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. 2024 Dec 5;4(12):e0003844. doi: 10.1371/journal.pgph.0003844

Unimproved source of drinking water and the associated factors: Insights from the 2020 Somalia demographic and health survey

Abdisalam Mahdi Hassan 1, Nimo Mohamoud Barakale 1, Omran Salih 2,*, Abdisalam Hassan Muse 1
Editor: Razak M Gyasi3
PMCID: PMC11620610  PMID: 39637088

Abstract

Access to safe drinking water is a fundamental human right and a critical public health concern, particularly in lower- and middle-income countries with limited infrastructure. Somalia faces significant challenges in providing improved drinking water sources, with a high prevalence of unimproved sources. This study analyzes data from the SHDS 2020 to investigate the prevalence of unimproved drinking water sources and identify associated factors. A cross-sectional study of 32,300 participants was conducted to identify factors associated with using unimproved drinking water sources. Multivariable logistic regression analysis was performed using Stata 16 software. Variables with a p-value < 0.05 in bivariate analysis were included in the multivariate model. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were used to estimate the association of significant variables with the outcome. Approximately 22.04% (95% CI: 21.5%, 22.4%) of the Somali population utilizes unimproved drinking water sources. Households with a head aged 20 years and above (AOR = 0.88, p = 0.059) were less likely to rely on unimproved sources than households with a head under 20 years. Female household heads (AOR = 1.17, p = 0.000) were more likely to use unimproved sources than male household heads. Unemployed partners (AOR = 1.14, p = 0.000) were more likely to use unimproved sources than employed partners. Rural (AOR = 1.12, p = 0.013) and nomadic (AOR = 0.93, p = 0.175) residents were more likely to use unimproved sources than urban residents. Households in Mudug (AOR = 31.18, p = 0.000), Nugaal (AOR = 4.15, p = 0.000), Bari (AOR = 5.26, p = 0.000), and Sanaag (AOR = 2.52, p = 0.000) regions were less likely to use unimproved sources compared to households in other regions. These findings highlight the urgent need for Somalia to improve its provision of safe and accessible water sources.

Introduction

Access to clean water is a fundamental human right, essential for human development, growth, and well-being [1]. It is a crucial element in achieving sustainable development, as highlighted by Sustainable Development Goal (SDG) 6, which explicitly addresses water and sanitation with the target of providing universal and equitable access to safe and affordable drinking water for all by 2030 [2]. The long-term objective is to ensure that everyone has access to safe water at home, ideally within a 30-minute round trip [3, 4]. However, globally, over 2 billion people still lack access to safely managed drinking water services [5].

The burden of inadequate water access disproportionately affects low- and middle-income countries, particularly in sub-Saharan Africa, where infrastructure limitations, poverty, and conflict often impede the provision of safe water sources [3]. The majority of households with unimproved water sources are found in sub-Saharan Africa, often requiring long journeys to collect water [3]. This lack of safe water access contributes to increased risks of infectious diseases, including cholera, typhoid, schistosomiasis, and infections of the respiratory, skin, and eye systems [1].

Somalia, a country located in sub-Saharan Africa, faces significant challenges in providing safe drinking water to its population [6–8]. Despite the national target of achieving universal access to an improved source of drinking water outlined in the Somalia National Development Plan (NDP), the population in Somalia has not yet been able to reach this goal [5, 9, 10]. In Somalia, slightly over three-quarters (76%) of urban households have access to improved water sources, compared to just over half (55%) of rural households and 35% of nomadic households [11]. This disparity in water access has serious implications for the health and well-being of Somali communities, leading to increased vulnerability to waterborne diseases and hindering progress towards achieving national development goals.

The lack of comprehensive research on the prevalence and associated factors of unimproved drinking water sources in Somalia represents a significant research gap [3]. Existing data suggests that 35% of Somali households rely on unimproved sources for drinking water [11], highlighting the need for a deeper understanding of this issue. Previous studies have examined factors influencing water access in other African countries, providing valuable insights into the complex factors at [12–16]. However, a comprehensive investigation using nationally representative data on unimproved sources in Somali households is lacking.

This study aims to fill this critical research gap by analyzing data from the 2020 Somalia Health and Demographic Survey (SHDS) to investigate the prevalence of unimproved drinking water sources and identify associated factors. The study’s findings could assist policymakers in implementing measures to reduce the consequences of utilizing water from unimproved sources in Somalia and work towards achieving the national goal of universal access to safe water.

