dissertation on health and hygiene

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Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

Ashraful kabir.

1 Children Without Worms, The Task Force for Global Health, Dhaka, Bangladesh

2 School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

3 Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh

Korima Begum

4 Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh

Ariful Haq Kabir

5 Institute of Education and Research, Dhaka University, Dhaka, Bangladesh

Md Shahgahan Miah

Associated data.

Interview and discussion guidelines are available in the Supporting Information files. Additional data cannot be made publicly available due to ethical restrictions regarding participant consent to data release. Interested parties may contact Mr. Jitu Mia ( moc.liamg@tsusutij ), Assistant Administrative Officer, Departments of Anthropology, Shahjalal University of Science and Technology for further inquiries in this regard.

Introduction

Improved hygiene and sanitation practices in educational settings are effective for the prevention of infections, controlling the transmission of pathogens, and promoting good health. Bangladesh has made remarkable advances in improving higher education in recent decades. Over a hundred universities were established to expand higher education facilities across the country. Hundreds of thousands of graduate students spend time in university settings during their studies. However, little is known about the sanitation and hygiene practice of the university-going population. This study aims to understand and uncover which factors influence students’ sanitation and hygiene behavior in university settings.

This study was conducted in a public university named Shahjalal University of Science and Technology located in a divisional city of Bangladesh. Based on the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we adopted an exploratory qualitative study design. We developed semi-structured interview guides entailing sanitation and hygiene behavior, access, and practice-related questions and tested their efficacy and clarity before use. We conducted seventeen in-depth interviews (IDIs), and four focus group discussions (FGDs, [6–8 participants per FGD]) with students, and seven key informant interviews (KIIs) with university staff. Thematic analysis was used to analyze the data. Triangulation of methods and participants was performed to achieve data validity.

Despite having reasonable awareness and knowledge, the sanitation and hygiene practices of the students were remarkably low. A broad array of interconnected factors influenced sanitation and hygiene behavior, as well as each other. Individual factors (gender, awareness, perception, and sense of health benefits), contextual factors (lack of cleanliness and maintenance, and the supply of sanitary products), socio-behavioural factors (norms, peer influence), and factors related to university infrastructure (shortage of female toilets, lack of monitoring and supervision of cleaning activities) emerged as the underpinning factors that determined the sanitation and hygiene behavior of the university going-population.

The results of this study suggest that despite the rapid expansion of on-campus university education, hygiene practices in public universities are remarkably poor due to a variety of dynamic and interconnected factors situated in different (individual, contextual, socio-phycological) levels. Therefore, multi-level interventions including regular supply of WASH-related materials and agents, promoting low-cost WASH interventions, improving quality cleaning services, close monitoring of cleaning activities, promoting good hygiene behavior at the individual level, and introducing gender-sensitive WASH infrastructure and construction may be beneficial to advance improved sanitation and hygiene practices among university students.

The benefits of improved hygiene and sanitation are well-documented and largely recognized as an effective strategy for the prevention of infection and controlling the transmission of pathogens [ 1 , 2 ]. The promotion of good hygiene and sanitation practices is also well-recognized as a cost-effective, easy-to-practice, convenient, and useful public health measure to prevent and control the spread of infectious diseases and promote good health [ 3 , 4 ]. The importance of promoting appropriate sanitation and hygiene practices has been endorsed in many international policy documents and global commitments. The United Nations (UN) emphasized access to improved sanitation and good hygiene practices within the Sustainable Development Goals (SGD target 6), indicating that it is likely to achieve sustainable economic growth and a better future [ 5 , 6 ].

In recent years, Bangladesh has made overwhelming advances in economic development. The country maintained over six percent of Gross Domestic Product (GDP) over the last two decades and was positioned as the fastest-growing economy in the world [ 7 – 9 ]. Such economic growth enhances the government’s ability to substantially invest in the education sector (i.e., education stipend program, gender parity, geographical coverage), resulting in greater access to school attainment and boosting primary and secondary education [ 10 , 11 ]. Similar to the primary and secondary education sector, the government also took policy initiatives, such as the promulgation of the first Private University Act in 1992 and a 20-year Strategic Plan for Higher Education 2006–2026. The country has received technical and financial support from the World Bank since the 1990s to expand and meet the demands of higher education in Bangladesh [ 12 ]. The Private University Act of 1992 helped to expand higher education in the private sector, whereas the Strategic Plan for Higher Education 2006–2026 focused on the reformation of the entire higher education sector and is largely based on neoliberal policy doctrine [ 13 ]. The neoliberal policy shift has emphasized the need to expand technical and market-oriented knowledge [ 14 ]. This resulted in the establishment of many science- and technology-oriented new universities in older districts (which have a large population and land territory), headquarters, and townships [ 13 ]. According to the most recent statistics of the University Grants Commission (UGC)—the peak body charged with the higher education sector—as of 2020, the country has 148 universities [ 15 ]. The UGC’s latest annual report released in 2018 indicated that there are 136 functioning universities (out of 148, the rest are in the process of becoming operational). Of these, 47 are public (state-funded), and 107 are private (non-state-owned) [ 15 ]. Over the last decade, students’ enrolment in both public universities and their affiliated colleges and private universities has been increased by ten-fold [ 15 ]. Currently, 4,434,451 students are enrolled in a wide array of departments and schools. The share of female students’ enrolment in higher education institutes is around 38 percent [ 16 ]. Public universities largely provide on-campus residential facilities in university halls [ 17 ]. A high proportion of students stay on campus during their studies, which typically extend over a period of five to seven years. Despite the proven effectiveness of improved sanitation and hygiene practices in educational settings [ 18 ], there is evidence that maintaining good hygiene practices in low-income countries has a relatively low implementation rate [ 19 ]. Until recently, sanitation and hygiene practice-related studies in educational settings mainly focused on the school level (mostly in primary schools, ages six to eleven) in Bangladesh [ 20 – 22 ]. Few studies have reported the hygiene and sanitation behaviors of university students in the context of Bangladesh. Moreover, most of these studies have used quantitative methodological approach and focused on either the users’ perspective, such as students, or the suppliers’ perspective, such as access to facilities. This is insufficient to completely recognize and explore hygiene and sanitation related behaviour and practices. For example, few cross-sectional studies reported WASH-related descriptive statistics in university students [ 23 – 26 ]. Against this backdrop this paper uses a qualitative methodological approach to investigate hygiene and sanitation related behaviour and practices from a holistic perspective. Adopting a conceptual framework, this study recognizes and explains how and whether sanitation and hygiene practices among university students are influenced. This investigation will provide a total picture of factors associated with WASH-related processes and outcomes in a specific context. This pragmatic study will add information from the perspective of users and suppliers and contribute to the literature. Moreover, the study will inform the Water Sanitation and Hygiene (WASH)-related actions needed in public universities to improve sanitation and hygiene practices among university students.

Study time and setting

This study was conducted at Shahjalal University of Science and Technology (SUST) in Sylhet, a north-eastern city, approximately 240 km from Dhaka, the capital of Bangladesh. SUST is a public university established in 1986 to promote science and technology-oriented education and research. The campus has 320 acres of land [ 27 ]. The university supports residential facilities for students in five halls on campus. In addition, the university hires three privately-run halls for its female students outside the campus (in the central city). They are privately managed but aligned with a standard (i.e., WASH facility, security, physical space, etc.) set by the university. Students in these privately-operated halls pay higher rent compared to those who stay in the campus-based halls. In 2020, the university had approximately 11,000 students across seven schools, twenty-seven departments, and two institutes [ 27 ]. During their stay on campus, students usually move across different buildings and facilities, including academic buildings, libraries, residential halls, auditoriums, teacher-student center restaurants, cafeterias, and shops. There are several cafeterias, restaurants, and grocery stores that provide essential services for both campus-based students, off-campus students, and visitors. Among these, coffee shops are visited by thousands of students each day for breakfast, lunch, and dinner. There are also many mobile food vendors who prepare and sell various foods across campus [ 17 ].

Theoretical framework

We used the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) to inform our research [ 28 ]. This model offers an analytical and conceptual tool to explore and understand an array of factors that influence the use of water, sanitation, and hygiene dynamically in a resource-limited setting [ 29 ]. We, therefore, considered this model the best-suited in the current study setting that is characterized by constraints to the infrastructure required to promote better sanitation and hygiene practices. Based on this model, we developed a conceptual framework to analyze the data ( Fig 1 ). For this model, sanitation and hygiene practices are influenced by a broad range of factors at various levels. The individual-level factors include prior exposure and understanding of the importance of maintaining hygiene. The physical environmental factors refer to the availability of infrastructural facilities or shortages. Socio-behavioural factors are related to the psychological, and social determinants such as norms, beliefs, habits, self-efficacy that influence the adoption of sanitation and hygiene practices. Societal factors related to the institution focus on the polity and/or supply-related issues. The practice of sanitation and hygiene is the combined result of these factors, which are interconnected and influence each other.

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Study population and sampling strategy

We conducted seventeen in-depth interviews (IDIs) and four focus group discussions (FGDs, [6–8 participants per FGD]) with both on-campus (students who stay in the halls) and off-campus students from various departments, and seven key informant interviews (KIIs) with university staff ( Table 1 ). We included undergraduate students based on eligibility criteria such as voluntary participation and completion of at least one year of study. We did not include students who did not have the capacity to provide informed consent or these who were doctoral students or enrolled in short-term courses (evening courses, short professional courses). Considering our study aims, we purposefully recruited the participants, which was used in qualitative studies the context of Bangladesh [ 30 , 31 ]. First, the interviewers approached potential students and shared the research aims, objectives, and expectations of the study. If the interviewee met all the criteria, they were approached to participate in the interview. During this process, we followed all steps described in the consent form, such as the subject matter of the study, participants’ rights, possible risks and benefits, the liberty of withdrawing from the interview at any point in time, confidentiality, anonymity, and additional information sources. We obtained the written consent of the participants before starting the interview. The interviews were audio-recorded. The number of interviews was determined based on the principle of data saturation; point of time, no new data, or dimension, or theme emerged [ 32 ]. Coordinated teamwork throughout had the strength of determining data redundancy, increasing data validity, and rigors. Multiple researchers concurrently conducted and analyzed interviews. After each interview day, the research team completed a debrief sheet to discuss the primary initial/axial codes. After two-thirds of the interviews were completed, the research team checked the independently developed codes and identified that no new information or codes were generated. Following a discussion and having reached a consensus, the research team decided to conduct a few more interviews to reach saturation of directional logic [ 33 ]. We stopped interviewing when the data was saturated. However, we considered the three basic principles of selecting a study participant: (i) maximum variation (we included participants from different years or semesters, disciplines, genders, and residences); (ii) iterative process (we re-interviewed two IDI participants and one KII participant to gather relatively accurate and nuanced data by verifying and cross-checking a few pieces of information); and (iii) reflexivity (assessed self-roles).

Data collection procedure

The data collection team consisted of four members who were graduates in the fields of anthropology and public health. They had extensive expertise in qualitative research methods and the application of different techniques. The second and third authors conducted FGDs, while the first and last authors conducted IDI and KII. The fourth author coordinated the data collection activities with methodological feedback. The interviews were conducted in Bangla, the mother tongue of both the interviewees and interviewers. Semi-structured interview questionnaires and guides were developed and their appropriateness and clarity were tested at another educational institute. These question guides explored several aspects relating to the availability of sanitation and hygiene facilities, facilitators, and/or barriers, habits, infrastructure, supplies, maintenance, and so on. The interviewers first attempted to develop a good rapport with participants by asking about daily activities, preferences, and university-related lifestyles. We subsequently elicited detailed information about sanitation and hygiene-related issues. On average, the IDIs and KIIs took 40–55 minutes and the FGDs 80–100 minutes.

