Background: Lack of sanitation facilities and inadequate water is key to many diseases' outcomes, mainly diarrhea. These factors affect the health status of a country and result in increased mortality and morbidity pattern, particularly among the vulnerable population like children and women. Thus, the study assesses the linkages between diarrheal diseases and sanitation in Afghanistan affected since long by political instability, which has derailed the country's health system.
Methods: We used the 2015 Afghanistan Demographic and Health Survey to assess the linkages between sanitation and diarrheal diseases among under-five children. Bivariate and multivariate analyses have been used to carry out the study. The logistic model was used to evaluate the risk factors that lead to diarrheal outcomes.
Results: Our findings from the results showed that the prevalence of diarrhea among under-five children in Afghanistan was 29%. Pashai is the most affected, with 36% among ethnicities, whereas eastern Afghanistan is the most affected region with a prevalence of (38%). Open defecated Population (OR: 1.17, p<0.001), Tap water (OR: 1.31, p<0.001), Well water (OR: 1.24, p<0.001), and Sharing toilet (OR: 1.15, p<0.001) are significantly associated with childhood diarrhea.
Conclusions: A significant impact has been found with inadequate sanitation, shared toilet facility, clean water, and other elements with childhood diarrhea in Afghanistan. The region-wise difference has also been found to be very high across the regions. Thus, it has been found that a lack of such factors has a more significant impact on children's health and needs a particular focus from a policy purpose.
Morbidity patterns resulting from pneumonia, diarrhea, fever, and acute respiratory infection are vital in increasing the risk of mortality among under-five children 1 , 2 . Diarrheal diseases constitute a significant problem among under-five children worldwide after pneumonia 3 , 4 . Children in the developing world are positively affected by diarrheal diseases, which can be preventable and eradicated by possible interventions 5 , 6 . Previous studies have shown that children in developing countries are ten times more likely to die before five years than children in the developing world 7 , 8 . Empirical studies reflect this fact that one-fourth of these deaths among children result in south Asia among the under-five children, and Afghanistan is one of the most affected countries in the region 9 , 10 , 11 , 12 , 13 . According to the 2015 Afghanistan Demographic and Health Survey (AfDHS) report, around one in every 18 children die before completing the age five in Afghanistan, and these deaths mostly occur in the very first year of birth among children 14 . The risk factors to these deaths are manifold and result from both demand and supply-side factors. Other things include the lack of spending in the health care system and socio-behavioral and contextual factors.
Diarrhea is the second leading cause of deaths, accounting for nearly one in every nine deaths worldwide 15 . It is one of the largest reasons for the disease burden in Afghanistan after pneumonia 16 .
Figure 1 . Percentage of deaths due to diarrhea in Afghanistan from 2000-2015.
The above figure Figure 1 shows the percentage of deaths due to diarrhea in Afghanistan since 2000 based on UNICEF data, and the results show that although there is a decline in diarrheal deaths, it still accounts for nearly 9% of deaths. A recent survey of 2015 AfDHS showed that around 29% of children have an acute diarrheal disease in Afghanistan. Therefore, the present study explores the possible factors that affect the greater prevalence of diarrhea among under-five children based on the recent round of 2015 AfDHS.
According to UNICEF, around 2.4 billion people lack adequate sanitation facilities globally, and approximately 663 million people do not have access to improved water 5 . However, the SDG have aimed at improving the conditions of health, particularly of children and women. Nevertheless, these challenges persist and affect a grander scale through morbidity and mortality patterns among under-five children, particularly in developing countries. Children at younger ages are at greater risk of water-borne diseases like diarrhea, affecting their health and well-being and putting them at greater risk. Around 800,000 children die yearly due to conditions resulting from the lack of sanitation facilities cured 15 . Diarrhea has become one of the leading causes of morbidity and mortality among children 17 . Though the diseases have attributed to many factors, some closely associated reasons are inadequate water and lack of sanitation facilities 18 . These factors affect the burden of diarrheal deaths and contribute to a greater prevalence of acute diarrheal diseases 19 . A study has found that socio-demographic factors have played an essential role among Congo children. Other factors, such as open defecation, unhygienic practices, and unimproved water, have shown a significant effect on a child's health 20 . Numerous studies in this context have found that households having inadequate sanitation facilities have a more substantial impact on the incidence of diarrheal outcomes 21 , 22 . A study 23 showed that drinking water availability is an essential factor and lack of it results in a greater incidence of childhood diarrheal deaths. A report on Sustainable Development Goals in 2017 also reflected that higher risk for infectious diseases like diarrhea is mainly due to the lack of safe water sanitation and other hygiene services 24 . Increased risk of diarrhea is also due to sanitation facilities' proximity to homes, the sharing of sanitation facilities, and poor hygiene 25 .