Material and methods

Study design

This cross-sectional study utilized secondary data from the 2020 Somalia Health and Demographic Survey (SHDS), the first nationally representative household survey conducted in Somalia. The SHDS is a crucial resource for strengthening national data systems and promoting evidence-based planning for improved public health outcomes.

Study setting

The study focused on Somalia, a country located in the Horn of Africa with an estimated population of 12.3 million. Somalia boasts the longest coastline in Africa, stretching 3,333 kilometers along the Indian Ocean and the Gulf of Aden. It shares borders with Ethiopia to the west, Kenya to the southwest, and Djibouti to the northwest.

Data source

This study utilized the 2020 SHDS dataset, collected between 2018 and 2020. The data was obtained from the DHS website: www.dhsprogram.com. Variables relevant to the study were extracted from the household record (HR file) dataset. The SHDS sample was specifically designed to represent key indicators across various strata within Somalia, achieving a response rate of 99%. This high response rate, encompassing urban, rural, and nomadic areas, reflects the willingness and cooperation of participants. The final sample size for this study, after data cleaning and the removal of missing variables, was 32,300 participants [7, 8, 17].

Study variables

Dependent variable

The outcome variable for this study is the utilization of unimproved sources of drinking water. The drinking water source was classified as unimproved if a household gets drinking water from an unprotected dug well, unprotected spring, surface water, and tanker truck/cart with a small tank. For more clarification, to define improved and unimproved drinking water sources, we utilize the classification system employed in the DHS dataset. A household’s primary drinking water source is categorized as improved if it falls within the following categories: piped into dwelling or yard, public tap, standpipe, piped to neighbor, tube well/borehole, protected well, protected spring, rainwater collection, tanker truck/cart, or bottled water. These sources generally indicate a greater level of infrastructure, protection from contamination, and hygiene. Conversely, unimproved sources, categorized as unprotected well, unprotected spring, or "other," are more susceptible to contamination due to the lack of protective measures. It is important to note that even within these categories, the actual quality of the water can vary depending on the specific context, level of maintenance, and overall hygiene practices. For the purposes of our analysis, we utilize this classification system from the DHS dataset, acknowledging its inherent limitations and the potential for variation in water quality within these broad categories.

Independent variables

Individual and community-level independent variables were considered in this study. The age of the household head (less than 20 years or 20 years and more), husband’s education level, whether he attended school or not (yes or no) level of education of the respondent (no education, primary, secondary and higher), gender of the household head (male or female), household head employment status (yes or no) and the employment status of the husband/partner during the previous year was included as an individual-level factor in this study. Community-level factors, residence (urban, rural or nomadic), region (Awdal, Waqooyi galbeed, Togdheer, Sool, Sanaag, Bari, Nugaal, Mudug, Galgaduud, Hiraan, Middle shabelle, Banadir, Bay, Bakool, Gedo and Lower juba) wealth index of the family (lowest, second, middle, fourth and highest), family size members (less than four members and four or more members) and type of sanitation facility (improved or unimproved) were considered.

Data management and statistical analysis

Data analysis was conducted using Stata version 16. Following data cleaning and coding, descriptive analysis was performed to determine the frequency and percentages of variables of interest. Due to the binary nature of the outcome variable (improved vs. unimproved water sources), bivariate analysis utilizing chi-square testing was employed to explore associations between the outcome variable and independent variables. Subsequently, multivariate binary logistic regression was conducted to assess the relationship between the outcome variable and a set of independent variables. Statistical significance was determined using an adjusted odds ratio (AOR) with a 95% confidence interval (CI) and a p-value threshold of 0.05.

Ethical consideration

This study utilizes publicly available data from the Somalia Demographic and Health Survey (DHS) program. The data, obtained from the official Somalia DHS website, has been anonymized and contains no personal identifiers. As such, ethical approval was not required for this research. We adhere to the ethical principles of respecting data privacy and ensuring the anonymity of individuals.