Data analysis

Adopting this approach, we started to transcribe interviews immediately after completion. After transcribing the data, we translated it into English. We conducted a theme-based analysis following the thematic approach [ 30 , 34 ]. A stepwise procedure was followed [ 35 ]. First, all authors independently and repeatedly read the interviews to familiarize themselves with the content. Second, the primary codes were identified, namely, meaningful statements or information. Third, we searched for some clusters based on similarities in these codes. Finally, we identified four major themes to report the findings ( Fig 1 ). All authors independently prepared some codes and themes to check the similarities and dissimilarities among them. A thematic analysis approach enabled us to develop uncategorized themes, which is useful to explore and capture associated factors that influence sanitation and hygiene practices among students. However, one of the challenges of this approach was organizing and merging the codes/themes that appropriately capture participants’ comments and views. Any disagreements were resolved following a discussion or consensus. No text management software (i.e., Nvivo, Atlas-ti) was used to analyze the data.

This study received ethical approval from the institutional review board of Shahjalal University of Science and Technology. We developed consent forms for participants explaining issues related to confidentiality and anonymity, risk and harm, benefit and loss, additional information sources, and participants’ rights. We maintained all aspects described in the consent form, such as removing any personal identification during the analysis. All data were kept within the research teams. We obtained written consent from the participants.

The socio-demographic characteristics of the participants are presented in Table 2 . The mean age (mean ± standard deviation) of the IDI participants was 20.2 years (20.2±2.4) and 21.6 years for FGD participants (21.6±2.6). The highest number of participants was third-year students in the IDIs (7 out of 17) and FGDs (11 out of 29). The highest number of participants in the IDIs was female (9 out of 17) and from the Faculty of Social Sciences, whereas over half (15 out of 29) were male, and the majority were from the Faculty of Physical Sciences (8 out of 29) for FGD participants. The majority of the participants for both IDIs and FGDs were Muslim and came from rural households.

Thematic analysis

We found that four key factors, namely, individual factors, socio-behavioural factors, contextual factors, and factors related to the university, determine sanitation and hygiene practices among students at the university ( Fig 1 ). Each of these major factors was further divided into sub-factors, as presented below. The data gathered from all sources revealed that students are substantially aware of the need for improved hygiene and sanitation; however, contextual and university-related factors jeopardize their practices.

Theme 1: Individual and structural factors

Our data revealed that sanitation and hygiene behavior was influenced by a wide array of individual factors, such as level of knowledge and awareness, past habits (developed through family education/orientation, and media exposure), privacy, gender, and the perceived benefits of improving sanitation and hygiene practices. A high proportion of participants were aware of the importance of using sanitary toilets and maintaining personal hygiene. The majority of participants said that they gained a good level of knowledge mostly from their families and schools, such as washing their hands with soap after defecation, and before and after eating, and by coming into contact with dirt throughout their childhoods. One participant stated the following:

" We normally learned many norms , such as ’hand wash behavior’ from our families . From childhood naturally , mom used to wash my hands after using toilets and obviously before eating food . I became used to washing my hands this way . " (A male student in an IDI)

A similar view was shared by another participant:

" From my childhood , my family members taught me how to wash my hands , use toilets , and maintain good hygiene . I think that was the base . I am now used to doing so . " (A male student in an IDI)

A parallel view was shared in the focus group discussions:

" From my childhood , my mother trained me how to wash my hands . She taught me about healthy sanitation behavior . Thus , I have adopted a sanitary and hygienic practice . " (A female student in an FGD)

Apart from family, exposure to media (i.e., TV programs, commercial advertisements, and school programs) was reported as a good source of knowledge about sanitation and hygiene habits. One participant explained:

" I have learned the primary lesson of ’sanitation and hygiene behavior’ from home . My mother taught me cleanliness , personal hygiene , and handwashing from early childhood . As I grew up , I have learned some additional sanitation stuff (i . e ., liquid soap , hand sanitizer , sanitary napkins) from my surroundings , television programs , school wash programs , and so on . " (A female student in an FGD)

More than two-thirds of participants said that they felt that using sanitary toilets and maintaining personal hygiene on campus largely depended on how much they allowed them to maintain their privacy. Students viewed toilets and washing facilities in campus buildings including academic buildings, libraries, residential halls, and auditorium buildings as safe places to use. However, female students expressed concern over not having a strict privacy policy. As a result, they emphasized the need to improve privacy issues within campus buildings in toilets and other sanitation facilities. One participant said:

"… We need privacy , and it’s really essential for females . " (A female student in an IDI)

A few students raised concerns about toilets located in places other than university buildings (i.e., located in shopping malls, cafes, restaurants). Toilets in commercial places might not always be safe for women and girls. Thus, the female students felt confident using the toilets and washing facilities in university buildings. Both the male and female participants reported that gender was an issue in toilet use. The participants mentioned that the number of toilets and sanitary facilities is inadequate across university buildings, and that it jeopardized maintaining improved sanitary and hygiene habits, especially for female students. One student reported:

" There are a lot of problems in campus bathrooms/toilets . We have to be in a queue to use the bathroom , and it’s quite normal for everyone in the hall . To be in a queue might be good in terms of maintaining discipline . But suppose , if you have an emergency and someone is already in the bathroom , then ? Sometimes things happen like you are in the toilets , and you suddenly discover that there is no water , then ? Sometimes you will see there is no soap , and toilets are left dirty and uncleaned—these types of things we know happen , but still we have to use this kind of dirty and unsafe latrines . " (A female student in an IDI)

Due to the long queues and the unusable conditions of the toilets, female students tended to hold their urine for a long time, which may affect their urinary system. One participant mentioned that holding urine for a long time may weaken the bladder and increase the risk of urinary tract infections:

" The tendency of holding urine among female students is very high . There are many reasons for this , including unusable toilet conditions , an insufficient number of toilets , and unhygienic toilets . I guess the incidence of urine infections may be high among female students and this could be linked to holding urine for a long time . " (A female student in an FGD)

Nearly two-third of IDI participants (11 out of 17) shared concerns about the barriers for maintaining menstrual hygiene both in the halls and other buildings. There was no proper arrangement to dispose of menstrual products in the toilets or washrooms. A vast majority of female participants reported that they usually fail to follow hygienic methods for managing menstrual waste. Toilets located in campus buildings were reported as unfriendly to female students as no waste disposal facilities exist except for the presence of a small basket in the toilet area. The following quotes explain the situation:

" The sanitation system of the campus is not female-friendly . Sometimes , the supply of water gets stopped for unknown reasons . There is no hand wash products or soap in any washroom . The only thing present is a small basket and a water pot in some toilets . There is no way to flush the toilets after use . There should be an emergency pad facility in the female washrooms , but unfortunately , we cannot see it . " (A female student in an FGD) " The scenario of women sanitation facilities on this campus is not good . If I have a period of unexpected time , I have to go to my room . And if I want to change pad , there is no dustbin or soap bar or sanitizer . " (A female student in an IDI)

This limitation was acknowledged by the one of the KII participants who said that the gender perspective related to hygiene and sanitation might have been overlooked over the years. The toilets do not seem gender friendly, especially in the academic buildings where no menstrual disposal materials are available. The participant said:

“ The condition is grossly poor . But this is worst in the academic buildings which are commonly used . Menstrual hygiene management facilities are poor in the academic buildings . ” (A house-tutor in a KII)

This view was reflected by another participant:

“ Overall the hygiene and sanitation facilities seem poor for female students . However , female students may relatively manage this inside the halls . But , this situation remains poor in academic buildings . ” (A tutor in a KII)

The majority of participants reported the perceived benefits of improved sanitation and hygiene practices, which act as a facilitating factor for the adoption of good hygiene habits. However, some female students reported that they carried personal hygiene products (i.e., hand sanitizer, toilet tissue). One participant reported:

" I carry my own sanitary and hand wash materials , so I used that . " (A female student in an IDI)

However, more than two-thirds of the participants reported that a negligible number of students carry personal hygiene materials with them. One participant mentioned:

" Carrying personal hygiene material has become a good strategy for coping with the situation , especially where the resources are limited . However , this is a recent trend and thus has not been widely practiced … it’s quite new in our culture . " (A female student in an FGD)

The majority of male students reported that they do not carry any sanitizer or any other means to maintain hygiene. One participant reported:

Maybe females and girls are more sensitive and have a good arrangement for carrying any materials. They usually carry a handbag where they easily keep such products. But it is very tough to carry this in the male school bags." (A male student in an FGD)

Theme 2: Socio-behavioural factors: Perceptions and beliefs

Mixed views were reported regarding the influence of friends and peers in promoting improved sanitation and hygiene habits. The majority of male participants acknowledged that they were neither motivated nor discouraged by their peers and friends in the adoption of sanitary and hygiene practices. In contrast, female participants said that they sometimes copied or followed what others were practicing. One of the female participants reported:

" I noticed that some of our friends were carrying personal hygiene products with them . I found that it is useful to carry a hand sanitizer or toilet tissue in my bag … I can use it if I feel so . " (A female student in an FGD)

Some participants stated that male students were found to urinate in open space mostly at roadsides and in alleyways across campus. In Bangladesh, males often urinate at roadsides or in alleyways; however, it is quite impossible for females to do the same. Unlike female students, male students seemed to have fewer concerns about maintaining hygiene at a personal level. One of the participants stated:

" I think male students do not think much about sanitation and hygiene issues . They get influenced by their surroundings … hygiene , sanitation , may remain concerned . " (A male student in an IDI)

A similar view was shared by a KII informant:

“ In our culture , females are more sensitive to maintaining their privacy which may help them adopt positive hygiene and sanitation habits . The social and cultural construction support the view that a male person can urinate by a roadside and in alleyways . ” (A tutor in a KII)

Theme 3: Contextual factors

Supply-side factors such as the improper maintenance of toilets, poorly managed services, a lack of cleanliness, unpleasant odors, lack of sanitary products (i.e., soap, hand wash agents, sanitizers, etc.) mostly appeared as constraining factors for the adoption of improved hygiene practice in university settings. The majority of students reported that the cleaning service was insufficient. The university authorities rarely supply soap and/or other sanitary materials. One of the participants stated:

" I cannot remember any scene that I saw any soap at the toilets … the authorities may not be concerned about the importance of providing this product . " (A male student in an FGD)

Additionally, most students reported that their proper hygiene practices are strongly impacted by how well the toilets are maintained and cleaned at the university. Almost all participants said that clogged toilets or dirt were frequently visible in the toilets. Some participants mentioned that the number of toilets was noticeably insufficient, thus creating pressure on the functioning ones. Therefore, regular maintenance of toilets and using sanitary cleaning materials are very critical to maintain cleanliness. However, the reality is, frustratingly, the opposite of this. One participant noted:

" Toilets are rarely cleaned with proper toilet cleaning products (chemicals) . Often , they use merely water and/or a small amount of chemical agent which might fail to kill germs , remove dirt , or clogs . " (A female student in an IDI)

Another student stated:

" To date , inadequate sanitation facilities remain the primary cause of unimproved sanitary and hygiene practices . The number of students is huge , so the authorities need to provide a good number of hand wash or soaps for the students and take care if they are finished or not . The authorities need to appoint more employees to do the cleaning . But I hardly noticed that all the mentioned actions were taking place in a timely manner . " (A female student in an IDI)

A similar view was expressed by another participant:

" The students are aware of the importance of good hygiene habits . But often , they fail to maintain it mostly because of the supply side . You rarely see any handwashing material readily available in the washrooms . How can a student maintain good handwashing practices after using the toilet ? " (A male student in an FGD)

However, a few KII participants explained why there is such a lack of or shortage in the cleaning workforce and university budget. Nevertheless, they acknowledged that there is a severe shortage of cleaning staff in almost all areas (halls and academic buildings). Thus, there are failures in the routine maintenance of sanitary activities and areas. One participant stated:

" We don’t have adequate budget support and a workforce to provide sanitary and hygiene support at the optimum level . I feel that this causes problems . Many of us acknowledge this shortage , but it is a very structural problem . " (A house tutor in a KII)

A similar view was shared by a cleaner:

" The number of cleaners is low . It sometimes causes problems in routinely maintaining cleaning activities . But I try to do my best . The cleaning products are supplied as per rules . " (A cleaning staff member in a KII)

Additionally, some participants reported that unstable water supply triggers the dirtiness or poor maintenance of toilets. On many occasions, the lack of a reliable water supply results in the improper flushing of toilets after use, which deteriorates the toilet hygiene condition. One participant stated:

" It’s prevalent that one leaves the toilet without proper flushing due to the lack of adequate water . This causes the toilet to be unusable for next users … thus deteriorating hygiene quality . " (A male student in an FGD)

Another participant noted:

" Bad odor is very common in the toilets because excreta are not properly flushed out . It is created when the toilet holes are not properly flushed out . Very often the reason is either a lack of stable water supply or a problem with the flushing system (the flushing system does not work for any reason . " (A male student in an IDI)

Theme 4: Factors related to the university

Access to toilets and handwashing facilities is restricted even further in the buildings around campus after office hours (8.00 am to 5.00 pm). Regular classes and administrative services are provided during this time; however, students remain on campus for longer periods of time for various reasons, such as library work, group assignments, social gatherings, and so on. During this time, they felt embarrassed as access to the toilets and hand wash facilities remain closed in and around campus. This situation becomes very problematic for female students as they need to go to the nearby halls or restaurants. However, a male student mentioned that it is not unusual for male students to urinate in an open place near a bush or building corner. One participant mentioned:

" A male student can manage his need by peeing at a roadside . But it creates a problem for female students . They either hold their needs for a long time or go to the nearby halls , which is embarrassing . "

The number of female toilets is noticeably low compared to male toilets, which causes female students to abstain from toilet use. The following participants explained the situation:

" In our academic building , there is only one common room for female students . And there are six departments in our academic building . So , for all the female students , there is only one common room . In this common room , we have only three toilets and one basin , which is usable , and the other is broken . This common room is open till 5 pm . But for male students , they have two washrooms available in this building . " (A female student) " In our academic building , there is only one common room for females , and it is being rebuilt . In the common room , there were three washrooms and two basins , but one basin was unusable . Two new washrooms have been built recently on the ground floor of the building . But I am not sure if these new washrooms are for male students . There are two washrooms for males and on the opposite side we have two washrooms for females also . " (Another female student)

Some participants mentioned that the lack of appropriate technology and poorly managed construction/repair work made it difficult for students to maintain good sanitary and hygiene practices. A few participants reported that the toilets often do not flush or stop properly, causing the toilet pans to become waterlogged. Some participants mentioned that the authorities (hall administrations, engineering office) do not check the toilets and talk to students about it.

" I never heard that someone from the authorities talked with students and checked if the cleaning activities are properly maintained . " (A male student in an IDI)

Another participant stated:

" The toilets are not clean enough to use . Though the authorities have employed staff to clean the toilets of the academic buildings and residential halls , I don’t think they clean the toilets as required . There are bad odors in every toilet , and sometimes the toilets seem to be clogged also . As I stay in a residential hall , I have no other option than using these toilets . But I can’t maintain hygiene , and I am afraid for my health . I think it is about the monitoring and supervision of cleaning work . " (A female student in an IDI)

Using IBM-WASH model, this study aimed to explore and recognize how and which factors influence sanitary and hygiene practices among university students at a public university in Bangladesh. Data from multiple sources and participants identified a broad array of elements situated on different levels of the IBM-WASH model (i.e., individual, socio-behavioural, university, and contextual) that impact sanitation and hygiene practices. These factors are noticeably comparable and interconnected to each other.

In Bangladesh, few studies have examined sanitation and hygiene practices in educational settings. Those that are available tend to focus on primary and secondary schools [ 36 – 39 ]. Beyond the school-based WASH-related studies, few cross-sectional studies have focused on and determined the prevalence of handwashing attitudes, perceptions, and practices in university settings [ 23 , 25 ]. This shortage of information may limit the scope of comparing and contrasting our results with similar studies. Our findings revealed that university students were aware of and possessed adequate knowledge about sanitation and hygiene-related illnesses and health problems. This contrasts with several international studies in Turkey [ 40 ] and elsewhere [ 41 ]. The findings of this study revealed that students were aware of the importance of handwashing and possessed positive attitudes towards maintaining good hygiene practices despite structural barriers. These positive attitudes may be linked to WASH-related understanding gained at a pre-university age. Over the past two decades (2000–2020), there has been extensive school-based WASH-related interventions (i.e., hardware facilities such as latrine construction, tube-well installation, supplying handwashing products, cleaning materials, hygiene promotion messaging, IEC materials) in Bangladesh that familiarized and habituated students to adopt good hygiene practices [ 29 , 42 – 44 ]. A similar observation was noted in a recent study conducted in Dhaka University, the largest public university in Bangladesh. The study noted that hygiene and sanitation practices differed significantly by gender and socio-economic status; female students and students from nuclear families had better hygiene and sanitation practices compared to male students and students from joint families, where typically three or more generations living together in a single household [ 25 ]. Another reason is that university students may come from relatively middle and upper-middle class families with greater access to WASH information (i.e., media exposure) that helps them to adopt acceptable hygiene practices from their families [ 45 , 46 ]. Another reason may be that the majority of students (mostly born around the beginning of the current millennium) gained contemporary views on lifestyle as informed by (social) media. This is consistent with greater access to telecommunication media associated with economic growth in the last two decades, resulting in improvements in quality of life, particularly to the middle and upper-middle class population. Such views favored the adoption of enhanced sanitary and hygiene practices at personal and family levels. The adoption of enhanced hygiene practices became a symbol of politeness or standard courtesy.

However, our data showed that despite these positive habits related to individual level of WASH behaviors, the lack of contextual and socio-behavioural dimensions of WASH practices at the higher education institutions work as barrier for individuals not to maintain and foster these positive habits at the individual level. The data revealed that students noticeably failed to maintain improved sanitary and hygiene behavior at their university properly. The supply-side response substantially caused this failure, as noted in one study [ 36 ]. The university authorities lacked adequate support to monitor and supervise the management of cleaning activities at different levels, which might result in poor outcomes [ 36 ]. Similarly, the findings of this study also showed that an inadequate supply of cleaning products (soap, sanitizer, or other means) restricted the timely maintenance quality of sanitation facilities and arrangements across halls and other buildings at the University in Bangladesh. Conversely, the timely and regular supply of sanitary and hygiene material enhanced hygiene practices. A similar observation was noted in systematic reviews and control trials, as well as cross-sectional studies in several international settings [ 47 , 48 ].

One of the significant findings of this study is that the meaning of sanitation and hygiene was narrowly viewed by participants. Sex and gender sensitivity were largely ignored by the universities in the provision of sanitation-related supplies. The lack of gender sensitivity at the contextual level works as a barrier to improve and foster sanitation and hygienic practices at the individual level. This limitation jeopardized female students adopting improved hygienic behavior in and across campus buildings. Such a lack was noted in Bangladesh and elsewhere in previous studies where girls and women rarely had access to disposing of menstrual products or using cleaning agents [ 49 – 52 ]. Arranging a gender-friendly sanitation system was likely not seriously considered in construction plans. Structural constraints such as reliable water sources, timely managed services, and cleanliness appeared as an underlining barrier for adequate sanitation and hygiene practices. The absence of these factors significantly affected the female students as they are socially and culturally sensitive to using toilets in unfamiliar places (i.e., public toilets). They attempted to take an alternative strategy to cope with such a situation by holding their urine for a long time or tried to avoid drinking water. Due to the study design, our data do not enable us to determine how and whether the female students experienced any health problems caused by this practice. Another study reported that such a strategy negatively impacts girls’ and women’s health outcomes [ 53 – 55 ].

Our findings indicate that institutional-based higher education has expanded rapidly to align with the economic growth of the country in the past two decades. This economic growth might have created increasing demands on hygiene and sanitation facilities. To meet these increasing demands, the Government of Bangladesh announced a national goal known as “Sanitation for All by 2010” as a major policy initiative that facilitated multi-level programmatic supports at household levels [ 56 ]. To comply with this national goal, extensive programmatic interventions were implemented at the school level. The need to improve WASH facilities in higher educational institutions was therefore neglected, which resulted in poor facilities, management, and maintenance of WASH facilities. The current study advocates that WASH-related facilities and practices at universities need special focus to promote improved hygiene and sanitation practices in universities.

Limitation of the study

The findings of this research could not be generalized to those universities that offer fee-earning evening courses. This is because they earn money from professional degrees with high tuition fees and are intended to provide healthy facilities for their professional/executive students (i.e., the Business Faculty or Institute of Education and Research of Dhaka University or private universities). However, the situation of colleges under the National University may be worse than public universities. There are more than 2,200 colleges under the National University offering degrees. Our study is limited as we could not obtain interviews with high-level policy makers/administrators. The high-level policy makers/administrators had engaged with some pre-existing activities during the data collection period that might have focused on sanitation service provision and management in the university. Whilst we included participants from different years, semesters, disciplines, genders, and residences to maximize variation, we recognize that some students, such as those with hearing impairment or other physical/neurological disabilities, were not included in this research, and future research could consider this. However, we are confident that we sampled a diverse range of participants, ensured self-reflexivity, and applied an iterative process during the interviews. Careful consideration of these steps and the standard procedures of qualitative methods enabled us to generate valid evidence that might be generalizable to other public universities.

This study revealed that sanitation and hygiene practices in public universities are remarkably poor due to supply-side responses. Despite the remarkable increase in the number of universities and resource allocation, the promotion of improved sanitary and hygiene facilities has been overlooked over the years. Therefore, a multi-level promotional intervention focusing on provider responses is needed to advance an enhanced, need-oriented, and effective sanitary and hygiene system that can promote improved hygiene and sanitary practices among university students.

Suggested recommendations to improve hygiene and sanitation practices

WASH-related materials and agents (i.e. supplying handwashing products, cleaning materials, washing equipment) should be regularly supplied to ensure quality cleaning services.
A toilet cleaning checklist may be introduced to ensure quality cleaning services by cleaning professionals.
WASH-related pictorials and key messages may be developed and displayed to promote good hygiene habits that remind the individual user to maintain good hygiene behavior.
Regular monitoring and inspection of cleaning professionals and checking the toilet checklist to ensure quality services.
Promote low-cost solutions such as soapy water or chlorine tablets/a tablet that has been proven effective in resource-limited settings should be introduced to minimize costs.
Improve provision of toilets for female students. Consider gender perspectives in planning new infrastructure and construction. Low-cost menstrual hygiene-related disposal materials should be placed in existing buildings.

Supporting information

Acknowledgments.

The authors would like to express their gratitude to those who participated in the interviews and group discussions.

Funding Statement

This study received no funding support to design, conduct, analyze, and report the findings. Although the first author (AK) had a consultant position with Children Without Worms, The Task Force for Global Health during the study time, that position did not play any role in this study. This study was conducted under a separate arrangement. Children Without Worms, The Task Force for Global Health provided support for this study via salary for AK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

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Research Article

Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Children Without Worms, The Task Force for Global Health, Dhaka, Bangladesh, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Roles Data curation, Formal analysis, Methodology, Validation

Affiliation Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh

Roles Formal analysis, Investigation, Methodology, Validation, Writing – review & editing

Affiliation Institute of Education and Research, Dhaka University, Dhaka, Bangladesh

Roles Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing – original draft

Ashraful Kabir,
Shuvo Roy,
Korima Begum,
Ariful Haq Kabir,
Md Shahgahan Miah

Published: September 22, 2021
https://doi.org/10.1371/journal.pone.0257663
Reader Comments

Introduction

Citation: Kabir A, Roy S, Begum K, Kabir AH, Miah MS (2021) Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh. PLoS ONE 16(9): e0257663. https://doi.org/10.1371/journal.pone.0257663

Editor: Mary Hamer Hodges, Helen Keller International, SIERRA LEONE

Received: October 11, 2020; Accepted: September 7, 2021; Published: September 22, 2021

Copyright: © 2021 Kabir et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Interview and discussion guidelines are available in the Supporting Information files. Additional data cannot be made publicly available due to ethical restrictions regarding participant consent to data release. Interested parties may contact Mr. Jitu Mia ( [email protected] ), Assistant Administrative Officer, Departments of Anthropology, Shahjalal University of Science and Technology for further inquiries in this regard.