Diarrheal deaths account for nearly 1.87 million deaths annually, resulting in numerous factors but primarily due to unsafe water and inadequate sanitation 7 , 9 . Better sanitation facilities are essential to reduce diarrheal morbidity 26 . Studies clearly show that sanitation infrastructure is most effective, reducing diarrhea incidence by about 20% while as clean water by 11% 27 . It has been observed that interventions in providing better access to clean water and toilet facilities lower the risk of diarrhea reduction ranging from 27% to 53% among the children aged below five years 28 . Improved sanitation and hygiene are essential to avert the impact of diarrheal deaths 29 . However, a better standard of living conditions can also reduce the burden of diarrhea among under-five children 30 . Thus, targeting the measures that can reduce the levels of inadequate sanitation and lack of access to clean water can lower the morbidity patterns resulting from diarrhea among children aged below five, particularly in a developing world 31 .
Furthermore, hygiene improvement effectively reduces diarrhea and is a critical element of child health and nutritional promotion 32 , 33 , 34 . Though the evidence is strong despite this, there has been little sound evidence published so far on to what extent the availability and utilization of latrines and better water facilities can reduce diarrheal prevalence 35 , 36 and the country like Afghanistan has least explored. Therefore, this study tried to examine the linkages between diarrhea and its possible association with sanitation and inadequate water facilities.
Diarrhea is defined as the passage of three or more liquid stools within 24 hours 26 . Diarrhea can last for several days, but according to this study, acute diarrhea is the condition where a child suffers from diarrhea for less than 14 days since this leads to severe dehydration and loss of fluids resulting in diarrheal deaths. According to WHO, other causes like septic bacterial infections also account for more diarrheal deaths. Whereas medically, it is defined as a symptom of infection in the intestinal tract, resulting in bacterial, viral, and parasitic organisms were resulting in unimproved water, inadequate sanitation, and poor hygiene.
Sanitation is critical to promote not just human health but also socio-demographic conditions like food security, women empowerment, girl education, social security, and reduction in morbidity and mortality. It just not reduces intestinal and vector-borne diseases but also has a significant impact on diarrhea 28 . In simple words, sanitation means the provision of facilities and services for the safe disposal of human urine and feces. Sanitation refers to the maintenance of hygienic conditions through services such as garbage collection and wastewater disposal. The study uses various measures to measure sanitation access, such as lack of adequate water, toilet facility, access to water, and toilet-sharing facilities.
Material â€” Methods
The data of the study has taken from Afghanistan Demographic and Health Survey (AfDHS) conducted in 2015-16. AfDHS surveys consist of data on a wide range of public health topics, including anthropometric, demographic, socio-economic, family planning, and domestic violence issues. The AfDHS (2015-16) provides up-to-date information on the respondents' socio-demographic characteristics between the ages of 15â€“49 from randomly selected households. AfDHS is a national sample survey that provides up-to-date information on fertility levels; marriage; fertility preferences; awareness and use of family planning methods; child feeding practices; nutrition, adult, and childhood mortality; awareness and attitudes regarding HIV/AIDS; women's empowerment; and domestic violence.
The total sample for this analysis was 30303 children aged 0-59 months, who had complete morbidity data and were living with their mothers at the survey time. The AfDHS collected data on morbidity such as diarrhea, which is defined as passing three or more liquid, watery or loose stools per day. The data was collected based on a survey question to mothers, whether any of their children below five years of age had diarrhea during the preceding weeks in the survey.
The outcome variable was the prevalence of diarrhea during the two weeks. This question was asked to Mothers whether or not their child suffered from diarrhea during the past two weeks. The leading independent variables are proxies of indicators like sanitation facility, drinking water, and other socio-demographic variables like age of the child, sex residence, and region.