Results

Exploratory analysis

The study’s findings, based on data from the 2020 Somalia Health and Demographic Survey (SHDS), revealed several key factors associated with the use of unimproved drinking water sources. Univariate analysis (Table 1) showed that a significant proportion of household heads (80.64%) were aged 20 years and older. Additionally, a large percentage of respondents (87.02%) lacked formal education. The majority of household heads were male (66.40%), and a small percentage were employed (1.14%). Respondents resided in urban (41.35%), rural (27.29%), and nomadic (31.36%) areas. Notably, wealth status varied significantly among households, with the lowest (24.04%) and highest (16.46%) wealth indices representing the extremes. Most households (77.30%) consisted of four or more members, and a substantial proportion (59.70%) utilized unimproved sanitation facilities.

Table 1. Univariate analysis of both individual and community level factors associated with source of drinking water using SHDS 2020.

(n = 32300).

Variable Categories Frequency (n) Percentage %
Age of household head Less than 20 years 6253 19.36
20 years and more 26047 80.64
Head of household education level Yes 26985 83.54
No 5315 16.46
Level of education of the respondent No education 28108 87.02
Primary education 3229 10
Secondary education 796 2.46
Higher education 167 0.52
Gender of household head Male 21447 66.40
Female 10853 33.60
Household head employment status Yes 367 1.14
No 31933 98.86
Partner work Yes 13985 43.30
No 18315 56.70
Residence Urban 13357 41.35
Rural 8814 27.29
Nomadic 10129 31.36
Region Awdal 1333 4.13
Waqoyigalbed 2299 7.12
Togdheer 2798 8.66
Sool 2733 8.46
Sanaag 2727 8.44
Bari 1274 3.94
Nugaal 1498 4.64
Mudug 1490 4.61
Galgadud 1852 5.73
Hiran 2131 6.60
Middle shabele 1564 4.84
Banadir 4154 12.86
Bay 789 2.44
Bakool 1670 5.17
Gedo 1895 5.87
Lower juba 2093 6.48
Wealth index of the family Lowest 7766 24.04
Second 7352 22.76
Middle 6045 18.72
Fourth 5819 18.02
Highest 5318 16.46
Family size Less than four members 7331 22.70
Four members or more 24969 77.30
Type of sanitation facility Improved 13016 40.30
Unimproved 19284 59.70
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Correlational analysis

Table 2 presents the bivariate analysis of factors associated with drinking water sources using the SHDS 2020 data. The results reveal several statistically significant relationships between explanatory variables and the use of unimproved water sources. Notably, younger respondents (under 20 years) were significantly more likely to access unimproved water sources (χ² = 996.47, p < .001). Higher levels of education were significantly associated with a lower likelihood of using unimproved water sources (χ² = 17.67, p < .001). Male household heads were significantly more likely to use unimproved water sources compared to female heads (χ² = 45.76, p < .001). Similarly, unemployed household heads (χ² = 22.09, p < .001), partners without employment (χ² = 203.58, p < .001), residents of rural areas (χ² = 516.12, p < .001) and nomadic areas (χ² = 4200, p < .001) were all significantly more likely to access unimproved water sources. Households with the highest wealth status were significantly more likely to use unimproved water sources compared to those in the middle and lower wealth strata (χ² = 164.04, p < .001). Finally, larger families were less likely to use unimproved water sources (χ² = 5.51, p < .02).

Table 2. Bivariate analysis for factors associated with source of drinking water in Somalia using SDHS 2020.

