six times to reach universal coverage by 2030.5 11 12

Global water use efficiency increased by 9% between 2015 and 2020, from $17.4/m3 to $18.9/m3, with major regional variations, including an 18% increase in Northern Africa and Western Asia between 2015 and 2020. Between 2015 and 2021, official development assistance (ODA) payments to the water sector declined by 15% from $9.6 billion to $8.1 billion. The total amount of ODA pledged to the water industry decreased from $11.2 billion in 2015 to $9.8 billion in 2021, a 12% decrease.11

Most people affected by poor WASH live in low- and middle-income countries (LMICs).10 Africa’s sub-Saharan region lags the most, with 17 nations having less than 40% of basic drinking water facilities and 16 nations having less than 40% of basic sanitation facilities. In pursuit of the 2030 Agenda, the continent has a wide gap in meeting its water and sanitation targets.18 19 Within LMICs, inadequate WASH for urban areas is an emerging policy concern in Africa.20

A previous study by Rahut et al highlighted that 16 of the 23 sub-Saharan African countries had less than 70% basic drinking water coverage.16 Urban households were 1.9 and 1.2 times higher, respectively, than those of rural households to access basic drinking water and hygiene services. In sub-Saharan Africa, approximately 98% of individuals with limited access to safe drinking water live in rural areas. Approximately 42% of the rural population continues to practise open defecation.21

Zimbabwe is one of several African nations fighting to reduce morbidity and mortality from waterborne and water-related illnesses.22 In pursuit of the transformative 2030 Agenda for Sustainable Development, Zimbabwe, like many nations, faces the pressing challenge of achieving SDG 6 to ensure access to clean water and sanitation.10 The country continues to face significant challenges with WASH.4

In Zimbabwe, the water-related indicators revealed differing levels of progress, having access to safe drinking water at 27% progress against the country’s National Development Strategy (NDS) target of 83% and sanitation achievement at 32% against the NDS target of 73%, respectively. The hygiene practices indicator for Zimbabwe shows 42% progress against a global performance of 75%.11 Rural areas account for over 30% of households accessing drinking water from unimproved sources in Zimbabwe.23 Despite the Zimbabwean government’s efforts to increase access to WASH, significant disparities remain because of inadequate resources, frequent droughts and rapid urbanisation. To mitigate the impact of WASH-related diseases and expand access to potable water and sanitation, it is vital to implement research-informed interventions and maintain investment in the WASH infrastructure. It should also be noted that some unplanned events could have impacted WASH-related issues and influenced health outcomes. Because of the cyclones, the COVID-19 pandemic and dry spells that have occurred over the past few years, there is a need to review evidence of what has transpired as far as WASH-related issues are concerned, with the aim of consolidating all the findings into one review that would give a better and integrated account of occurrences to inform policies. Therefore, the proposed scoping review provides a window of opportunity for synthesising the available evidence. This systematic review, therefore, aims to explore the status of WASH and health outcomes in Zimbabwe. In line with the primary objective, this systematic review seeks to answer the wider research question, ‘How has WASH status affected the health outcomes in Zimbabwe?’ As a result, this study proposes leveraging the existing literature to address specific objectives and the corresponding review questions outlined in table 1.

Table 1

Specific objectives and the corresponding research questions

Methods and analysisStudy setting

This study focuses on Zimbabwe, a landlocked country in Southern Africa, sharing borders with Mozambique to the east, South Africa to the south, Botswana to the west and Zambia to the north and northwest. It comprises 10 provinces, with eight being rural and two metropolitan (figure 1). Rural provinces were subdivided into 63 districts. The country includes 15 major cities and small towns. Both rural and urban areas have smaller administrative units known as wards. In the 2022 census, the estimated human population of Zimbabwe was 15 178 979.23 The country is located in a semiarid region with unpredictable rainfall. Low-lying areas, particularly along rivers and streams, are vulnerable to flooding during heavy rainfall, notably in the Zambezi River Basin in the north. The southern and western parts of Zimbabwe, including regions such as Matabeleland and Masvingo, are often prone to drought due to lower and erratic rainfall, leading to water scarcity and socioeconomic challenges which could impact WASH status and related health outcomes.17 23 24

Figure 1

Geographic areas covered by this scoping review. Studies published about Zimbabwe, as depicted in the map, would be considered for inclusion in the scoping review as long as they meet the other criteria described in the inclusion and exclusion criteria.