Bivariate and Multivariate analysis was carried out in the paper to study the association between sanitation and diarrhea. We used a logistic model with a dependent variable categorized into a binary outcome variable as diarrhea and regress it with other closely associated risk factors.
Figure 2 shows the prevalence of diarrhea by regions. Diarrheal prevalence has found to be higher in the Eastern region (39%) of Afghanistan, followed by West (31%) and North (30%) regions. In contrast, lower prevalence is in the Sothern region of Afghanistan (23%). Here, the prevalence rate has been computed by regions, and the values were significant at one percent level of significance for all the regions.
Figure 2 . Prevalence of diarrhea by regions in Afghanistan in 2015.
Figure 3 shows the prevalence of diarrhea by ethnic groups, which has the highest among the Pashai (35%), followed by Uzbeks (33%). The lowest prevalence was found to be among the Balochs, which was just 15 %. Here, the prevalence rate has been computed by ethnic groups, and the values were significant at one percent level of significance for all the ethnic groups.
Figure 3 . Prevalence of diarrhea by ethnic-groups in Afghanistan in the year 2015.
Table 1 shows the prevalence of diarrhea and demographic and socio-economic characteristics prevalence of diarrhea is higher among the children aged 6-12 and 13 to 24 months. Similarly, we see prevalence higher among female children than male children. We found that diarrhea among children was found to be higher among working women. In contrast, children of adolescent mothers have a 2% higher prevalence of diarrhea than the children of adult mothers. Those householdsâ€™ children who are defecating in the open area are having a higher prevalence of diarrhea. Similarly, the prevalence of diarrhea is also higher among those householdsâ€™ children who are sharing toilets.
Table 2 studies the association of diarrhea and various determinants of sanitation and water and some vital demographic factors. We found that age is closely associated with diarrhea, particularly from 6 to 18 months (OR = 2.26 & 2.45; p < 0.001). Similarly, female children are 6% less likely to have diarrhea than males (OR = 0.94; p < 0.001). Our results showed that children belonging to households defecating in the open are 17 times more likely to have diarrheal diseases than those that do not (OR = 1.17; p < 0.001). Similarly, we can see that children belonging to households sharing toilets are at greater risk of diarrheal diseases (OR = 1.15; p < 0.001). Simultaneously, it has been found that those using tap water are at greater risk of having diarrheal diseases followed by well water (OR = 1.31 & 1.24 p < 0.001). Similarly, those taking another form of water are also at a greater risk of having any diarrheal diseases with an odds ratio of 1.12 at a 10% significance level.
Child health is an important issue to be addressed around the globe. Deteriorating child health also has long-run consequences on the health system apart from its socio-economic adversities. Child health is affected by various diseases ranging from diarrhea to acute respiratory infections due to vulnerability and less immune systems of children at an early age than the other population groups 37 . Furthermore, the lack of better access to sanitation and clean water results in children's greater vulnerability at a lower age and puts them at higher risk. It has been found that nearly 90% of diarrheal deaths occur among children in developing countries 38 , 39 , 40 . Studies show that low-income countries are not just affected by deficient water system but by higher open defecation levels and lack access to adequate drinking water 7 , 41 .
Afghanistan is one of the most affected regions globally due to conflict, and the health system is one of the poorest. While it is evident that higher rates of diarrhea prevail due to multiple risk factors ranging from socio-demographic to economic factors 42 , 43 . Nevertheless, our study focused mainly on the aspects related to sanitation and water-hygiene. While examining a few behavioral factors like age, sex of the selected population, we found their impact very much consistent with the earlier studies 43 , 44 , 45 , 46 , 47 . To address this paper's key purpose, we studied the factors like open defecation, shared toilet facility, access to drinking water, and drinking water sources in Afghanistan. The results showed a significant association between diarrhea with these essential factors. It has been found that piped water supplied to households was a key risk factor with greater odds of affecting Afghanistan's diarrheal diseases. Studies have clearly shown that the sanitation facility has correlated with diarrheal morbidity, incredibly open defecation 48 , 49 , 50 , 51 , 52 , 53 . While examining the linkages between open defecation and diarrhea, our result was consistent with the earlier findings.