Variable Categories Source of drinking water Chi-square Df P-value
Improved Unimproved
Age of household head Less than 20 years 5804 (92.82)  449 (7.18) 996.4742 1 0.000
20 years and more 19377 (74,39)  6670 (25.61)
Head of household education level Yes 21132 (78.31)  5853 (21.69) 11.7196 1 0.001
No 4049 (76.18)  1266 (23.82)
Level of education of the respondent No education 21928 (78.01)  6180 (21.99) 17.6716 3 0.001
Primary education 2552 (79.03)  677 (20.97)
Secondary education 576 (72.36)  220 (27.64)
Higher education 125 (74.85)  42 (25.15)
Gender of household head Male 16482 (76.85)  4965 (23.15) 45.7568 1 0.000
Female 8699 (80.15)  2154 (19.85)
HH head employment status Yes 249 (67.85)  118 (32.15) 22.0925 1 0.000
No 24932 (78.08)  7001 (21.92)
Partner work Yes 10376 (74.19)  3609 (25.81) 203.5755 1 0.000
No 14805 (80.84)  3510 (19.16)
Residence Urban 9581 (71.73)  3776 (28.27) 516.1233 2 0.000
Rural 7296 (82.78)  1518 (17.22)
Nomadic 8304 (81.98)  1825 (18.02)
Region Awdal 1077 (80.80)  256 (19.20) 4200 15 0.000
Waqoyi-galbed 2026 (88.13)  273 (11.87)
Togdheer 2167 (77.45)  631 (22.55)
Sool 2415 (88.36)  318 (11.64)
Sanaag 2542 (93.22)  185 (6.78)
Bari 1225 (96.15)  49 (3.85)
Nugaal 1440 (96.13)  58 (3.87)
Mudug 1483 (99.53)  7 (0.47)
Galgaduud 1601 (86.45)  251 (13.55)
Hiraan 1839 (86.30)  292 (13.70)
Middle-shabele 919 (58.76)  645 (41.24)
Banadir 2274 (54.74)  1880 (45.26)
Bay 533 (67.55)  256 (32.45)
Bakool 1127 (67.49)  543 (32.51)
Gedo 1307 (68.97)  588 (31.03)
Lower-juba 1206 (57.62)  887 (42.38)
Wealth index of the family Lowest 6451 (83.07)  1315 (16.93) 164.0400 4 0.000
Second 5654 (76.90)  1698 (23.10)
Middle 4658 (77.06)  1387 (22.94)
Fourth 4429 (76.11)  1390 (23.89)
Highest 3989 (75.01)  1329 (24.99)
Family size Less than four members 5642 (76.96)  1689 (23.04) 5.5071 1 0.019
Four members or more 19539 (78.25)  5430 (21.75)
Type of sanitation facility Unimproved 13194 (68.42)  6090 (31.58) 2500 1 0.000
Improved 11987 (92.09)  1029 (7.91)
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Regression analysis

Table 3 presents the results of multivariable binary logistic regression analysis, examining the association between individual and community-level factors and unimproved drinking water sources. Household heads aged 20 years and older were less likely to use unimproved water sources compared to those under 20 years (AOR = 0.88, 95% CI = 0.77, 1.00, p = .059). Respondents with secondary or higher education levels were more likely to use unimproved water sources compared to those with no education or primary education (AOR = 1.32, 95% CI = 0.90, 1.93, p = .128). Female household heads were more likely to use unimproved water sources compared to male heads (AOR = 1.18, 95% CI = 1.10, 1.25, p < .001). Unemployed household heads were also more likely to access unimproved water sources compared to employed household heads (AOR = 1.14, 95% CI = 0.89, 1.44, p = .276). Partners without employment were more likely to use unimproved water sources compared to employed partners (AOR = 1.14, 95% CI = 1.07, 1.21, p < .001). Households in rural and nomadic areas were more likely to use unimproved water sources compared to those in urban areas (AOR = 1.12, 95% CI = 1.02, 1.23, p = .013; AOR = 0.93, 95% CI = 0.83, 1.03, p = .175). Households in the Mudug, Nugaal, Bari, and Sanaag regions were also more likely to use unimproved water sources compared to households in other regions (AOR = 31.18, 95% CI = 14.62, 66.52, p < .001; AOR = 4.15, 95% CI = 3.07, 5.61, p < .001; AOR = 5.26, 95% CI = 3.82, 7.24, p < .001; AOR = 2.52, 95% CI = 2.05, 3.10, p < .001). There was no significant association between wealth index and the use of unimproved water sources. Finally, households with four or more members were less likely to use unimproved water sources compared to households with fewer members (AOR = 0.98, 95% CI = 0.92, 1.05, p = .607).

Table 3. Multivariable logistic regression analysis for individual and community level factors associated with unimproved source of drinking water using SHDS 2020 data.

