Mapping the evidence on environmental health services in healthcare facilities in low- and middle-income countries: A systematic literature inventory of over 4,000 studies

Abstract

Background: Environmental health services in healthcare facilities -including water, sanitation, hygiene, waste management, cleaning, and infection control-prevent disease and strengthen healthcare delivery. Yet environmental health service provision is inadequate in many low- and middle-income countries (LMICs). Despite the importance of monitoring and improving services, no comprehensive evidence map exists to describe global knowledge and gaps for action and improvement. The study objectives were to comprehensively catalog published literature on environmental health services in healthcare facilities in LMICs by service domain, study type, and relevance to policy and practice.

Methods: We conducted a systematic literature search in 2023 and performed an update in 2025. Through a title/abstract screening and tagging process, we developed a literature inventory that categorized studies by topic, design, and relevance to policy and practice objectives.

Results: The literature inventory included 4,381 studies. Fifty-eight percent of the studies were baseline assessments of environmental health services, 36% involved formative research (e.g., qualitative methods), and 13% evaluated interventions or implementation strategies. Most studies (62%) examined hygiene at points of care, while 9% examined water and 6% sanitation. Twenty-seven percent of studies examined services in the context of the COVID-19 pandemic.

Conclusions: There is little evidence for effective interventions and implementation strategies to improve and sustain environmental health services, especially for water and sanitation services. Formative research on under-studied services can help policymakers and practitioners identify areas to prioritize investment and programming. Findings can inform the development of research agendas and practical guidelines for improving access to safe healthcare environments.

Keywords: WASH; healthcare; infection control; sanitation; systematic review; water.

Figure 1.

ROSES flow diagram for studies included in a systematic evidence map of environmental health services in healthcare facilities in low- and middle-income countries, 2025.

Figure 2.

Tableau interactive dashboard for evidence map and literature inventory, including default view (top) and view when filtered to show studies related to sanitation (bottom).

Figure 3.

Heat map of methods and environmental health service topics for 4,381 studies on environmental health services in LMIC healthcare facilities. Studies that involved multiple methods and/or topics are included in all applicable heat map cells.

Figure 4.

Heat map of policy-practice relevance and environmental health service topics for 4,381 studies on environmental health services in LMIC healthcare facilities. Studies that involved multiple practical steps and/or topics are included in all applicable heat map cells.

Figure 5.

Geographic distribution of 4,381 studies on environmental health services in healthcare facilities across low- and middle-income countries. A darker color indicates a larger number of identified studies.

Figure 6.

Time trend in the annual number of studies published on environmental health services in LMIC healthcare facilities.