Various factors are related to diarrheal diseases, remarkably low domestic sanitation water quality, service level, and hygiene 30 . Afghanistan is one of the world's affected regions globally, both in terms of health standards of living. It has the highest IMR poverty rates and other socio-demographic indicators 54 , 55 . The diarrheal disease still claims the lives of 26 children each day across the country, accounting for nearly 12% of deaths in Afghanistan 56 . So, understanding these contextual factors associated with diarrheal diseases in the country is critical. These identified factors have a significant impact due to externality effects and need a particular focus, particularly at the regional level, as indicated by our study. Further studies can be conducted to estimate the burden of these factors on morbidity patterns. Since it is already clear from the above that poor sanitation like open defecation, shared toilet facility, and lack of access to drinking water leave children more susceptible to infections that cause diarrhea.
The study tried to examine the linkages between sanitation and diarrhea in Afghanistan based on the DHS survey conducted in 2015. Our study is consistent with many other studies while examining the associations between open defecation and diarrheal diseases. We also found that a lack of water and toilet has a significant impact on children's health. Diarrhea has been closely associated with lack of access to proper drinking water and inadequate sanitation facilities. Thus, to reduce the burden of diarrheal diseases, it is essential to focus on the sanitation facilities apart from providing access to clean and purified water. An inclusive policy approach can enhance health challenges and give positive externalities in terms of public health challenges. Afghanistan needs to focus on bettering sanitation and water hygiene facilities so that the more significant burden of diarrheal diseases can be averted to improve child health.
AfDHS : Afghanistan Demographic and Health Survey
CSO: Central Statistics Organization
OR: Odds Ratio
SDG: Sustainable development Goals
UNDP: United Nations Development Programme
UNICEF: United Nations International Children's Emergency Fund
USAID: United States Agency for International Development
WHO: World Health Organization
All authors equally contributed in this work. All authors read and approved the final manuscript.
Conflict of interest
- United Nations Children's Fund. One is too many: Ending child deaths from pneumona and diarrhoea. (accessed August 31, 2020). . 2016;:. Google Scholar
- Rudan I., Nair H., MaruÅ¡iÄ‡ A., Campbell H.. Reducing mortality from childhood pneumonia and diarrhoea: The leading priority is also the greatest opportunity. J Glob Health. 2013;3:010101. View Article Google Scholar
- World Health Organization. Diarrhoeal disease, Key Facts. (accessed August 31, 2020). . 2017;:. Google Scholar
- Mokomane M., Kasvosve I., Melo E. de, Pernica J.M., Goldfarb D.M.. The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management. Ther Adv Infect Dis. 2018;5:29-43. View Article Google Scholar
- UNICEF, WHO, World Bank, UN-DESA Population Division, Levels and trends in child mortality 2015. (accessed August 31, 2020). . 2015;:. Google Scholar
- World Health Organization, World health statistics 2011, World Health Organization, Geneva, Switzerland. (accessed August 31, 2020). . 2011;:. Google Scholar
- PrÃ¼ss A., Kay D., Fewtrell L., Bartram J.. Estimating the burden of disease from water, sanitation, and hygiene at a global level, Environ. Health Perspect. 2002;110:537. View Article Google Scholar
- Roushdy R., Sieverding M., Radwan H.. The impact of water supply and sanitation on child health: Evidence from Egypt. Population Council. 2012;:. View Article Google Scholar
- Boschi-Pinto C.. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ. 2008;86:710-717. View Article Google Scholar
- Lamberti L.M., Walker C.L.F., Black R.E.. Erratum to: Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries. BMC Public Health. 2012;12:832. View Article Google Scholar
- Lanata C.F.. For the Child Health Epidemiology Reference Group of the World Health Organization and UNICEF, Global Causes of Diarrheal Disease Mortality in Children <5 Years of Age: A Systematic Review. PLoS ONE. 2013;8:e72788. View Article Google Scholar