Variables Categories AOR Coefficient (S.E) 95% CI P-value
Age of household head Less than 20 years Ref
20 years and more .883176 .0579984 .7765129 1.004491 0.059
Head of household education level Yes Ref
No 1.097976 .0480014 1.007813 1.196205 0.033
Level of education of the respondent No education Ref
Primary education .9066157 .0474836 .818167 1.004626 0.061
Secondary education 1.04202 .0966024 .8688877 1.249649 0.657
Higher education 1.322392 .2563345 .9044029 1.933563 0.657
Gender of household head Male Ref
Female 1.176338 .0374891 1.105108 1.252159 0.000
HH head employment status Yes Ref
No 1.14179 .13898 .8994495 1.449424 0.276
Partner work Yes Ref
No 1.143356 .0369817 1.073123 1.218185 0.000
Residence Urban Ref
Rural 1.123391 .0527323 1.02465 1.231648 0.013
Nomadic .9277132 .0513651 .8323096 1.034052 0.175
Region Awdal Ref
Waqoyi-galbed 1.725367 .1663881 1.428219 2.084338 0.000
Togdheer .7651895 .0649384 .6479346 .9036639 0.002
Sool 1.332351 .1266288 1.105908 1.60516 0.003
Sanaag 2.521921 .2667799 2.049688 3.102954 0.000
Bari 5.255723 .8575258 3.817245 7.236271 0.000
Nugaal 4.145597 .6379567 3.066179 5.605012 0.000
Mudug 31.18253 12.05507 14.61637 66.52473 0.000
Galgaduud 1.146988 .1154424 .9416438 1.39711 0.173
Hiraan 1.348201 .130061 1.115936 1.628809 0.002
Middle-shabele .3683359 .0332356 .3086303 .4395918 0.000
Banaadir .3903689 .032654 .3313394 .4599149 0.000
Bay .6709773 .0727668 .5424951 .8298886 0.000
Bakool .6522254 .0587195 .5467194 .7780918 0.000
Gedo .648793 .0570891 .5460175 .7709138 0.000
Lower-juba .4060782 .0349571 .3430318 .4807121 0.000
Wealth index of the family Lowest Ref
Second 1.016886 .0483318 .9264354 1.116167 0.725
Middle 1.121843 .0668487 .9981838 1.260822 0.054
Fourth 1.027572 .0649364 .9078649 1.163062 0.667
Highest .9914159 .0655665 .870888 1.128624 0.896
Family size Less than four members Ref
Four members or more .9823335 .0339963 .9179116 1.051277 0.607
Type of sanitation facility Improved 2.220988 .110268 2.015049 2.447974 0.000
Unimproved 2.706836 .4468044 1.958656 3.74081 0.000
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Discussion

This study, utilizing data from the 2020 Somalia Health and Demographic Survey, provides valuable insights into the prevalence and associated factors of unimproved drinking water sources in Somalia. Our findings highlight a significant prevalence of 22.04% of households relying on unimproved water sources, exceeding proportions reported in some other African countries, such as Ghana, while falling below those observed in Ethiopia and Eswatini. These disparities likely stem from variations in economic status, literacy rates, study periods, and specific study settings across these nations [1, 12, 18, 19].

The study partially aligns with prior research, confirming the significant role of individual and community-level factors in determining access to improved water sources. Consistent with studies in Ethiopia and Ghana, we found that higher levels of education are associated with a lower likelihood of using unimproved water sources, likely due to increased awareness of hygiene and sanitation practices [20, 21]. Similarly, we observed a correlation between wealth index and water source utilization, with lower income households being more likely to rely on unimproved sources, as observed in studies conducted in Ethiopia [3]. This finding underscores the importance of economic empowerment in promoting access to improved water sources.

However, the findings contradict some previously observed patterns. We found a significant association between female-headed households and the use of unimproved water sources, contrary to findings in Ghana [12]. This discrepancy may indicate specific challenges faced by female-headed households in Somalia, potentially due to limited economic resources or societal constraints, warranting further exploration. Additionally, our results demonstrate a significant association between unemployed partners and the use of unimproved water sources, suggesting that lack of employment may hinder access to improved water sources due to financial constraints.

A key contribution of this study lies in its comprehensive examination of factors associated with unimproved drinking water sources within the context of Somalia, using nationally representative data. This provides crucial information for policymakers and stakeholders to develop targeted interventions and policies to improve water access in the country. By identifying specific vulnerable populations, such as households headed by females, those with unemployed partners, and those residing in rural and nomadic areas, the study provides a framework for tailored strategies.

This study is particularly relevant in the context of Sustainable Development Goal (SDG) 6, which emphasizes the need to ensure access to safe and affordable drinking water for all by 2030 [2]. By highlighting the significant prevalence of unimproved water sources in Somalia and identifying associated factors, the study underscores the urgent need for targeted interventions to achieve SDG 6 in Somalia. This includes initiatives to improve water infrastructure, promote sanitation practices, and address socio-economic factors hindering access to clean water, particularly for vulnerable populations.