Funding: This study received no funding support to design, conduct, analyze, and report the findings. Although the first author (AK) had a consultant position with Children Without Worms, The Task Force for Global Health during the study time, that position did not play any role in this study. This study was conducted under a separate arrangement. Children Without Worms, The Task Force for Global Health provided support for this study via salary for AK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

Competing interests: The authors have read the journal’s policy and declare the following competing interests: AK received a salary from Children Without Worms, The Task Force for Global Health. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Study time and setting

Theoretical framework

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https://doi.org/10.1371/journal.pone.0257663.g001

Study population and sampling strategy

https://doi.org/10.1371/journal.pone.0257663.t001

Data collection procedure

Data analysis

https://doi.org/10.1371/journal.pone.0257663.t002

Thematic analysis

Theme 1: Individual and structural factors

" We normally learned many norms , such as ’hand wash behavior’ from our families . From childhood naturally , mom used to wash my hands after using toilets and obviously before eating food . I became used to washing my hands this way . " (A male student in an IDI)

A similar view was shared by another participant:

" From my childhood , my family members taught me how to wash my hands , use toilets , and maintain good hygiene . I think that was the base . I am now used to doing so . " (A male student in an IDI)

A parallel view was shared in the focus group discussions:

" From my childhood , my mother trained me how to wash my hands . She taught me about healthy sanitation behavior . Thus , I have adopted a sanitary and hygienic practice . " (A female student in an FGD)

" I have learned the primary lesson of ’sanitation and hygiene behavior’ from home . My mother taught me cleanliness , personal hygiene , and handwashing from early childhood . As I grew up , I have learned some additional sanitation stuff (i . e ., liquid soap , hand sanitizer , sanitary napkins) from my surroundings , television programs , school wash programs , and so on . " (A female student in an FGD)

"… We need privacy , and it’s really essential for females . " (A female student in an IDI)

" There are a lot of problems in campus bathrooms/toilets . We have to be in a queue to use the bathroom , and it’s quite normal for everyone in the hall . To be in a queue might be good in terms of maintaining discipline . But suppose , if you have an emergency and someone is already in the bathroom , then ? Sometimes things happen like you are in the toilets , and you suddenly discover that there is no water , then ? Sometimes you will see there is no soap , and toilets are left dirty and uncleaned—these types of things we know happen , but still we have to use this kind of dirty and unsafe latrines . " (A female student in an IDI)

" The tendency of holding urine among female students is very high . There are many reasons for this , including unusable toilet conditions , an insufficient number of toilets , and unhygienic toilets . I guess the incidence of urine infections may be high among female students and this could be linked to holding urine for a long time . " (A female student in an FGD)

" The sanitation system of the campus is not female-friendly . Sometimes , the supply of water gets stopped for unknown reasons . There is no hand wash products or soap in any washroom . The only thing present is a small basket and a water pot in some toilets . There is no way to flush the toilets after use . There should be an emergency pad facility in the female washrooms , but unfortunately , we cannot see it . " (A female student in an FGD) " The scenario of women sanitation facilities on this campus is not good . If I have a period of unexpected time , I have to go to my room . And if I want to change pad , there is no dustbin or soap bar or sanitizer . " (A female student in an IDI)

“ The condition is grossly poor . But this is worst in the academic buildings which are commonly used . Menstrual hygiene management facilities are poor in the academic buildings . ” (A house-tutor in a KII)

This view was reflected by another participant:

“ Overall the hygiene and sanitation facilities seem poor for female students . However , female students may relatively manage this inside the halls . But , this situation remains poor in academic buildings . ” (A tutor in a KII)

" I carry my own sanitary and hand wash materials , so I used that . " (A female student in an IDI)

However, more than two-thirds of the participants reported that a negligible number of students carry personal hygiene materials with them. One participant mentioned:

" Carrying personal hygiene material has become a good strategy for coping with the situation , especially where the resources are limited . However , this is a recent trend and thus has not been widely practiced … it’s quite new in our culture . " (A female student in an FGD)

The majority of male students reported that they do not carry any sanitizer or any other means to maintain hygiene. One participant reported:

Maybe females and girls are more sensitive and have a good arrangement for carrying any materials. They usually carry a handbag where they easily keep such products. But it is very tough to carry this in the male school bags." (A male student in an FGD)

Theme 2: Socio-behavioural factors: Perceptions and beliefs

" I noticed that some of our friends were carrying personal hygiene products with them . I found that it is useful to carry a hand sanitizer or toilet tissue in my bag … I can use it if I feel so . " (A female student in an FGD)

" I think male students do not think much about sanitation and hygiene issues . They get influenced by their surroundings … hygiene , sanitation , may remain concerned . " (A male student in an IDI)

A similar view was shared by a KII informant:

“ In our culture , females are more sensitive to maintaining their privacy which may help them adopt positive hygiene and sanitation habits . The social and cultural construction support the view that a male person can urinate by a roadside and in alleyways . ” (A tutor in a KII)

Theme 3: Contextual factors

" I cannot remember any scene that I saw any soap at the toilets … the authorities may not be concerned about the importance of providing this product . " (A male student in an FGD)

" Toilets are rarely cleaned with proper toilet cleaning products (chemicals) . Often , they use merely water and/or a small amount of chemical agent which might fail to kill germs , remove dirt , or clogs . " (A female student in an IDI)

Another student stated:

" To date , inadequate sanitation facilities remain the primary cause of unimproved sanitary and hygiene practices . The number of students is huge , so the authorities need to provide a good number of hand wash or soaps for the students and take care if they are finished or not . The authorities need to appoint more employees to do the cleaning . But I hardly noticed that all the mentioned actions were taking place in a timely manner . " (A female student in an IDI)

A similar view was expressed by another participant:

" The students are aware of the importance of good hygiene habits . But often , they fail to maintain it mostly because of the supply side . You rarely see any handwashing material readily available in the washrooms . How can a student maintain good handwashing practices after using the toilet ? " (A male student in an FGD)

" We don’t have adequate budget support and a workforce to provide sanitary and hygiene support at the optimum level . I feel that this causes problems . Many of us acknowledge this shortage , but it is a very structural problem . " (A house tutor in a KII)

A similar view was shared by a cleaner:

" The number of cleaners is low . It sometimes causes problems in routinely maintaining cleaning activities . But I try to do my best . The cleaning products are supplied as per rules . " (A cleaning staff member in a KII)

" It’s prevalent that one leaves the toilet without proper flushing due to the lack of adequate water . This causes the toilet to be unusable for next users … thus deteriorating hygiene quality . " (A male student in an FGD)

Another participant noted:

" Bad odor is very common in the toilets because excreta are not properly flushed out . It is created when the toilet holes are not properly flushed out . Very often the reason is either a lack of stable water supply or a problem with the flushing system (the flushing system does not work for any reason . " (A male student in an IDI)

Theme 4: Factors related to the university

" A male student can manage his need by peeing at a roadside . But it creates a problem for female students . They either hold their needs for a long time or go to the nearby halls , which is embarrassing . "

The number of female toilets is noticeably low compared to male toilets, which causes female students to abstain from toilet use. The following participants explained the situation:

" In our academic building , there is only one common room for female students . And there are six departments in our academic building . So , for all the female students , there is only one common room . In this common room , we have only three toilets and one basin , which is usable , and the other is broken . This common room is open till 5 pm . But for male students , they have two washrooms available in this building . " (A female student) " In our academic building , there is only one common room for females , and it is being rebuilt . In the common room , there were three washrooms and two basins , but one basin was unusable . Two new washrooms have been built recently on the ground floor of the building . But I am not sure if these new washrooms are for male students . There are two washrooms for males and on the opposite side we have two washrooms for females also . " (Another female student)

" I never heard that someone from the authorities talked with students and checked if the cleaning activities are properly maintained . " (A male student in an IDI)

Another participant stated:

" The toilets are not clean enough to use . Though the authorities have employed staff to clean the toilets of the academic buildings and residential halls , I don’t think they clean the toilets as required . There are bad odors in every toilet , and sometimes the toilets seem to be clogged also . As I stay in a residential hall , I have no other option than using these toilets . But I can’t maintain hygiene , and I am afraid for my health . I think it is about the monitoring and supervision of cleaning work . " (A female student in an IDI)

Limitation of the study

Suggested recommendations to improve hygiene and sanitation practices

WASH-related materials and agents (i.e. supplying handwashing products, cleaning materials, washing equipment) should be regularly supplied to ensure quality cleaning services.
A toilet cleaning checklist may be introduced to ensure quality cleaning services by cleaning professionals.
WASH-related pictorials and key messages may be developed and displayed to promote good hygiene habits that remind the individual user to maintain good hygiene behavior.
Regular monitoring and inspection of cleaning professionals and checking the toilet checklist to ensure quality services.
Promote low-cost solutions such as soapy water or chlorine tablets/a tablet that has been proven effective in resource-limited settings should be introduced to minimize costs.
Improve provision of toilets for female students. Consider gender perspectives in planning new infrastructure and construction. Low-cost menstrual hygiene-related disposal materials should be placed in existing buildings.

Supporting information

S1 file. guideline for in-depth interview..

https://doi.org/10.1371/journal.pone.0257663.s001

S2 File. Guideline for focus group discussion.

https://doi.org/10.1371/journal.pone.0257663.s002

S3 File. Guideline for key informant interview.

https://doi.org/10.1371/journal.pone.0257663.s003

Health, hygiene, and practical interventions, for people who are experiencing homelessness

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Gendered Perspectives on International Development

Volume 1, 2021/2022
Michigan State University Press

Additional Information

The Role of Water, Sanitation, Hygiene, and Gender Norms on Women's Health A Conceptual Framework
Rita Jalali (bio)

While the health impact of poor water, sanitation, and hygiene (WASH) conditions on children have been well documented, there has been less focus paid to its adverse impact on women's well-being and health. In this article, I highlight the health burden of water and sanitation insecurities for women by proposing a conceptual framework for understanding WASH-related diseases from a gender perspective, focused primarily on resource poor countries. The framework draws on feminist perspectives to examine how WASH insecure communities constrain women's functionings and capabilities. I identify eight different social–cultural pathways that fall into two synthetic constructs—gendered relations in the household and gendered presentation of the body—because they illustrate how social and cultural norms may burden women and put them at risk of exposure to a variety of WASH-related diseases. I use the critical interpretive synthesis methodology and draw on research from the fields of epidemiology, medicine, and social sciences to develop this conceptual framework that connects WASH-related diseases to gender norms that oppress women. The gender perspective proposed here has important implications for women living under poor water and sanitation conditions and for the WASH sector more broadly. It suggests providing women with direct financial assistance to purchase sanitary material, collecting sex-disaggregated data on sanitation access and on the health impact of gendered WASH-related tasks to improve women's health and quality of life.

Gender Inequality in Access to WASH, Burden of WASH-related Diseases in Women, Feminist Perspectives on WASH-related Diseases, Menstrual Hygiene, Gender-based Bathing Insecurity, WASH priorities in Development

[End Page 21]

Introduction: Water, Sanitation, and Hygiene Insecurities

Women's social roles (as caregivers) and bodies (when menstruating and pregnant) are intimately and critically dependent on adequate and safe water and sanitation access. However, their needs are often invisible in water, sanitation, and hygiene (WASH) policy making and programs ( Caruso et al. 2015 ). This article shows that women's exposure to WASH-related diseases in many parts of the world is mediated through unequal power relations in the household and cultural scripts that enforce bodily comportment (see Figure 1 ).