- Nataro J.P.. Diarrhea Among Children in Developing Countries. in N. Curtis, A. Finn, A.J. Pollard (Eds.), Hot Topics in Infection and Immunity in Children IX, Springer New York, New York, NY. 2013;:73-80. View Article Google Scholar
- World Gastroenterology Organisation. Acute diarrhea in adults and children: a global perspective, World Gastroenterology Organisation. (accessed August 31, 2020). . 2012;:. Google Scholar
- Central Statistics Organization (CSO). Ministry of Public Health (MoPH), ICF, Afghanistan Demographic and Health Survey 2015, Central Statistics Organization, Kabul, Afghanistan. (accessed August 31, 2020). . 2017;:. Google Scholar
- Fewtrell L.. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. The Lancet Infectious Diseases. 2005;5:42-52. View Article Google Scholar
- Akseer N.. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. The Lancet Global Health. ;4(2016):e395-e413. View Article Google Scholar
- Divya S.. A study on selected behavioral factors of mothers influencing acute diarrhoea in under- five children in a rural part of Kerala, India. Int J Community Med Public Health. 2016;2211(2216):. View Article Google Scholar
- Tarekegn M., Enquselassie F.. A case control study on determinants of diarrheal morbidity among under-five children in Wolaita Soddo Town, Southern Ethiopia. (accessed August 31, 2020). Ethiopian Journal of Health Development. 2012;26:. Google Scholar
- Dessalegn M., Kumie A., Tefera W.. Predictors of under-five childhood diarrhea: Mecha District, West Gojam, Ethiopia. (accessed August 31, 2020).. Ethiopian Journal of Health Development. 2011;25:. Google Scholar
- Mock N.B., Sellers T.A., Abdoh A.A., Franklin R.R.. Socioeconomic, environmental, demographic and behavioral factors associated with occurrence of diarrhea in young children in the Republic of Congo. Social Science & Medicine. 1993;36:807-816. View Article Google Scholar
- Mbugua S., Musikoyo E., Ndungi F., Sang R., Kamau-Mbuthia E., Ngotho D.. Determinants of diarrhea among young children under the age of five in Kenya, evidence from KDHS 2008-09. APS. 2014;28:1046. View Article Google Scholar
- VÃ¡squez W.F., Aksan A.-M.. Water, sanitation, and diarrhea incidence among children: evidence from Guatemala. Water Policy. 2015;17:932-945. View Article Google Scholar
- UNICEF. OrganizaciÃ³n Mundial de la Salud, Diarrhoea: why children are still dying and what can be done. United Nations Children's Fund, New York. 2009;:. Google Scholar
- Adane M., Mengistie B., Kloos H., Medhin G., Mulat W.. Sanitation facilities, hygienic conditions, and prevalence of acute diarrhea among under-five children in slums of Addis Ababa, Ethiopia: Baseline survey of a longitudinal study. PLoS ONE. 2017;12:e0182783. View Article Google Scholar
- Anteneh A., Kumie A.. Assessment of the impact of latrine utilization on diarrhoeal diseases in the rural community of Hulet Ejju Enessie Woreda, East Gojjam Zone, Amhara Region. Ethiopian Journal of Health Development. 2010;24:. View Article Google Scholar
- Keusch G.T., Fontaine O.. Disease Control Priorities in Developing Countries, 2nd ed. (accessed August 31, 2020). World Bank, Washington (DC). 2006;:. Google Scholar
- Yaya S.. Improving Water, Sanitation and Hygiene Practices, and Housing Quality to Prevent Diarrhea among Under-Five Children in Nigeria. TropicalMed. 2018;3:41. View Article Google Scholar
- World Health Organization. UN-water global annual assessment of sanitation and drinking-water: 2008 pilot reportâ€¯: testing a new reporting approach. (accessed August 31, 2020). World Health Organization, Geneva. 2008;:. Google Scholar
- Oyekale A.. Access to safe drinking water, sanitation, and under 5 diarrhea morbidity in South Africa. Ann Trop Med Public Health. 2017;10:187. View Article Google Scholar
- World Health Organization. The World Health Report 2005 - make every mother and child count, Geneva. . 2005;:. Google Scholar
- John T.J., Samuel R.. Herd immunity and herd effect: new insights and definitions. European Journal of Epidemiology. 2000;16:601-606. View Article Google Scholar
- Mara D., Lane J., Scott B., Trouba D.. Sanitation and Health. PLoS Med. 2010;7:e1000363. View Article Google Scholar
- Newson R.S., Lion R.. Behaviour change for better health: nutrition, hygiene and sustainability. BMC Public Health. 2013;13:S1. View Article Google Scholar
- USAID. Wash & nutrition water and development strategy implementation brief. (accessed August 31, 2020). . 2015;:. Google Scholar
