The research of the Environmental Health Group (EHG) focuses on how WASH influences health and wellbeing, and how investments in these services can improve people’s lives.

For more detailed information about our group, please visit the About page and explore the individual research profiles. Also, browse our list of publications for more information on specific researchers, projects, grants, and collaborations across LSHTM and with other institutions.

Some of the research areas across the Environmental Health Group:

Undernutrition

Inadequate access to safe water, sanitation and hygiene services can limit healthy growth and development in children through multiple interacting pathways. In 2020, approximately 150 million suffered from chronic undernutrition or stunting, and 50 million suffered from acute malnutrition or wasting. EHG investigates how WASH influences childhood growth and development, and also works with operational agencies to design and evaluate WASH interventions to improve various outcomes on different forms of undernutrition. The EHG has worked with various organisations across the WASH and nutrition sectors to support evidence-based strategy and policy in this area of public health. These organisations include the World Health Organisation (WHO), UNICEF, the World Bank, WaterAid, and Action Against Hunger (AAH). Current research includes:

The TISA Trial in Senegal

This cluster randomised trial evaluates the effect of adding a simple WASH kit to the standard national protocol for outpatient treatment of severe acute malnutrition (SAM) on recovery. The study is led by a consortium of AAH Senegal, the Université Cheikh Anta Diop de Dakar, and LSHTM in partnership with the Ministry of Health for Senegal.

The SAM Relapse Study in Mali, Somalia and South Sudan

Funded by BHA, USAID, and led by Action Against Hunger, this multi-site study is designed to estimate the post-recovery rate of sever acute malnutrition (SAM) relapse. The EHG is leading a sub-study to investigate whether domestic WASH conditions and exposure to contaminated water and food increase the risk of relapse to SAM.

Urban Sanitation Birth Cohort in Mozambique

This longitudinal study follows two birth cohorts in neighbourhoods of Maputo (Mozambique) over the first two years of life to assess how environmental conditions and exposure to enteric pathogens influences disease and growth. This study is co-led with the National Institute of Health in Mozambique.

Gender and social inclusion

Research in WASH has enormous potential to contribute to greater equality and address discrimination on the basis of gender, disability or social group. Responsive and inclusive WASH removes barriers for people of all backgrounds and facilitates their right to education, health care, and their participation in communities and broader public spaces.

Several of the EHG research projects include efforts to address gender equity by exploring the WASH needs of girls when managing menstruation at school, and the health and social impacts that women face associated with WASH access in the household and public domains. Other examples of work in this area include:

Menstrual health

Menstrual health (MH) is a recognised global public health challenge. Poor MH may lead to absence from school and work, and adverse health outcomes. MEGAMBO is a cluster-randomized trial of a public health and school WASH intervention in The Gambia funded by the Medical Research Council (MRC).

Gender and sanitation

Under the LSHTM-led, FCDO-funded SHARE Consortium, LSHTM in partnership with Water Supply and Sanitation Collaborative Council funded multiple research studies exploring the impact of sanitation access and menstrual hygiene management on psychosocial stress, behaviour, and health among women and girls in India. Key publications from this work include articles on women’s challenges in accessing WASH, women’s sanitation related stress, and menstrual health and hygiene.

Gender and quality of life

EHG researchers are working with the African Population and Health Research Center (APHRC) in Kenya on a body of work on gender, sanitation, and quality of life (QoL). The initiative aims to establish an agenda for action across policy, practice, and research funded by the Bill & Melinda Gates Foundation (BMGF). It includes representative surveys in Kenya and India to estimate the gap in sanitation-related QoL outcomes between women and men, both between and within households.

Policy and economics of WASH systems

The EHG research engages with different aspects of the WASH system (e.g., institutions, policy, finance). The economics discipline focuses on how people make decisions about the allocation of scarce resources in the delivery and use of WASH services. Economics research within the group includes preference research, for example employing discrete choice and willingness to pay methods to understand how people trade off different attributes of WASH services. It also includes economic evaluation, using benefit-cost and cost-effectiveness analyses to assess the relative efficiency of programmes. Some recent work includes: 

Discrete choice experiments

Resource allocation should be informed by what people value in their lives. Working with the National Institute of Health in Mozambique, a discrete choice experiment was used to value (weight) attributes of a sanitation-related quality of life index (SanQoL-5) and explore associations of the index with toilet type.