Gender Perspective on WASH-Related Diseases.

The framework proposed here 1 broadly follows on the footsteps of other scholars who have focused on social processes and structures to understand the links between [End Page 22] gender and health ( Connell 2012 ; Lupton 2003 ).

It is estimated that 30% of people worldwide lack access to safe, readily available water at home, and 60% lack safely managed sanitation ( WHO/UNICEF 2017 ). The public health model widely used to explain the role of WASH on health focuses on proximal factors such as water quality, sanitation, and hygiene that cause transmission of pathogens, while it often excludes the role of gender norms that determine health risks ( Eisenberg, Bartram, and Hunter 2001 ; White et al. 1972 ). Assessments for the disease burden associated with poor WASH are also dominated by diarrheal disease mortality and acute morbidity ( Langford, Bartram, and Roaf 2014 ; Langford and Winkler 2013 ). This article shows that infectious and noninfectious diseases that women are more vulnerable to because of their social roles and bodies are often missing from the models. 2 When gender determinants are discussed, they typically only include the prevalence and impact of carrying water as a gendered activity in many cultures ( WHO/UNICEF, JMP 2017 ).

In addition, when hygiene issues are addressed, the focus tends to be on hand hygiene ( WHO/UNICEF, JMP 2017 ), and rarely includes menstrual and personal hygiene needs. The key international agency ( WHO/UNICEF , Joint Monitoring Program for Water, Supply and Sanitation and Hygiene) that has been responsible since 1990 for developing global norms on WASH, collecting worldwide data, and monitoring global progress on WASH does not collect any data on the number of women and girls lacking access to menstrual hygiene or bathing facilities ( Loughnan et al. 2016 ).

This article uses the critical interpretive synthesis (CIS) method in order to synthesize large multidisciplinary evidence to generate theory ( Seers 2015 ; Tong et al. 2012 ; Barnett-Page and Thomas 2009 ; Dixon-Woods et al. 2006a ). A conventional systematic review aims to test theories and summarize the data, whereas CIS aims to generate theories and concepts through an iterative process, grounded in the studies included in the review to interpret the data ( Dixon-Woods et al. 2006b ; Noblit and Hare 1988 ). The critical interpretive synthesis approach was chosen because this study is exploratory in nature with the objective of developing a conceptual framework that would explain how poor WASH conditions affect women's health. The CIS method enables the literature review to guide the development of a new conceptual framework ( Dixon-Woods et al. 2006b ). In addition, the method is better suited for a large body of studies. I used 151 records in the final stage of the review process for this article ( Dixon-Woods et al. 2006b ; Seers 2015 ). CIS is recognized as being able to synthesize complex bodies of evidence from multiple disciplines ( Dixon-Woods et al. 2006b ), including both qualitative and quantitative evidence. For these reasons, CIS was chosen as an appropriate choice to achieve the goals of this article.

Data were gathered from electronic databases (Scopus, PUBMED, and Google Scholar) by using a combination of key and free text terms, such as gender or woman and water, toilet, latrine, sanitation, bathroom, menstrual hygiene and health or disease; gender inequality and health; and gender in combination with numerous diseases [End Page 23] caused by poor water and sanitation. Organizational websites (such as Sustainable Sanitation Alliance or SuSaNa, World Bank, WHO-UNICEF Joint Monitoring Program, WaterAid) were also searched for publications and reports using the same terms. Germane papers were also retrieved through hand searching bibliographies of significant articles.

The material extracted was in English, from all geographic regions, and included journal articles, reviews, documents, books, and the gray literature (such as theses and organizational reports). The objective was not to conduct a comprehensive search of all relevant literature but instead to search for potentially significant materials to develop and refine the framework.

Four hundred twenty-three records initially qualified for inclusion and were then grouped into three different areas: gender determinants of health; women's interactions with water, sanitation, and hygiene; and problems and diseases related to poor and inadequate access to WASH. All records were included regardless of study design or quality to capture concepts and regions often overlooked in mainstream WASH literature.

As the framework was refined, based on the evidence from the materials reviewed, 151 records were finally included if they focused (1) on the sociocultural and behavioral practices of women and girls in their interaction with water, sanitation, and hygiene, including menstrual hygiene (but not food or hand hygiene), and (2) on studies of WASH-related diseases that focused on women or on sex differences in prevalence, exposure, and outcome. Also, preference was given to peer-reviewed studies; other material was included only when such evidence was lacking (such as when a study focused on a region not covered by peer-reviewed studies). Many studies were also excluded if they focused only on the disease without reference to gender differences. However, studies on WASH-related diseases were included if they mentioned exposure pathways that are known to be gendered (such as child fecal disposal practices). In the final selection, besides conceptual papers and organizational reports, there were 80 empirical studies (13 qualitative and five mixed methods) and 22 reviews (including five systematic reviews). Most were in peer-reviewed journals. 43 empirical studies were from the Asia region (mostly from India), 38 from Africa (some studies covered countries in Asia and Africa), four from Latin America, two from North America, and one from Europe.

The draft of the framework was presented at a public health seminar. The feedback from experts (in the fields of water and sanitation; public health; gender and development; and social determinants of health) who attended the seminar was incorporated into the framework. This feedback shifted the framework away from a disease-based framework to one that emphasized the social–cultural determinants of WASH-related diseases. This shift sharpened the report and its focus on the impact of social norms on women's health in communities with poor water and sanitation conditions.

The final framework, presented here, identified multiple ways that shape women's interaction with WASH. These pathways generated two synthetic constructs, "gendered relations in the household" and "gendered presentation of the body," using the [End Page 24] grounded theory approach ( Tie et al. 2019 ). The first construct captured two distinct categories of gender relations within the household (gender division of household labor and gender differences in power) and six different pathways that expose women to health risks. The second construct (gendered presentation of the body) encompassed two categories of social norms that affect health. The categories and subcategories derived from these constructs are summarized next (also see Figure 1 ):

A. Gendered Relations in the Household

1. Gender Division of the Household

a. Caregiver

b. Washing Utensils and Laundry in Contaminated Water

c. Water Colletion

2. Gender and Power in the Household

a. Level of Control over Household Budget

b. Care and Treatment in Son-Preference Households

c. Health Care Seeking Behavior

B. Gendered Presentation of the Body

a. Gendered Use of Public Space

b. Menstruation and Cultural Taboos about Menstrual Blood

These categories were developed through an iterative process by repeatedly comparing them to the evidence in the literature, filing studies into the preexisting categories, and constructing new categories when needed. In total, the CIS method generated eight different social–cultural pathways that increase women's risk of exposure to a variety of infectious and noninfectious diseases related to WASH.

Gendered Relations in the Household

Scholars argue that the division of labor in the household is a central process through which gender inequality is created. For some sociologists and economists ( England and Folbre 2005 ; England and Folbre 2003 ; Williams 2001 ; Greenstein 2004 ; England 2000 ; Folbre and Nelson 2000 ; Ilahi 2000 ; Folbre 1997 ; Agarwal 1997 ; Lorber 1994 ; Brines 1994 ; Hochschild 1989 ), social norms play an important role in determining sex segregation of housework. In the developing world, social norms may also lead to unequal allocation of resources ( Ilahi 2000 ; Agarwal 1997 ) by systematically undervaluing women's contributions or needs and thus their access to resources. "Women and girls … receive less because their contributions to the household are seen as being less valuable than that of men or boys… and/or because they are seen as needing less" ( Agarwal 1997 , 15).

These feminist perspectives provide insights linking household allocation of labor and resources to women's health risks under poor water and sanitary conditions. Housework that women are primarily tasked with—from caring for children to collecting water—is closely intertwined with WASH and its effect on health (as described in the following under gender division of household labor). In addition, unequal allocation of resources for care and treatment of women and girls can also put them at risk, as the later section on gender and power in the household shows. [End Page 25]

Gender Division of Household Labor

Women in most societies have the responsibility to take care of children, the elderly, and the sick. As caregivers, they handle their children's feces and, in households lacking latrines, even the feces of sick adults. It has been estimated that one gram of fresh human excreta from an infected person contains many viral and bacterial pathogens and helminth eggs ( Mara et al. 2010 , 1). Therefore, caregivers who handle feces may be at risk of exposure to infectious diseases. However, studies that examine such links are very few and results are not definitive. Also, most studies ( Aluko et al. 2017 ; Majorin et al. 2017 ; Morita, Godfrey, and George 2016 ) that examine child feces disposal practices focus on the health risks to children but not to the caregivers, who are primarily women.

Rotavirus is a virus that causes diarrhea and spreads from person to person, mainly by fecal–oral transmission. It can spread if hands are not washed after changing a child's diaper or helping a child to use the toilet. Evan and Weber (2004) , in a literature review on rotavirus infection, report on several studies that found transmission of rotavirus to be a common event within families from children to parents (gender of parent was not mentioned) and in pediatric wards from sick children to nurses.

Gendered relations within the household determine some of the risk of exposure to trachoma (a leading cause of infectious blindness due to lack of water and poor hygiene practices). Women are affected more than men with trachoma-induced blindness because of close contact with their infected children, who infect their mothers ( West 2003 ). Due to repeated infection, women are blinded more often than men ( Cromwell et al. 2009 ).

Washing Utensils and Laundry in Contaminated Water

Nine percent of the world's population relies on water of poor quality for all household needs ( WHO/UNICEF, JMP 2015 ). In rural communities, women doing domestic chores (laundry or cleaning cooking utensils) in infested water may thus be at risk for schistosomiasis ( Gabr et al. 2000 ; Michelson 1992 ). However, a recent systematic review ( Sevilimedu et al. 2016 ) found a higher prevalence among males, who may be at increased risk of exposure to outdoor contaminated surface waters and soils that harbor parasitic worms. Men are more likely to work in occupations like fishing and farming or to bathe in canals, occupations and bathing/swimming practices that are prohibited for females in many cultures ( Sevilimedu et al. 2016 ). However, it is not clear whether the studies reviewed examined women's exposure risks due to these domestic chores.

Water Collection

Globally, 263 million people spent more than 30 minutes per round trip to collect water from an improved source outside their house ( WHO/UNICE,F JMP 2017 ), and in seven out of 10 households (in 45 developing countries) the physical and time burden of water hauling fell primarily on women and girls ( WHO/UNICEF, JMP 2015 ; Hope 2006 ; White et al. 1972 ). These heavy containers of water are carried on the head over [End Page 26] long distances ( Graham, Hirai, and Kim 2016 ; Crow, Davis, Paterson, and Miles 2013 ; Geere, Hunter, and Jagals 2010 ).

Not enough attention has been addressed to women's health status or quality of life due to the burden of carrying water ( Geere et al. 2010 ). Water loading can lead to musculoskeletal disorders, physical injuries, exhaustion, and dehydration ( Geere et al. 2018 ; Sorenson, Morssink, and Campos 2011 ; Scott, Charteris, and Bridger 1998 ). The energy expended in water collection can have a negative impact on people with poor nutritional intake and in pregnant women can reduce weight gain ( Mehretu and Mutambirwa 1992 ). Regular heavy physical work, including lifting, among other risk factors, is also associated with pelvic floor dysfunction that includes conditions such as pelvic organ prolapse (POP), urinary incontinence (UI), and fecal incontinence ( Walker and Gunasekera 2011 ; Kuncharapu, Majeroni, and Johnson 2010 ). During pregnancy and immediately after delivery, extensive physical labor also can lead to UI ( Bodner-Adler, Bodner, and Shrivastava 2007 ), increase the risk of miscarriages, exacerbate malnourishment, and also affect the quantity and quality of milk produced by lactating women ( Dufault 1988 ). Water insecurity also is significantly associated with psychosocial distress ( Boateng et al. 2018 ; Stevenson et al. 2012 ; Wutich and Ragsdale 2008 ) and can lead to women economizing on water used for hand washing, clothes washing, dish washing, bathing, cooking, and even drinking, with some women going to sleep thirsty, thereby affecting their hygiene and health ( Boateng et al. 2018 ; Stevenson et al. 2012 ; Cairncross and Cuff 1987 ). In addition to the direct health effects, the time spent collecting water significantly impacts women's employment opportunities, other home-based income-generating activities, and the health and care of children ( Crow et al. 2012 ; Stevenson et al. 2012 ; Pickering and Davis 2012 ; Cairncross and Cuff 1987 ).