Despite its strengths, this study has limitations. First, due to the cross-sectional design, it does not establish causality between the observed factors and the use of unimproved water sources. Longitudinal studies are needed to further investigate the directionality of these relationships. Second, the study relies on self-reported data, which may be subject to recall bias. Further investigation using objective measures of water source quality and access would enhance the study’s findings. Finally, the study focuses solely on access to water, neglecting other important factors such as water quality and sanitation, which are crucial for maintaining public health [1].

Overall, this study provides essential insights into the challenges and opportunities associated with access to clean water in Somalia. The findings highlight the need for multi-sectoral interventions to improve water infrastructure, promote hygiene and sanitation practices, and address socio-economic inequalities, particularly for vulnerable populations. By focusing on these factors, Somalia can work towards achieving the national goal of universal access to safe water and contribute to the achievement of SDG 6.

Conclusion

This study, using data from the 2020 Somalia Health and Demographic Survey (SHDS), revealed that approximately 22% of the Somali population utilizes unimproved drinking water sources. Our findings demonstrate that individual factors such as age of the household head, gender of the household head, education level, partner’s attendance of school, and occupation status, along with community-level factors like residence, region, wealth index, family size, and type of sanitation facility, significantly influence the use of unimproved water sources. These results highlight the multifaceted nature of this issue, underscoring the need for multi-sectoral approaches to address the challenge of inadequate access to safe drinking water in Somalia.

Policy implications

The findings of this study provide valuable insights for policymakers and stakeholders in Somalia to develop targeted interventions and policies aimed at improving access to safe drinking water and promoting sustainable development.

  1. Prioritize Vulnerable Groups: Policymakers should prioritize interventions for vulnerable populations, such as female-headed households, individuals with unemployed partners, and residents of rural and nomadic areas. This includes targeted programs to improve water infrastructure in these communities, provide financial assistance for water access improvements, and promote awareness of hygiene and sanitation practices.

  2. Promote Education and Economic Empowerment: Investing in education and economic empowerment initiatives can contribute to a long-term solution to the problem of unimproved water sources. Educated individuals are more likely to understand the importance of clean water and sanitation practices, and economic empowerment allows households to afford improved water sources.

  3. Strengthen Water Infrastructure: Investing in and maintaining water infrastructure is crucial for expanding access to safe drinking water. This includes constructing new water supply systems, rehabilitating existing ones, and promoting efficient water management practices.

  4. Foster Multi-Sectoral Collaboration: Addressing the challenges of unimproved water sources requires collaboration across various sectors, including government, civil society, and private sector. This collaboration is essential for developing comprehensive and effective solutions.

  5. Monitor and Evaluate Progress: Regular monitoring and evaluation of interventions is crucial to track progress and ensure that programs are effective in reaching their goals.

By focusing on these policy implications, Somalia can work towards achieving the national goal of universal access to safe water, contributing to the achievement of SDG 6 and improving the overall well-being of its citizens.

Data Availability

This study used secondary data from the Somalia Health and Demographic Survey (SHDS) 2020, which is publicly available on the website (https://microdata.nbs.gov.so/index.php/catalog/50). Access was granted after registration using an institutional email (abdisalam.hassan@amoud.edu.so). As the data is publicly available and anonymized, formal ethical approval from an Institutional Review Board (IRB) or Ethics Committee was not required for our study. However, it is important to acknowledge the ethical considerations during the original SHDS 2020 data collection. The National Bureau of Statistics (NBS), responsible for conducting the SHDS, likely has an established IRB or Ethics Committee that reviewed and approved the survey design and data collection procedures. The statement mentions that enumerators received training on obtaining informed consent (likely verbal) from participants, ensuring confidentiality, and building rapport. This aligns with ethical research practices for human subjects. Further details on the original SHDS 2020 IRB approval process or specific consent procedures could be obtained by contacting the NBS.

Funding Statement

The authors received no specific funding for this work

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003844.r001

Decision Letter 0

Razak M Gyasi

3 Sep 2024

PGPH-D-24-01613

Unimproved Source of Drinking Water and its Associated Factors: Insights from Somalia Health and Demographic Survey 2020 Data

PLOS Global Public Health

Dear Dr. Salih,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please you are implored to critically consider each and every comment provided by the reviewers and revise your manuscript accordingly. Very importantly, make sure to highlight any changes to the revised draft for further assessment.