- Semba R.D.. Relationship of the presence of a household improved latrine with diarrhea and under-five child mortality in Indonesia. Am. J. Trop. Med. Hyg. 2011;84:443-450. View Article Google Scholar
- Spears D., Ghosh A., Cumming O.. Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts. PLoS ONE. 2013;8:e73784. View Article Google Scholar
- Mintz E., Bartram J., Lochery P., Wegelin M.. Not Just a Drop in the Bucket: Expanding Access to Point-of-Use Water Treatment Systems. Am J Public Health. 2001;91:1565-1570. View Article Google Scholar
- Bitew B.D., Woldu W., Gizaw Z.. Childhood diarrheal morbidity and sanitation predictors in a nomadic community. Ital J Pediatr. 2017;43:91. View Article Google Scholar
- Lakshminarayanan S., Jayalakshmy R.. Diarrheal diseases among children in India: Current scenario and future perspectives. J Nat Sc Biol Med. 2015;6:24. View Article Google Scholar
- Wardlaw T., Salama P., Brocklehurst C., Chopra M., Mason E.. Diarrhoea: why children are still dying and what can be done. The Lancet. 2010;375:870-872. View Article Google Scholar
- World Health Organization. United Nations Children's Fund, Progress on sanitation and drinking-water: Joint Monitoring Programme 2010 update, World Health Organization, Geneva. (accessed August 31, 2020). . 2010;:. Google Scholar
- Ahiadeke C.. Breast-feeding, diarrhoea and sanitation as components of infant and child health: a study of large scale survey data from Ghana and Nigeria. J. Biosoc. Sci. 2000;32:47-61. View Article Google Scholar
- Boadi K.O., Kuitunen M.. Environmental and health impacts of household solid waste handling and disposal practices in third world cities: the case of the Accra Metropolitan Area, Ghana. J Environ Health. 2005;68:32-36. Google Scholar
- Arif G.M., Ibrahim S.. Diarrhoea Morbidity Differentials among Children in Pakistan. (accessed August 31, 2020). The Pakistan Development Review. 1998;37:. Google Scholar
- Janovsky K.. World Health Organization, The challenge of implementationâ€¯: district health systems for primary health care, World Health Organization. (accessed August 31, 2020). https://apps.who.int/iris/handle/10665/62369. 1988;:. Google Scholar
- Thea D.M.. A prospective study of diarrhea and HIV-1 infection among 429 Zairian infants. N. Engl. J. Med. 1993;329:1696-1702. View Article Google Scholar
- VanDerslice J., Briscoe J.. Environmental interventions in developing countries: interactions and their implications. Am. J. Epidemiol. 1995;141:135-144. View Article Google Scholar
- Desai R., McFarlane C., Graham S.. The Politics of Open Defecation: Informality, Body, and Infrastructure in Mumbai: The Politics of Open Defecation: Mumbai. Antipode. 2015;47:98-120. View Article Google Scholar
- Montgomery M.A., Elimelech M.. Water and sanitation in developing countries: including health in the equation. Environ. Sci. Technol. 2007;41:17-24. View Article Google Scholar
- Njuguna J.. Effect of eliminating open defecation on diarrhoeal morbidity: an ecological study of Namable sub-county, Kenya. (accessed August 31, 2020).. in: WEDC, Loughborough University, UK. 2015;:. Google Scholar
- Pickering A.J., Djebbari H., Lopez C., Coulibaly M., Alzua M.L.. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. The Lancet Global Health. 2015;3:e701-e711. View Article Google Scholar
- United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Malnutrition: the silent killer in Afghanistan. (accessed August 31, 2020). . 2016;:. Google Scholar
- World Health Organization. Preventing diarrhoea through better water, sanitaiton and hygiene: exposures and impacts in low- and middle-income countries. . 2014;:. Google Scholar
- Higgins-Steele A., Yousufi K., Sultana S., Ali A.S., Varkey S.. Ending Preventable Child Deaths from Pneumonia and Diarrhoea in Afghanistan: An Analysis of Intervention Coverage Scenarios Using the Lives Saved Tool. J Trop Med. 2017;2017:3120854. View Article Google Scholar
- The United Nations Development Programme (UNDP). Human Development Report 2015 - Work for Human Development. (accessed August 31, 2020). . 2015;:. Google Scholar
- World Health Organization (WHO. United Nations Children's Fund (UNICEF), Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines., World Health Organization, Geneva, Switzerland. (accessed August 31, 2020). . 2017;:. Google Scholar