Gender and Power in the Household

Level of control over household budget.

Where women have less or no economic and decision-making power over the spending priorities of a household, their preferences for some market goods may not be met, including on sanitation, hygiene, and preventive care. For example, women have greater preference for constructing toilets on the premises, but less decision-making authority to do so ( Routray et al. 2017 ; Hirai, Graham, and Sandberg 2016 ; Khanna and Das 2015 ; Coffey et al. 2014 ; O'Reilly 2010 ). This puts women at risk (from physical to mental health risks, as discussed later). However, women are eager to use government subsidies for toilet construction when available ( Clasen et al. 2014 ). Women also may have less access to financial resources to pay for travel expenses, health care, and medicine ( Sen and Iyer 2012 ; Raj 2011 ; Roy and Chaudhuri 2008 ).

In addition, women who do not have control over household income may not be able to engage in preventive care such as the purchasing of treated bed nets to protect them from diseases like malaria ( Bonilla and Rodriguez 1993 ; also see Rashed et al.1999 ), or buying soap or sanitary napkins ( Mason et al. 2013 ; Joshi, Fawcett, and Mannan 2011 ). Women's lack of autonomy may even explain why households spend [End Page 27] more on men's consumption items such as tobacco and alcohol and less on personal care and the toiletries women need ( Jalali 2019a ; Vaughn 2013 ; Subramaniam and Deaton 1991 ).

Unable to buy market napkins, poor women use unsanitary material to manage their monthly periods. Among Indian women 15–24 years of age, only 37% are known to use hygienic methods of protection during their menstrual periods ( Ram et al. 2020 ). Use of unhygienic material can lead to chafing ( Mason et al. 2013 ; Shah et al. 2013 ) and can become a risk factor for urogenital infection ( Das et al. 2015 ; Torondel et al. 2018 ) and human papillomavirus infection ( Bayo et al. 2002 ; Peng et al. 1991 ; Zhang et al. 1989 ; Chaouki et al. 1998 ). Further research is required to understand the role of gender inequality in hygiene practices under poor WASH conditions.

Care and Treatment in Son-Preference Families

In some societies, the unequal treatment of women starts early and carries through to adulthood ( Sen and Iyer 2012 ). This is especially true in South Asian countries, where there is a strong preference for boys and where abortion rates for female fetuses are high ( Jayachandran and Pande 2017 ).

Malnutrition poses very serious health risk from waterborne disease ( Griffiths 1998 ). Where WASH conditions are poor, gender discrimination in care and treatment (from being breastfed less, to receiving less nutrition and less access to treatment—see Degefa et al. 2018 ; Fledderjohann et al. 2014 ; Jayachandran and Kuziemko 2010 ; Corsi et al. 2009 ; Borooah 2004 ) puts girls at greater risk for waterborne diseases. In son-preference cultures, the biological advantage that girls enjoy disappears after 1 month, when social discrimination puts them at a disadvantage. For example, beyond the neonatal period (0–1 month), mortality rate in India due to diarrheal disease, including that attributable to rotavirus, is higher for girls than for boys for every age group under 5 years ( Morris et al. 2012 ), suggesting inequities in access to care as a plausible explanation, rather than biological or genetic factors ( Million Death Study Collaborators et al. 2010 ). In such son-preference cultures, investments in sanitation coverage were found to improve girls' health more than boys' ( Augsburg and Rodríguez-Lesme 2018 ).

The social biases continue into adulthood, affecting nutritional outcomes ( India, Ministry of Health and Family Welfare 2009 ; Vlassoff 2007 ). Under poor WASH conditions, such biases can have intergenerational health effects and set off a vicious cycle of chronic malnutrition, anemia, and stunted growth that impacts the health of a woman and her offspring, including poor pregnancy outcomes and neonatal health (fetal growth retardation, low birth weight—see Osmania and Sen 2003 ; also see Coffey et al. 2015 ).

Health Care Seeking Behavior

Unequal gender relations in the household may disadvantage women further when it affects their health care seeking behavior, especially in son-preference cultures. While better off households can afford health care, women in many such households may internalize biased beliefs about their worth ( Sen and Iyer 2012 ) or may have no power to make decisions about their own health care and limited freedom to travel ( Raj 2011 ; [End Page 28] India, Ministry of Health and Family Welfare 2009 ; Nikièma et al. 2008 ; Roy and Chaudhury 2008 ; Buor 2004 ) 3 because of the control of husbands and elders. Using a nationally representative survey of 41,554 Indian households, a study ( Saikia, Moradhvaj, and Bora 2016 ) on gender differences in health care expenditure found that expenditure on females was systematically lower than on males across all demographic and socioeconomic groups, although both short-term and major morbidity rates were significantly higher among females even after controlling for male–female differences in demographic, socioeconomic, and health care-related factors. The authors argue that families spend less on female health because they believe that female health is not as important as male health. Other studies from Asia also report similar findings ( Song and Bian 2014 ; Fikree and Pasha 2004 ).

Gendered Presentation of the Body

Feminist theories of embodiment help us understand how cultural norms governing male and female bodily comportment undermine women's hygiene and health in communities lacking water, toilets, and bathing spaces, but privilege men who also live in these communities. At the center of the embodiment perspective is the idea of an embodied self that is embedded within an environment—that is, the experience of embodiment is a product of situation ( De Beauvoir 1953 ), and unequal power relations shape the disciplinary practices of the body, and specifically, the female body. Women actively police their own bodies to comply with social norms ( Butler 1988 ; 1990 ; Young 2005 ).

In Gender Trouble , Butler (1990) argues that gender is an act constructed through repeated performances. As a performative act, gendered bodies are governed by punitive conventions when the cultural scripts are not followed. For Young (2005) , too, women's embodiment is shaped by social norms that determine female bodily comportment, from throwing like a girl to concealing the signs of menstruation. The rules of menstrual etiquette and in traditional societies of menstrual taboos "govern the comportment of menstruating women" to ensure their confinement in the "menstrual closet" ( Young 2005 , 106). From early on, girls bear the burden of personal shame as they learn to follow the imperative that the menstrual process should be hidden because menstruation is dirty, disgusting, and defiling (106).

An embodiment perspective gives a deeper understanding of the gendered nature of WASH deprivation. In a society with rigid cultural scripts and poor infrastructural conditions, where modesty is especially valued, the female body is hidden from public view, and menstruating women are considered impure, a lack of private toilets and bathing facilities does not allow for these scripts to be followed. By one conservative estimate, nearly half a billion women and girls globally lack adequate facilities for menstrual hygiene management ( Loughnan et al. 2016 ; WHO/UNICEF, JMP 2015 ). While no global data exist for access to bathing facilities, Indian Census data ( Census of India 2011 ) show that 42% of households do not have such a facility in the premises of their house.

This section illustrates how lack of water and lack of safe, private access to bathing [End Page 29] spaces and toilets affect women's ability to maintain hygiene in a manner that does not impact men who also live in these poor WASH communities. The extra burden on women's health and well-being results from social constructions of the body that affect norms about the use of public space for hygiene, the sexual behavior of men, and even the perception of women's bodily fluids.

Gendered Use of Public Space

Historically, in the Western world public toilets were not provided for women because "sanctioning the women's lavatory effectively sanctioned the female presence in the streets, thus violating middle-class decorum and ideals of women as static and domestic" ( Gershenson and Penner 2009 , 45). By making women's bodies and their "private" functions publicly visible, the lavatory threatened to transform its users into "public women" ( Gershenson and Penner 2009 ).

In many resource-poor settings in South Asia, gendered norms continue to dictate the use of public space for toileting or bathing. Men face no social strictures when they urinate, defecate, or bathe in the sight of others and whenever the need arises, but cultural norms dictate that women should not be seen nor their bodies exposed while urinating, defecating, or bathing. Poor women thus face a double burden—inadequate infrastructure, and social opprobrium for performing acts that are basic to human health. Women are forced to bathe at dawn and hold the urge to urinate or defecate until dark ( Jalali 2019b ; Routray et al. 2015 ; Reddy and Snehalatha 2011 ), or to walk long distances to seek a safe place, inducing high levels of stress ( Caruso et al 2017 ; Hulland et al. 2015 ). Women also learn to control their diet (avoiding drinking water or food, especially at night) and patrol their bodies (bathe with clothes) while practicing personal hygiene in public under the gaze of predatory men ( Jalali 2019b ; Sahoo et al. 2015 ; O'Reilly 2010 ), a hardship borne on a daily basis.

In crowded urban spaces, women face similar challenges ( Desai et al. 2015 ; Corburn and Hildebrand 2015 ; Sommer et al. 2015 ; Joshi et al. 2011 ; Reddy and Snehalatha 2011 ; UNICEF, WaterAid, and WSUP 2018 ) and are even willing to work in low-paying domestic jobs because it offers "privacy for bathing and defecating" (see Joshi et al. 2011 , 104, on Dhaka, Bangladesh). In the slums of Hyderabad, India, Reddy and Snehalatha (2011, 393) report, women bathe with their petticoat on and ask someone to look out as "men move around on some pretext or the other & try to watch [women bathing]" said Neenavati Nanu of Banjara Colony. The women are thus very tense while bathing [and] "have to bathe hurriedly."

While the burden women face due to lack of access to safe, private toilets is now recognized within the WASH sector, there is no mention of the need for bathing facilities to maintain bodily hygiene, especially for women, nor are there efforts to measure its availability (the WHO/UNICEF Joint Monitoring Program designated to monitor the WASH sector does not collect this information). Recent attempts by researchers to develop gender-sensitive sanitation security indicators also failed to include a measure for bathing ( Caruso et al. 2017 ; Loughnan et al. 2016 ; Sahoo et al. 2015 ). [End Page 30]

Menstruation and Cultural Taboos About Menstrual Blood

Women's menstruating bodies require access to clean absorbent material, facilities to dispose used material, a private toilet, and a bathroom with water and soap to manage special cleansing needs, but these facilities are lacking for poor women and girls in parts of Africa and South Asia ( Jalali 2019b ; Loughnan et al. 2016 ; Das et al. 2015 ; Sommer et al. 2014 ; Mason et al. 2013 ; Vaughn 2013 ) and in some Western countries ( Ensign 2001 ). Lack of access not only is a major barrier preventing hygiene but also is deeply humiliating since there are strict norms against washing and drying menstrual cloth in the sight of others.

Besides prohibitions that restrict menstruating women from many social and religious activities, cultural taboos about menstrual blood also require women to follow washing and drying practices that may be unhygienic, such as where and how the menstrual cloth is stored, washed, and dried ( Jalali 2019b ; Das et al. 2015 ; Sahoo et al. 2015 ; Vaughn 2013 ). Taboos about menstrual blood also inhibit menstruating women from bathing in communal spaces ( Jalali 2019b ; Caruso et al. 2017 ). Many of the same taboos apply to postpartum bleeding ( Jalali 2019b ; Coffey and Spears 2017 ). Given these social restrictions, women and girls report high levels of stress managing menstruation ( Benshaul-Tolonen et al. 2020 ; Hennegan et al. 2016 ; Hulland et al. 2015 ; Oruko et al. 2015 ; Jewitt and Ryley 2014 ). Women also complained of the smell of stale blood from their bodies, hands, and poorly washed rags ( Jalali 2019b ; Hennegan et al. 2016 ; Oruko et al. 2015 ; Sahoo et al. 2015 ; Joshi et al. 2011 ) because of lack of private facilities to manage menstrual hygiene.