Please submit your revised manuscript by Oct 18 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Razak M Gyasi, PhD, PD

Academic Editor

PLOS Global Public Health

Journal Requirements:

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Partly

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript has no issues about dual publication, research ethics, or publication ethics however there are some minor issues to be addressed. The author should address the following issues:

1. The definition or criteria for improved and unimproved sanitation facilities

2. The author indicated that variables with p-values less than 0.4 in the multivariate model were fitted in the bivariate analysis. Why was less than 0.4 was used?

3. The author should address a few grammatical error issues. For instance, was is used instead of were, Can have got more, etc.)

4.Six (6) references are not enough for such research.

Reviewer #2: The study has a commendable objective of attempting to explore factors associated with unimproved drinking water sources in Somalia.

However, some of the major concerns with the submitted manuscript include:

1. It is not well formatted. The manuscript has sections that needs to be rewritten for clarity.

2. The discussion section is not thoroughly informed by the presented exploratory analysis.

3. The study does not sufficiently engage existing literature or previous works (or may have not accurately cited all of the sources used) hence only 6 articles are referenced in the reference section.

4. The study does not sufficiently address practical implications or recommendations for its discussed findings.

Reviewer #3: Original and pertinent work using robust methodology.

The recommendation in concluding section is generic and does not clearly link to study findings.

Both authors state contribution to data the collection, but it’s not clear if they participated in primary study.

Authors should verify, ethical approval process of the primary study and affirm that standard ethical principles were followed rather than an assumption that it “likely” followed the same.

Reviewer #4: Manuscript is well coordinated however there are a few points to consider.Please refer to review submitted. Please re look at manuscript for grammatical errors and areas where lowercase and uppercase letters has been used.

Reviewer #5: The manuscript presents an important topic in the field of global public health. This document outlines a study examining the factors associated with the use of unimproved drinking water sources in Somalia, based on data from the 2020 Somalia Health and Demographic Survey (SHDS). The study highlights that approximately 22.04% of the Somali population relies on unimproved water sources, with significant disparities based on household characteristics, such as age, education level, residence, region, wealth index, and employment status.

The manuscript is generally well-written, but there are areas where clarity could be improved. Some sections, particularly the methods and discussion, are dense and could benefit from more concise language. Additionally, some figures and tables are difficult to interpret and would be more effective with clearer labels and explanations.

The manuscript briefly mentions ethical approval, but there is no discussion of how informed consent was obtained from participants. Given the sensitive nature of the study topic, it is crucial to provide more information on the ethical procedures followed to ensure participant safety and confidentiality.

I recommend the authors address the methodological issues raised, particularly regarding the sample size and data analysis. A more cautious interpretation of the results would also strengthen the manuscript. Clarifying the ethical considerations and improving the presentation of data will help ensure the study's impact on the field.

Reviewer #6: Feedback:

1. Clarity and Structure:

o Introduction: The introduction is somewhat cluttered with information and could benefit from clearer organization. The background information on global water access and the SDG goals is useful, but the connection to Somalia’s specific context could be strengthened. The narrative would be clearer if it flowed from the global context to the specific challenges in Somalia, leading into the study’s objectives.

o Results Section: The presentation of results is dense and could be streamlined for better readability. The inclusion of too many details in the text, such as the exact percentages and odds ratios is overwhelming. Consider summarizing key findings in a more digestible format, perhaps using bullet points or summary tables for major results, and focusing the narrative on interpreting these findings.

2. Interpretation of Findings:

o The discussion does not fully explore the implications of the findings. For example, the higher likelihood of unimproved water sources in female-headed households is noted, but the underlying reasons for this disparity are not sufficiently explored. Additionally, the manuscript could benefit from a more in-depth discussion on why certain regions, such as Mudug and Nugaal, show different patterns compared to others.

o The conclusion mentions that Somalia should enhance its provision of improved water sources but does not provide specific recommendations or strategies on how this could be achieved, given the identified factors.

3. Inconsistencies in Reporting:

o There are some inconsistencies in the reporting of results, particularly in the regression analysis. For instance, the manuscript states that "the odds of unemployed household heads are 1.14 times more likely to use unimproved sources of drinking water," but it is unclear whether this association is statistically significant. Clearer reporting of significance levels and confidence intervals throughout the results section would improve clarity.

4. Lack of Policy Implications:

o While the study identifies several factors associated with the use of unimproved water sources, the practical implications of these findings for policy and intervention strategies are not well developed. The paper would be stronger if it included more detailed recommendations for policymakers on how to address these issues, particularly in the Somali context.

