Evidence on the links between water insecurity, inadequate sanitation and mental health: A systematic review and meta-analysis

PLoS One. 2023 May 25;18(5):e0286146. doi: 10.1371/journal.pone.0286146. eCollection 2023.


Background: Water insecurity and inadequate sanitation have adverse impacts on the mental health of individuals.

Objective: To review and synthesize evidence on the relationship between water insecurity, inadequate sanitation, and mental health globally.

Data sources: Relevant studies were identified by searching PubMed, PsycINFO, and EMBASE databases from inception up to March 2023.

Study eligibility criteria: Only quantitative studies were included. The exposure was water insecurity and or inadequate sanitation. The outcome was common mental disorders (CMD: depression or anxiety), mental distress, mental health or well-being. There was no restriction on geographical location.

Participants: General population or people attending health facilities or other services.

Exposure: Water insecurity and/ or inadequate sanitation.

Risk of bias: The effective Public Health Practice Project (EPHPP) assessment tool was used to assess quality of selected studies.

Synthesis of results: A meta-analysis was conducted using a random effects statistical model.

Results: Twenty-five studies were included, with 23,103 participants from 16 countries in three continents: Africa (Kenya, Ethiopia, Ghana, Uganda, South Africa, Malawi, Mozambique, and Lesotho), Asia (Nepal, Bangladesh, India, and Iran) and the Americas (Brazil, Haiti, Bolivia and Vietnam). There was a statistically significant association between water insecurity and CMD symptoms. Nine studies reported a continuous outcome (5,248 participants): overall standardized mean difference (SMD = 1.38; 95% CI = 0.88, 1.87). Five studies reported a binary outcome (5,776 participants): odds ratio 5.03; 95% CI = 2.26, 11.18. There was a statistically significant association between inadequate sanitation and CMD symptoms (7415 participants), overall SMD = 5.36; 95% CI = 2.51, 8.20.

Limitations: Most of the included studies were cross-sectional which were unable to examine temporal relationships.

Conclusions: Water insecurity and inadequate sanitation contribute to poorer mental health globally.

Implications of key findings: Interventions to provide basic water, sanitation and psychosocial support, could substantially contribute to reducing the burden of CMD alongside other health and social benefits.

Trial registration: PROSPERO registration number: CRD42022322528.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Anxiety / epidemiology
  • Ethiopia
  • Humans
  • Mental Health*
  • Sanitation
  • Water Insecurity*

Grant support

The authors received no specific funding for this work.