Social and geographic inequalities in water, sanitation and hygiene access in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe

Abstract

Introduction: Many refugees face challenges accessing water, sanitation, and hygiene (WASH) services. However, there is limited literature on WASH access for refugee populations, including for menstrual health services. Unmet WASH access needs may therefore be hidden, amplifying morbidity and mortality risks for already vulnerable refugee populations. The aim of this study was therefore to quantitatively analyze WASH access among refugee camps, with a focus on households with women of reproductive age.

Methods: This was a cross-sectional study that utilized the Standardized WASH Knowledge, Attitude and Practice (KAP) Survey. A total of 5632 household questionnaires were completed by the United Nations Refugee Agency in 2019 in 21 refugee camps and settlements in Bangladesh, Kenya, South Sudan, Uganda, and Zimbabwe. WASH access (14 items) and social and geographic stratifiers were analyzed at the household-level including the refugee camp, country of the settlement, having women of reproductive age, members with disability/elderly status, and household size. We calculated frequencies, odds ratios, and performed bivariate and multivariate analyses to measure inequalities. We developed a Female WASH Access Index to characterize WASH access for households with women of reproductive age.

Results: Most refugee households had high levels of access to improved water (95%), low levels of access to waste disposal facility (64%) and sanitation privacy (63%), and very low access to basic sanitation (30%) and hand hygiene facility (24%). 76% of households with women of reproductive age had access to menstrual health materials. WASH access indicators and the Female WASH Access Index showed large inequalities across social and geographic stratifiers. Households with disabled or elderly members, and fewer members had poorer WASH access. Households with women of reproductive age had lower access to basic sanitation.

Conclusions: Large inequalities in WASH access indicators were identified between refugee sites and across countries, in all metrics. We found high levels of access to improved water across most of the refugee camps and settlements studied. Access to basic hygiene and sanitation, sanitation privacy, waste disposal, and menstrual health materials, could be improved across refugee sites. Households with women of reproductive age, with 4+ members, and without members with disability/elderly status were associated with higher WASH access. The female WASH access index piloted here could be a useful tool to quickly summarize WASH access in households with women of reproductive age.

Keywords: Africa; Asia; Menstrual health; Refugees; WASH; WASH access index; Women.

Fig. 1

Percentage of Household with WASH Access Indicators in 21 Refugee Camps in 2019. This heat map illustrates the percentage of households with WASH access among 21 refugee camps in Bangladesh, Kenya, South Sudan, Uganda and Zimbabwe in 2019. On the y axis six selected WASH indicators are shown, and on the x axis the name of refugee camps followed by the abbreviation of the settlement country. The lighter the color in the box, the lower the percentage of households with WASH access in the corresponding refugee camp. This figure was created from the Standardized WASH KAP Surveys, UNHCR, 2019

Fig. 2

Percentage of Households with WASH Access by Household Characteristics in 21 Refugee Camps in 2019. This heatmap illustrates the percentage of households with WASH access according to having at least one woman at reproductive age (left), having members with disability or who are elderly (center), and household size (right) in 21 refugee camps in five countries in 2019. On the y axis, six selected WASH indicators are shown, and on the x axis the household characteristics. The lighter the color in the box, the lower the percentage of households with WASH access in the corresponding group. This figure was created from the Standardized WASH KAP Surveys, UNHCR, 2019

Fig. 3

Female WASH Access Index in 21 Refugee Camps in 2019. This bar graph illustrates the Female WASH Access Index according to 21 refugee camps in five countries in 2019. On the y axis the Female WASH Access Index value is shown, and on the x axis the name of refugee camps. Each settlement country is indicated by a different color. This figure was created from the Standardized WASH KAP Surveys, UNHCR, 2019

Fig. 4

Female WASH Access Index by Household Characteristics in 21 Refugee Camps in 2019. This bar graph illustrates the Female WASH Access Index according to household size (left) and having members with disability or who are elder (right) in 21 refugee camps in five countries in 2019. On the y axis, is the Female WASH Access Index value, and on the x axis the corresponding household characteristic. This figure was created from the Standardized WASH KAP Surveys, UNHCR, 2019

Fig. 5

Multivariate Association with Female WASH Index Among 20 Refugee Camps Households in 2019. This graph illustrates the multivariate association with Female WASH Access Index among social and geographic stratifiers in 20 refugee camps households with at least one woman of reproductive age in 2019. On the y axis, are the social or geographic predictors, the name of each refugee camp is followed by the abbreviation of the settlement country. On the x axis the effect, outlined by the dotted line that represents the zero effect. Black points represent effects and white points references. The horizontal lines that cross each black point represents the CI95%. Kyangwali, Uganda refugee camp is not included in the multivariate logistic regression. This figure was created from the Standardized WASH KAP Surveys, UNHCR, 2019