Recommendations:

1. Reorganize the Introduction: Streamline the introduction to provide a clearer narrative that connects global water access issues to the specific challenges in Somalia, leading naturally into the study's objectives.

2. Enhance the Discussion: Expand on the discussion of findings, particularly regarding the socio-cultural and economic factors that may explain the disparities in water access. Provide more detailed policy recommendations based on the study’s findings.

3. Simplify the Results Presentation: Consider summarizing the key findings in a more accessible format and focusing the narrative on the interpretation rather than the granular details of the data.

4. Improve Reporting Consistency: Ensure that all significant results are clearly reported with appropriate p-values and confidence intervals. Address any inconsistencies in the statistical reporting.

5. Expand Policy Implications: Develop a more robust section on the practical implications of the findings, offering specific recommendations for how Somalia can improve water access, taking into account the identified factors.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: FELIX GUMAAYIRI AABEBE

Reviewer #2: No

Reviewer #3: Yes: Bonaventure Ahaisibwe MBChB , MPH

Reviewer #4: No

Reviewer #5: Yes: AYA AKSH

Reviewer #6: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003844.r003

Decision Letter 1

Razak M Gyasi

5 Nov 2024

PGPH-D-24-01613R1

Unimproved Source of Drinking Water and its Associated Factors: Insights from Somalia Health and Demographic Survey 2020.

PLOS Global Public Health

Dear Dr. Salih,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 05 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Professor Razak Gyasi, PhD, PD

Academic Editor

PLOS Global Public Health

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Please, review the attachment by the Reviewer thoroughly and revise the manuscript accordingly. Very importantly, please revise the manuscript for language correctness and critically improve the English structure.

Revise the title as follows: Unimproved Source of Drinking Water and the Associated Factors: Insights from the 2020 Somalia Demographic and Health Survey, instead of the way you initially provided it.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: The authors have comprehensively addressed the gaps flagged in the initial review

Reviewer #4: Dear authors

Thank you for addressing previous comments. I am attaching a word document with a few track changes, of some items that were missed.

All the best!

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Felix Gumaayiri Aabebe

Reviewer #2: No

Reviewer #3: Yes: Bonaventure Ahaisibwe

Reviewer #4: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: PGPH-D-24-01613_R1 Rereview.docx

pgph.0003844.s002.docx (180.8KB, docx)
PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003844.r005

Decision Letter 2

Razak M Gyasi

14 Nov 2024

Unimproved Source of Drinking Water and the Associated Factors: Insights from Somalia Health and Demographic Survey 2020.

PGPH-D-24-01613R2

Dear Dr Salih,

We are pleased to inform you that your manuscript 'Unimproved Source of Drinking Water and the Associated Factors: Insights from Somalia Health and Demographic Survey 2020.' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact globalpubhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Professor Razak Gyasi, PhD, PD

Academic Editor

PLOS Global Public Health

Reviewer Comments (if any, and for reference):

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: Response To Reviewers.docx

    pgph.0003844.s001.docx (27.5KB, docx)
    Attachment

    Submitted filename: PGPH-D-24-01613_R1 Rereview.docx

    pgph.0003844.s002.docx (180.8KB, docx)
    Attachment

    Submitted filename: Respond to reveiwer.docx

    pgph.0003844.s003.docx (17KB, docx)

    Data Availability Statement

    This study used secondary data from the Somalia Health and Demographic Survey (SHDS) 2020, which is publicly available on the website (https://microdata.nbs.gov.so/index.php/catalog/50). Access was granted after registration using an institutional email (abdisalam.hassan@amoud.edu.so). As the data is publicly available and anonymized, formal ethical approval from an Institutional Review Board (IRB) or Ethics Committee was not required for our study. However, it is important to acknowledge the ethical considerations during the original SHDS 2020 data collection. The National Bureau of Statistics (NBS), responsible for conducting the SHDS, likely has an established IRB or Ethics Committee that reviewed and approved the survey design and data collection procedures. The statement mentions that enumerators received training on obtaining informed consent (likely verbal) from participants, ensuring confidentiality, and building rapport. This aligns with ethical research practices for human subjects. Further details on the original SHDS 2020 IRB approval process or specific consent procedures could be obtained by contacting the NBS.

    Articles from PLOS Global Public Health are provided here courtesy of PLOS

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