Zimbabwe is one of several African nations fighting to reduce morbidity and mortality from waterborne and water-related illnesses.22 Rural areas account for over 30% of households accessing drinking water from unimproved sources in Zimbabwe.23 Trends in key performance indicators highlight the major disparities between urban and rural areas. Rural households accounted for 67.4%, whereas urban households accounted for 23.6% of the travel to collect water for general use within 30 min. There were 2 795 386 (73.2%) households with handwashing facilities in urban areas, while there were 1 023 348 (26.8%) rural households.4 23 25 More than 60% of rural water supply infrastructure is in ruins, and 44% of people in remote areas practise open defecation, with schistosomiasis affecting 62.3% of the population in some areas.26

Previous studies have revealed that persistent cholera epidemics highlight a lack of access to basic sanitation, clean water and healthcare. The breakdown of potable water and sanitation infrastructure, backed by the widespread contamination of readily accessible drinking water sources, has contributed to the rapid, widespread transmission of epidemics in Zimbabwe.27

Study design

The scoping review seeks to respond to the research questions by employing the research philosophy of pragmatism, which recognises the importance of practical and adaptable methodologies.28–31 A scoping review is a literature review that maps the key concepts, types of evidence and research gaps related to a particular topic.32 33 It is not limited to specific study designs, allowing for the inclusion of a diverse range of evidence, such as quantitative and qualitative studies, policy documents and grey literature.33 This inclusivity is crucial for gaining a holistic perspective of Zimbabwe’s WASH and the health landscape. Considering our proposed timelines, a scoping review is a feasible choice, as it is generally more time efficient, yet allows this study to address the objectives (table 1).

Data and information sources

This review involves the collection of published and grey literature meeting the inclusion and exclusion criteria (table 2) with a specific emphasis on WASH status and health outcomes in Zimbabwe. The primary databases, including PubMed, EBSCO, SAGE, SpringerLink, Nature, Cochrane Library, ScienceDirect, Scopus, Web of Science, African Journals Online and ProQuest, were searched for relevant sources published in English with an unrestricted search back (ie, dating back to the inception of the databases) until May 2024. It should be noted that studies addressing multiple settings and countries will also be included if they address WASH issues related to Zimbabwe. These can be largely accessed from the University of Indonesia’s (UI) link (https://remote-lib.ui.ac.id/menu). The selected databases are reputable and cover a wide range of disciplines, ensuring a mix of high-quality sources and comprehensive understanding of Zimbabwe’s WASH status and health milestones. This approach minimises the risk of bias by relying solely on a single database (Chigbu et al34 2023). Additionally, organisational websites and databases such as the Government of Zimbabwe websites, the Global Analysis and Assessment of Sanitation and Drinking Water and the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene will be searched for grey literature. The unrestricted search until May 2024 allows for the consideration of specific events, policy changes, or environmental, socioeconomic and political factors that might have occurred in the past and could influence WASH status and health outcomes in Zimbabwe.

Table 2

Inclusion and exclusion criteria

Search strategy

The proposed search strategy for peer-reviewed literature comprises search terms within the three main constructs underpinning the review research questions: (1) WASH status (progress and challenges), (2) WASH-related health outcomes and (3) WASH interventions. A librarian from the UI will be iteratively consulted to develop and refine the search strategy, whereby database-specific search terms and related Boolean operators will be used. Therefore, the main Boolean operators (AND, OR), but with slight variation depending on the search database, are used to combine the following proposed search string:

“Water, Sanitation, and Hygiene” OR “WASH” OR “Sanitation services” OR “Clean water supply” OR “Hygiene” OR “Inadequate access” OR “Lack of access” OR “Limited access” OR “Poor access” OR “WASH Infrastructure” OR “Health inequalities” OR “Health determinants” OR “Water quality” OR “Water contamination” OR “Water-borne pathogens” OR “Water treatment” OR “Sanitation facilities” OR “Toilet facilities” OR “Open defecation” OR “Sewage disposal” OR “Hygiene practices” OR “Menstrual hygiene” OR “Menstrual health” OR “Sanitation” OR “Handwashing” OR “Personal hygiene” OR “Behavior change” OR “Interventions” OR “WASH programs OR “WASH initiatives” OR “Policy measures” AND “health impacts” AND “Population health” AND “Child health” AND “Health disparities” AND Maternal health AND “Household health” and “Hygiene-related diseases” AND “Sanitation-related diseases” AND “Health Outcomes” AND “Health effects” AND “Health impacts” AND “Public health” AND “Disease prevalence” AND “Disease incidence” AND “Water-borne diseases” AND “Community health” AND Zimbabwe.

Furthermore, beyond the published literature, a manual search of government reports, policies and reports from non-governmental organisations addressing WASH issues will be snowballed and included in this research. In this study, Mendeley software will be used to download documents in the Research Information Systems format, taking advantage of its ability to efficiently organise, store and cite references.35 36 The titles and abstracts of articles retrieved from the databases in response to the search terms will be imported into Rayyan, a cloud-based tool (https://www.rayyan.ai/) designed to facilitate collaborative efforts among reviewers. This tool will aid in identifying and organising relevant sources for scoping review.37–39 Integrating these tools will create a more efficient and organised scoping review process. It is worth noting that the literature search process will be conducted in collaboration with a qualified librarian at the UI to maximise the comprehensiveness of the review.