Economic evaluation

Information on programme costs, as well as effectiveness, is crucial to priority-setting. Working with the World Health Organization (WHO), EHG researchers estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 least developed countries.

Other publications in this area include articles on water-adjusted person years, impacts on quality of life, and benefit-cost analysis.

WASH systems strengthening

Organisations working in WASH have increasingly adopted systems strengthening approaches, based on the understanding that sustainable WASH requires strong institutions, policies, and financing. LSHTM is partnering with IRC WASH, the University of Leeds, and the UK’s Foreign and Commonwealth Development Office (FCDO) to support inclusive and resilient WASH systems in five countries in sub-Saharan Africa and South Asia.

Behaviour and behaviour change

Understanding the determinants of WASH behaviours and developing and testing novel approaches to WASH behaviour change are central to the work of the EHG.

Spanning theoretical models to guide the development and design of behaviour change interventions, new methods for documenting and understanding behaviour and evidence synthesis. EHG researchers have also developed practical tools to support the rapid development of behaviour change interventions to inform global initiatives to improve hand hygiene. The behaviour and behaviour change research of the EHG has informed science, policy, and practice for decades, some recent work includes:

Project CLEAR in Tanzania

Reaching the Sustainable Development Goals (SDG) targets for sanitation will require national-level strategies. Commissioned by the Government of Tanzania with support from UK FCDO, Project CLEAR was led by EHG researchers - with partners at Innovex, McCann, and WaterAid - and supported the design, implementation, and evaluation of the National Sanitation Campaign. Articles have been published on the design and evaluation of this successful national campaign.

The COVID-19 Hygiene Hub

From hand hygiene to mask use and vaccine uptake, understanding and changing a range of behaviours was critical to reducing the impact of COVID-19. The EHG-led COVID-19 Hygiene Hub, funded by the Bill & Melinda Gates Foundation (BMGF) and FCDO, was a free service to help actors in low- and middle-income countries design, share, and adapt COVID-19 prevention programmes.

Safe Start Trial in Kenya

Complementary food hygiene is an important determinant of health among younger children. Together with partners from the Great Lakes University of Kisumu and University of Iowa, and under the FCDO-funded SHARE Consortium, the Safe Start trial explored the determinants of complementary food hygiene in urban informal settlements in Kisumu, Kenya, and designed and tested the delivery of a novel complementary food hygiene intervention. Publications of this work also include articles on infant food hygiene and childcare practices and environmental and behavioural risk factors for enteric disease in infants. 

WASH in institutions

Water, sanitation, and hygiene are important determinants of health and well-being across multiple settings. In healthcare facilities, poor WASH services and behaviour are linked with healthcare acquired infections, poor birth outcomes, and reduced patient satisfaction. In schools, WASH services are important predictors of student health and educational attainment, particularly among girls.

Research led by the EHG and its partner organisations has explored multiple aspects of improving WASH services in schools and health care facilities, documenting and measuring the impacts of institutional WASH interventions, and understanding how water, sanitation, and hygiene contribute to or mitigate critical health outcomes. Past and current work include:

Safe birth environments

As part of the FCDO-funded SHARE consortium, EHG researchers and LSHTM colleagues explored how water, sanitation, and hygiene services at home and in clinics contribute to maternal and neonatal health. Key publications from this work include conceptual models linking WASH to maternal and neonatal health and using secondary data to assess WASH service availability in birth environments at the national level.

CHAMP / CHAMP Plus

As part of the Australian Department of Foreign Affairs and Trade-funded Water for Women Programme, EHG researchers worked in partnership with WaterAid Cambodia and the Cambodian National Institutes of Public Health to develop and test innovative approaches to improving hand hygiene during childbirth and post-natal care in peri-urban settings in Cambodia.