Thus, lack of access to WASH services, including menstrual hygiene facilities, together with gendered social norms may dictate women's sanitation behavior. Women may bathe infrequently, may be unable to perform vulvar and perineal hygiene on a daily basis and during the menstrual cycle, and may be unable to adequately wash and dry underclothes and menstrual material, especially in the rainy season ( Jalali 2019b ; Hulland et al. 2015 ; Sahoo et al. 2015 ; Mason et al. 2013 ; Reddy and Snehalatha 2011 ). All these factors increase the risk of various genital infections. There is limited research on how gendered body norms under poor WASH conditions affect women's hygiene behavior and infections to the female genital system and affect the conditions of chronic constipation and dehydration. Some of the potential health risks are discussed next.

Human papillomavirus (HPV) infection and reproductive-tract infection (RTI)

Poor genital hygiene has been suggested as a risk factor for the development of cervical cancer as well as reproductive-tract infections (RTIs). For example, a few studies suggest genital hygiene practices as an independent risk factor for HPV infection (the major etiological agent for the development of cervical cancer), practices such as absence of daily genital washing ( Zhang et al. 1989 ; Schmauz et al. 1989 ; Peng et al. 1991 ; Varghese et al. 1999 ) or washing infrequently during menstruation ( Herrero et al. 1990 ). Washing the genital area before and after sexual intercourse is a protective factor against HPV infection ( Kataja, Syrjanen, and Merja Yliskoski 1993 ). Other studies have found that menstruating women who had to change outdoors were more prone [End Page 31] to have bacterial vaginosis than those who had a private room or toilet ( Das et al. 2015 ; Torondel et al. 2018 ), and those who washed their bodies regularly during menstruation also had a lower risk ( Torondel et al. 2018 ).

The exact biological pathways between poor WASH conditions and RTIs or HPV infections remain unknown. Also not known are how factors such as the quality of water and absorbent material used (the quality of even reusable material varies; see Jalali 2019b and Smith et al. 2020 ) or perineum hygiene practices after defecation may increase exposure risks to RTI/HPV.

Gender-based violence

Studies from many poor countries have reported that a lack of safe toilets and bathrooms puts women and girls at risk for sexual harassment and rape ( Winter and Barchi 2016 ; Jadhav, Weitzman, and Smith-Greenway 2016 ; Khanna and Das 2015 ; for a review of this literature see Sommer et al. 2015 ) and induces high levels of stress, especially among adolescent girls ( Bisung and Elliot 2017 ; Caruso et al. 2017 ; Hulland et al. 2015 ; Sahoo et al. 2015 ; Routray et al. 2015 ; Corburn and Hildebrand 2015 ) who have no privacy when performing the necessary rituals of ablution and hygiene. There is very little evidence on how the fear and experience of sexual harassment affect women's hygiene practices.

Hygiene for maternal health

Burdened by gendered social norms, how do poor women manage genital hygiene during pregnancy and in the postpartum period when lacking clean water or private toilets or bathrooms? Access to water and sanitation is essential for the healing of perineum ruptures and episiotomy after deliveries. In one study, 77% of rural and urban respondents found sanitation management in the postnatal period to be stressful ( Hulland et al. 2015 ). For a pregnant woman, good hygiene practices are important to prevent genital-tract infections ( Sinha and Motify 2012 ) or neonatal sepsis. Poor perineal hygiene and bathing also can predispose pregnant women to puerperal sepsis ( Bako et al. 2012 ; Winani et al. 2007 ). Better sanitation facilities may improve undernutrition in adult and pregnant women ( Radhika et al. 2018 ; Janmohamed 2016 ) and lack of access to toilets may also lead to adverse pregnancy outcomes because of psychosocial stress due to poor facilities or because women may limit intake of food and water to avoid using inadequate toilet facilities ( Padhi et al. 2015 ; Baker et al. 2018 ).

Dehydration and chronic constipation

Women who have restricted access to toilets and cannot urinate or defecate in public as men do avoid fluid intake, causing dehydration ( Sahoo et al. 2015 ) and increasing the risk of kidney stones, gallstones, and urinary-tract infections (UTIs) ( Rudaitis et al. 2009 ; Institute of Medicine 2005 ). Higher fluid intake is important for those women engaged in heavy physical activity, living in warm climatic regions, and lactating ( Institute of Medicine 2005 ). Higher fluid intake may also reduce the risk of bladder and colon cancer ( Institute of Medicine 2005 ).

In pregnant women, UTIs can increase the risk of preterm labor, preterm birth, pregnancy-induced hypertension, preeclampsia, and anemia ( August and De Rosa 2012 ). The symptoms of UTIs are harder to manage for those without easy access to toilets. Restricted toilet opportunities also are known to increase the risk for chronic constipation ( Human Development Report 2006 ). Furthermore, for women, straining [End Page 32] with constipation (among other factors) may contribute to pelvic organ prolapse ( Kuncharapu et al. 2010 ). The link between diet and toilet access has not been studied, especially whether the diet of women and girls (controlling what they eat and when they eat) is affected by lack of access to safe toilets ( Sahoo et al. 2015 ).

The two sites of injustices (gendered nature of intrahousehold relations and body norms) are closely interlinked, for they both constrain women's functioning and capabilities in WASH-insecure communities ( Sen 1993 ). As Sen's capability approach (1993) has shown, it is important not only to give value to measures of women's good physical health, education, and paid work, but also to place equal emphasis on women's mental well-being, bodily integrity and safety, the choice to do domestic work and care, mobility, leisure activities, time autonomy, and the respect women receive in the family and community as a way to measure women's well-being ( Robeyns 2003 ).

This article has illustrated that there is a need for policymakers, public health specialists, and others in the WASH sector to address how gender norms and the needs of women's bodies impact the health and quality of life of women and girls living under poor water and sanitation conditions. As has been suggested, "an integrated public health perspective for water-related diseases should account not only for the disease transmission perspective addressing the proximal causalities, but also the distal causalities that may impact on those proximal factors" ( Eisenberg et al. 2001 , 231).

A critical interpretation of the studies mentioned here indicates that while many acknowledge the role of gendered social norms on women's health under poor WASH conditions, only a few successfully study the detrimental health effects of these social norms. A good example is the set of studies that document the burden of water collection on women. The burden of this gendered task has been widely accepted, but only a limited number of studies examine the type and severity of health risks women experience ( Geere et al. 2018 ; Graham et al. 2016 ). The same can be said for studies of fecal disposal practices where the focus is on the health impact on children but not on the caregiver. In fact, of the eight social–cultural pathways examined in this study, only one has begun to receive some attention by numerous scholars—the link between gendered use of public space and psychological stress and violence (although the links between hygiene behavior and gendered body norms have yet to be studied).

The framework proposed here places women's bodies at the center of a WASH agenda so that the "H" in WASH is expanded beyond hand hygiene and even monthly menstrual hygiene to include the ability to practice daily bodily and perineal hygiene. Collection of global data on menstrual hygiene prevalence rates would be a beginning ( Loughnan et al. 2016 ), privacy and other concerns notwithstanding (e.g., data on contraceptive prevalence rates have been collected for decades now). Also, direct financial assistance to poor women to purchase menstrual products would also ease their burden. In addition, there is a need to gather sex-disaggregated data on differences in sanitation access (toilets and bathrooms); differential exposure risks due to differences in gender roles, norms, and bodily needs; and gender differences in hygiene practices [End Page 33] and privileges. WASH programs should target men and boys to sensitize them to the burden of menstruation for women and girls. In addition, menstrual health education should not only provide biomedical information but also include programs that change social norms and stigma about menstruation ( Benshaul-Tolonen et al. 2020 ). Further research is also needed to understand how women's exposure to WASH-related diseases may differ by region, ethnicity, caste, and class. The costs and benefits of safe water and sanitation cannot be accurately estimated if such evidence that affects the health and well-being of millions of poor women and girls is not collected. Finally, as this article has shown, providing women access to adequate and safe water and sanitation is critical to reducing gender inequalities in functioning and capabilities and removing a major source of unfreedoms for women. [End Page 34]

Rita Jalali is a Sociologist and Resident Scholar at American University in the Department of Sociology. Her research has focused on cross-national issues of race and ethnicity; social movements; civil society; gender inequalities; and water and sanitation deprivation. Her work has been published in numerous peer-reviewed journals. Her current work in the field of water, sanitation, and hygiene (WASH) focuses on several research areas including a quantitative study to examine if gender bias within the household affects menstrual product usage; historical examination of WASH issues in multilateral development organizations; and impact of water and sanitation deprivation on menstrual hygiene practices. She is also working on the relationship between governance and response to the COVID-19 pandemic. She received her PhD in Sociology from Stanford University.

. The author is grateful for the critical feedback provided by the participants of the seminar at Center on Heath, Risk, and Society at American University and participants of the Sustainability and Development Conference at Ann Arbor, University of Michigan. Special thanks are also owed to Dr. Rae Blumberg and colleagues in the Department of Sociology, especially Dr. Kim Blankenship who provided very helpful comments on several drafts of the paper and broadened my intellectual focus.

1. This article does not cover gender discrimination in access to and treatment within health care institutions, the impact of occupational differences on health outcomes (such as farming), or the exclusion of women from decision-making roles in WASH programs and policies.

2. This article adopts the expanded definition of health as stated by the World Health Organization (1948, 1) : "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

3. In some cultures, men may not use health care routinely because of occupational roles that keep them away from treatment programs or because they assign a low priority to their health ( Garley et al. 2013 ).

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Antenatal and Delivery Care in Afghanistan Knowledge and Perceptions of Services, Decision Making for Service Use, and Determinants of Utilization
Early Maternal Morbidity and Utilization of Delivery Services by Urban Slum Women of Dhaka, Bangladesh
An Assessment of Maternal Health Service Needs of Immigrant Women Living in East Calgary, Canada
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Evaluating an Intervention to Prevent Motorcycle Injuries in Malaysia: Process Performance, and Policy
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A neglected epidemic of childhood drowning in Bangladesh: Epidemiology, risk factors and potential interventions

Equity and fairness in distribution of health services

Gender and Access to DOTS Program (Directly Observed Treatment, Short-Course) in a Poor, Rural and Minority Area of Gansu Province, China
Empowering the Socially Excluded: A Study of Impact on Equity by Gender, Caste and Wealth in Access to Health Care in Rural Parts of Four North Indian States
Gender, Empowerment, and Women's Health in India: Perceived Morbidity and Treatment-Seeking Behaviors for Symptoms of Reproductive Tract Infections among Women of Rural Gujarat
Trust in Maternity Care: A Contextual Exploration of Meaning and Determinants in Peri-Urban Kenya
The Effect of Contracting for Health Services on the Equity of Utilization and Out-of-Pocket Health Expenditure in Rural Afghanistan

Health economics

The Equity and Cost-Effectiveness of HIV Voluntary Counseling and Testing in Tanzania
Hospital Coding Practice, Data Quality, And DRG-Based Reimbursement Under the Thai Universal Coverage Scheme
Willingness-to-Pay and Cost-Benefit Analysis on Introducing HIB Conjugate Vaccine into the Thai Expanded Program on Immunization
Economic Evaluation of the Costs and Cost-Effectiveness of the Diarrhea Alleviation through Zinc and Oral Rehydration Therapy Program at Scale in Gujarat, India
The Economics of Non-Communicable Diseases in Rural Bangladesh: Understanding Education Gradients in Mortality and Household Wealth Impacts from an Adult Death

Health outcomes and burden of disease methods

Measuring the Burden of Disease: Introducing Healthy Life Years
Measuring the Burden of Injuries in Pakistan Epidemiological and Policy Analysis
Strengths and Limitations of Population-Based Health Surveys in Developing Countries: A Case Study of National Health Survey of Pakistan: 1990-94
Approaches to Measuring Non-Fatal Health Outcomes: Disability at the Iganga-Mayuge Demographic Surveillance System in Uganda
A National Burden of Disease Study for The United Arab Emirates (UAE): Quantifying Health Differentials Between Nationals and Migrants

Bibliography
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Dissertations / Theses on the topic 'Women - Health and hygiene - Social aspects'

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Carango, Kathryn Price. "An analysis of President Barack Obama's Global Health Initiative within the framework of a women-centered approach to the socialdeterminants of health." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2010. http://hub.hku.hk/bib/B45170757.