Screening process

This study employs a two-step screening process to identify relevant literature. This approach is essential because systematic searches frequently yield substantial literature.33 The initial phase of study selection involves reviewing the titles and abstracts of the articles identified through a systematic search. Two independent reviewers simultaneously commenced this process. While the first reviewer will screen all titles and abstracts, the second reviewer will randomly screen at least 20% of the titles and abstracts. To assess inter-rater reliability, this study employs Cohen’s kappa coefficient statistics to estimate the extent of agreement or disagreement between the two reviewers. Suppose that the titles and abstracts align with the inclusion criteria established by the researchers (table 2). In this case, the screening process proceeds to the second stage of study selection, which involves a thorough examination of the full-text articles. Similarly, when the title and abstract lack adequate information for determining eligibility, the material will be subjected to a full-text review by the two reviewers. These processes adhere to the frameworks designed to enhance rigour, as outlined in the strategies to enhance the rigour paragraph. If inter-rater reliability cannot be reached, a third reviewer will act as a mediator in the screening process to resolve any disagreements that could have arisen between the two independent reviewers. Researchers will employ the citation mining approach to examine the reference lists or bibliographies of the final selected articles within Mendeley and Rayyan outputs to identify any potentially overlooked relevant sources.

Strategies for enhancing rigour

Evaluating the quality of the screened literature is crucial as it ensures that the selected literature is appropriate in answering the scoping review questions comprehensively, thereby improving the reliability of the evaluation process.40–42 Critical appraisal checklists from the Critical Appraisal Skills Programme offer specific criteria for assessing different research types, such as randomised controlled trials, cohort studies and case–control studies.43 44 These checklists guide researchers through key questions to evaluate the strengths and weaknesses of these specific studies, thus helping to determine the trustworthiness and relevance of the research for scoping review needs.45–47 The results will be analysed descriptively, and the reporting will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (making use of 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.48 49 The frameworks in this protocol will guide the development of a structured data extraction tool that will enable the collection and organisation of contextual data in response to the identified variables from the specific review questions and objectives in tables 1 and 2. These variables may include information about the study context (including study population, design and setting/location with Zimbabwe), WASH interventions from policy to activities, all WASH-related health outcomes beyond diarrhoeal conditions/diseases, and measurement outcomes, such as prevalence, ORs and relative risk. This form serves as a guide for collecting and organising information from the literature so that the extracted data can be entered into a structured database or spreadsheet, aligning each piece of information with the corresponding data variable.50

Analysis and synthesis

The results will be analysed descriptively, as it may not be feasible to perform a meta-analysis given the potential limitation of the low number of studies and variability in interventions or outcome measures. The extracted data will be synthesised quantitatively by examining the data to identify patterns, relationships or trends between WASH-related variables and health outcomes, and qualitatively by employing thematic analysis in line with the objectives and research questions (table 1). Additionally, data charting streamlines the synthesis of data, thereby making it more accessible for analysis and interpretation. Conclusions will be directly tied to the research objectives and the evidence collected and analysed.

Strengths and limitations

The utilisation of a longitudinal timeframe in this research design offers a distinctive strength by allowing for the assessment of both short- and long-term WASH measurement outcomes and providing a comprehensive understanding of the temporal dynamics involved. Another notable strength lies in the broader focus on WASH-related health outcomes beyond diarrhoeal conditions, which contributes to a more holistic exploration of the subject matter. Including grey literature, such as unpublished theses, further enriches the scope of the review and captures valuable insights that might not be available through traditional publication channels. Additionally, rigorous searches of highly comprehensive databases have enhanced the reliability of this study. However, the decision to restrict the scope of the study to Zimbabwe while enhancing its contextual relevance may limit the external validity of the findings to other settings. Moreover, the potential heterogeneity between studies regarding interventions, populations and outcomes poses a challenge to the generalisability of the findings. This heterogeneity may hinder the seamless integration of results into broader contexts, emphasising the importance of cautious interpretation and context-specific application of the research outcomes.

Patient and public involvement

None.

Timelines

The timeline for the scoping review, set to initiate in May 2024, and the subsequent submission of the final review manuscript to a journal by October 2024 have been carefully crafted to ensure a comprehensive and rigorous examination of the relevant literature (table 3). Recognising the potential variability in data complexity, an ample timeline was allocated to ensure that the reviewers adhered to the rigorous standards set by PRISMA-ScR. This comprehensive approach guarantees a transparent and thorough account of the review process and enables the incorporation of valuable feedback. Providing ample time to the researchers in this study is crucial for ensuring a rigorous synthesis of the extracted data which requires organising and summarising information and the critical task of identifying patterns, trends and gaps within the existing literature. This intricate process requires sufficient time for a thoughtful analysis and reflection. Additionally, the interpretation and discussion phase, where findings are contextualised within the broader research landscape, requires careful consideration, which is facilitated by a well-paced research timeline. Finally, investing sufficient time in each process in this study improves the quality of the research and robustness of the results. This iterative procedure refines the text and guarantees that the final result meets the journal’s standards.

Table 3

Proposed study timelines