Read findings from this research project – Changing Hygiene around Maternal Priorities (CHAMP) and it’s follow-up study – CHAMP Plus.

Humanitarian crises

Humanitarian crises are occurring at increasing rates and affecting a growing number of people. Evidence-based WASH strategies are vital to aid decision making and selection of effective, appropriate, and efficient interventions for people affected by or at risk of humanitarian crises. Over the years, EHG researchers have worked with humanitarian agencies to design and evaluate different interventions, including water infrastructure and hygiene kit distribution for cholera control and also qualitative research on hygiene and sanitation behaviours in refugee settings.

EHG also convenes the annual Emergency Environmental Health Forum which brings together researchers, operational actors and funder to discuss new research and operational innovation. Current EHG research projects include:

WASH in Crises Research Agenda 2023

The WASH in Crises Research Agenda serves as a guide for researchers, humanitarians, and donors providing a prioritised list of research questions that, when answered, will contribute to improved WASH policy and practice in humanitarian crises. Funded by ELRHA and conducted collaboratively by LSHTM, Tufts University and the Global WASH Cluster, the list of prioritised questions can be found in the full report.

Surprise Soap

The Surprise Soap project, funded by ELRHA, evaluated the distribution of a modified soap bar, designed to appeal to the motives of play and curiosity, in a rapidly deployable, handwashing promotion intervention for children in humanitarian settings. Read more from the proof-of-concept study and formative research in Northern Iraq in partnership with Save the Children, and results from two randomised control trials in Somalia and Sudan in partnership with Action Contre La Faim (ACF) and Care International.

WASH’EM

WASH’EM supports humanitarian actors to rapidly create context-specific hygiene programs that make a difference. WASH’EM was developed by EHG in collaboration with Action Contre la Faim (ACF), CAWST (Centre for Affordable Water and Sanitation Technology) and funded by the Bureau of Humanitarian Assistance (BHA), USAID. Access the assessment tools and recommendations through their website, and read papers on WASH’EM.

WASH-related pathogen transmission

Exposure to enteric pathogens is linked to adverse health outcomes like diarrhoea, poor growth, and reduced vaccine effectiveness. Characterising exposure and identifying important environmental transmission pathways of enteric pathogens is key to designing effective interventions that improve health. To achieve this, the EHG researchers use novel clinical and environmental microbiological tools to identify environmental hazards and measure past exposure via stool-based pathogen detection, behavioural science to better understand human interaction with hazards and interventions, and epidemiology to link pathogen exposure with health outcomes and assess how interventions impact exposure. This is an important area of research for the EHG, some recent work in this area includes:

SaniVac & EPIC

Sanitation interventions can reduce exposure to enteric pathogens and may improve oral rotavirus immunogenicity. In collaboration with the National Institute of Health in Mozambique, the SaniVac trial follows children born into compounds with and without access to an onsite sanitation intervention to assess: (1) seroconversion following vaccination, and (2) the rate of acquisition of enteric pathogens during early childhood. The Environmental Pathways of Infection in Children (EPIC) study builds upon the SaniVac study and aims to identify how children in this setting are likely exposed to enteric pathogens.

Cholera endemic settings

Working with national actors, including the Ministry of Health of DRC and the national water utility, REGIDESO, the EHG has studied cholera in the city of Uvira in eastern Democratic Republic of the Congo (DRC) since 2009. Funded by the Agence Française de Développement and the Veolia Foundation, evaluated the impact of a largescale water supply intervention on cholera. More recently, and funded by GAVI and the Wellcome Trust, and in collaboration with Johns Hopkins University, the EHG has assessed the effectiveness of a single dose oral cholera vaccine, and is now investigating the environmental exposures that drive household transmission.

Urban Infant Foodscape

Contaminated food is an important transmission pathway for enteric pathogens and is responsible for a substantial health burden globally. Funded by the Bill and Melinda Gates Foundation, and in collaboration with the National Institute of Health in Mozambique and the International Livestock Research Institute in Kenya, the EHG is examining risk factors for food contamination and enteric infection across the entire food system, from production to household.