Gordon, Roberta June. "Pregnant women's perception and application of health promotion messages at community health centres." Thesis, University of the Western Cape, 2005. http://etd.uwc.ac.za/index.php?module=etd&amp.

Bitangaro, Barbara Kagoro. "The role of gender relations in decision-making for access to antiretrovirals. A study of the AIDS Support Organisation (TASO) clients, Kampala district, Uganda." Thesis, University of the Western Cape, 2005. http://etd.uwc.ac.za/index.php?module=etd&amp.

Valencia, Venus Zamarripa. "A descriptive study of Orange County Latinas' breast cancer knowledge levels." CSUSB ScholarWorks, 2005. https://scholarworks.lib.csusb.edu/etd-project/2852.

Hembroff, Nicole, and University of Lethbridge Faculty of Arts and Science. "Orthodox Hindu attitudes to menstruation / Nicole Hembroff." Thesis, Lethbridge, Alta. : University of Lethbridge, Dept. of Religious Studies, c2010, 2010. http://hdl.handle.net/10133/2600.

Evans, Gina. "Psychosocial and cultural predictors of dietary fat intake in African American women." Virtual Press, 2006. http://liblink.bsu.edu/uhtbin/catkey/1354641.

Armeni, Elizabeth. "Menstruation goes public : aspects of womens's menstrual experience in Montreal, 1920-1975." Thesis, McGill University, 1996. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=26674.

Bridges, Jennifer. "Reclaiming Female Virtue: Social Hygiene, Venereal Disease and Texas Reclamation Centers during World War I." Thesis, University of North Texas, 2018. https://digital.library.unt.edu/ark:/67531/metadc1404551/.

Papole, Magdeline Kgomotso. "Exploring the factors influencing non-participation of women living with HIV/AIDS in empowerment projects attached to primary health care clinics, Tembisa, South Africa." Thesis, Stellenbosch : University of Stellenbosch, 2010. http://hdl.handle.net/10019.1/4322.

Murtagh, Madeleine Josephine. "Intersections of feminist and medical constructions of menopause in primary medical care and mass media: risk, choice and agency." Title page, table of contents and abstract only, 2001. http://web4.library.adelaide.edu.au/theses/09PH/09phm9851.pdf.

Warren, Ann Marie. "Partner abuse: Health consequences to women." Thesis, University of North Texas, 2003. https://digital.library.unt.edu/ark:/67531/metadc5534/.

Cooper, Diane. "Women's social position and their health : a case study of the social determinants of the health of women in Khayelitsha, Cape Town, South Africa." Doctoral thesis, University of Cape Town, 1995. http://hdl.handle.net/11427/14955.

Horner, Katrina E. "The effect of increasing physical activity on health benefits in sedentary women." Virtual Press, 1997. http://liblink.bsu.edu/uhtbin/catkey/1041902.

Gagné, Marie-Anik. "Worry and the traditional stress model." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1998. http://www.collectionscanada.ca/obj/s4/f2/dsk1/tape11/PQDD_0004/NQ44434.pdf.

Hunt, Kate. "Understanding gender and health : systematically comparing the health and health experiences of men and women." Thesis, University of Glasgow, 2007. http://theses.gla.ac.uk/99/.

Ward, Jessica. "The relationship between exercise and physical self-concept among nonparticipants, exercisers, and athletic college females." Virtual Press, 2001. http://liblink.bsu.edu/uhtbin/catkey/1221292.

Roussy, Joanne Marie. "How poverty shapes women's experiences of health during pregnancy, a grounded theory study." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1999. http://www.collectionscanada.ca/obj/s4/f2/dsk1/tape9/PQDD_0028/NQ38967.pdf.

Gerber, Roné. "Exploring the perceptions of women with rheumatoid arthritis of how their illness impacts their relationship with their intimate partner." Thesis, University of the Western Cape, 2006. http://hdl.handle.net/11394/2069.

Clark, Lauren. "Mormon women and the role of religion in obtaining relevant health care." Thesis, The University of Arizona, 1988. http://hdl.handle.net/10150/276791.

Carter, Alice Powers. "Biopsychosocial Factors Related to Health among Older Women." Thesis, University of North Texas, 1995. https://digital.library.unt.edu/ark:/67531/metadc277811/.

Dunk, Pamela Wakewich. "My nerves are broken : the social relations of illness in a Greek-Canadian community." Thesis, McGill University, 1988. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=64074.

Bartholomew, Michelle L. "Health experiences of older African Caribbean women living in the UK." Thesis, University of Huddersfield, 2012. http://eprints.hud.ac.uk/id/eprint/17501/.

Woo, Violet Ryo-Hwa. "The effects of moderate exercise on dietary intake, iron status, and cardiovascular endurance of 56- to 67-year-old women." Thesis, Virginia Tech, 1990. http://hdl.handle.net/10919/41533.

Tibbetts, Dorothy S. "Women who Select Naturopathic Health Care During the Menopausal Transition: A Study in Grounded Theory." PDXScholar, 1994. https://pdxscholar.library.pdx.edu/open_access_etds/4879.

Frank, Beth. "Conjoint treatment : impact on married couples with and without PMS." Virtual Press, 1994. http://liblink.bsu.edu/uhtbin/catkey/917831.

Bender, Melissa Ann. "An investigation into disordered eating among athletes." CSUSB ScholarWorks, 2008. https://scholarworks.lib.csusb.edu/etd-project/3390.

Boyer, Duane, and mikewood@deakin edu au. "Defining moments in men's lives: A study of personal narratives." Deakin University, 2004. http://tux.lib.deakin.edu.au./adt-VDU/public/adt-VDU20050727.123714.

Gardner-Ray, Janet. "The impact of social groups and content on the maintenance of health behavior practices over a one-year period." Virtual Press, 1996. http://liblink.bsu.edu/uhtbin/catkey/1036819.

Li, Qianhui, and 李茜晖. "Second-hand smoke exposure of pregnant women and a randomized controlled trial of brief intervention for non-smoking pregnant womenin Guangzhou, China." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2011. http://hub.hku.hk/bib/B46939325.

陸袁楨德 and Yuen Jean Tak Alice Loke. "Exposure of pregnant women to passive smoking and a randomized controlled trial of the effectiveness of doctor's advice to non-smoking pregnant women in Guangzhou, China." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 1998. http://hub.hku.hk/bib/B31237496.

McEwen, Marylyn. "Family adaptability, family cohesion, spirituality and caregiver strain in women as caregivers of elder kin." Thesis, The University of Arizona, 1987. http://hdl.handle.net/10150/558069.

Sabina, Theresa Elizabeth. "Longitudinal changes in VOb2smax as a function of fitness training and body composition changes in women." Virtual Press, 1996. http://liblink.bsu.edu/uhtbin/catkey/1020156.

Anderson, Lynda May. "Privacy needs of women hospitalized for gynecological surgery." Thesis, University of British Columbia, 1990. http://hdl.handle.net/2429/28720.

Silberman, Melissa. "The effects of age and physical activity on VOb2s max in men and women : a longitudinal study." Virtual Press, 1993. http://liblink.bsu.edu/uhtbin/catkey/865943.

Galloway, Alison. "Long term effects of reproductive history on bone mineral content in women." Diss., The University of Arizona, 1988. http://hdl.handle.net/10150/184477.

Green, Carla Ann. "Social Support in an Urban Moroccan Neighborhood: the Effects of Social Networks, Mediation and Patronage on the Physical Health and Psychological Adjustment of Women." PDXScholar, 1995. https://pdxscholar.library.pdx.edu/open_access_etds/1335.

Menard, Janelle Marie. "The social context of cervical cancer knowledge and prevention among Haitian immigrant women." [Tampa, Fla] : University of South Florida, 2008. http://purl.fcla.edu/usf/dc/et/SFE0002679.

Thompson, Brittany, and University of Lethbridge Faculty of Arts and Science. "Under pressure : Women's Health and the social constructions of aging / Brittany Thompson." Thesis, Lethbridge, Alta. : University of Lethbridge, Dept. of Kinesiology, c2011, 2011. http://hdl.handle.net/10133/2610.

Clüver, Frances Rose Mannix. "Negotiating sexuality in Grahamstown East: young black women's experiences of relationships in the context of HIV risk." Thesis, Rhodes University, 2010. http://hdl.handle.net/10962/d1002460.

Viljoen, Janet Erica. "The effect of progressive resistance training on the blood lipid profile in post-menopausal women." Thesis, Rhodes University, 2009. http://hdl.handle.net/10962/d1005191.

Rupkalvis, Carol Anne Cude 1946. "THE RELATIONSHIP OF HEALTH WITH ROLE ATTITUDES, ROLE STRAIN, AND SOCIAL SUPPORT IN ENLISTED MILITARY MOTHERS." Thesis, The University of Arizona, 1987. http://hdl.handle.net/10150/276399.

Xabakashe, Ayanda. "Experiences and perceptions of mothers recovering from depression with regard to the impact of depression on family roles and coping skills." Thesis, University of the Western Cape, 2007. http://etd.uwc.ac.za/index.php?module=etd&action=viewtitle&id=gen8Srv25Nme4_2854_1254815311.

The aim of the present study was to explore the subjective experiences and perceptions of mothers diagnosed with depression. The study investigated mothers' understandings of the extent to which their illness had impacted on their appraisal of their mothering and associated roles within the family. Furthermore, it investigated mothers' coping skills with regard to their illness.

Nicaragua, Odila. "Design and application of a nutrition education program based on a test of improved practices for pregnant women and women of childbearing age in La Rinconada and Cuambo." BYU ScholarsArchive, 2003. https://scholarsarchive.byu.edu/etd/5407.

Craig, Rushing Stephanie Nicole. "Use of Media Technologies by Native American Teens and Young Adults: Evaluating their Utility for Designing Culturally-Appropriate Sexual Health Interventions Targeting Native Youth in the Pacific Northwest." PDXScholar, 2010. https://pdxscholar.library.pdx.edu/open_access_etds/24.

Viljoen, Janet Erica. "Strength training and cardiovascular risk post-menses, with particular emphasis on the plasma lipoproteins: a controlled trial." Thesis, Rhodes University, 2014. http://hdl.handle.net/10962/d1013578.

Xiao, Sumei, and 肖蘇妹. "Genome-wide association study of bone mineral density in Chinese." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2010. http://hub.hku.hk/bib/B43703628.

Rubino-Watkins, Maria Francesca. "Hormones, Distress, and Immune Functioning in Women." Thesis, University of North Texas, 1998. https://digital.library.unt.edu/ark:/67531/metadc277812/.

Huerta, Serina. "Evaluating Social Factors in Diabetes Management by Mexican American Ethnicity." Thesis, University of North Texas, 2010. https://digital.library.unt.edu/ark:/67531/metadc33167/.

Hene, Nceba Mzimkulu. "Physical fitness of elite women's rugby union players over a competition season." Thesis, University of the Western Cape, 2011. http://etd.uwc.ac.za/index.php?module=etd&action=viewtitle&id=gen8Srv25Nme4_6193_1305016359.

The primary aim of this study was to investigate the changes in physical fitness characteristics of elite women&rsquo s rugby union players over the duration of the season. Thirty two elite female rugby players who were identified as members of the South African Rugby Union High Performance Squad were assessed on three separate occasions (pre-season, mid-season and post-season) throughout the competition season. The players were sub-divided into two positional categories consisting of 17 forwards and 15 backs. On all testing occasions, players underwent anthropometric (stature, body mass and sum of 7 skinfolds) and physical performance measurements (sit-and-reach, vertical jump, 10m and 40m speed, 1 RM bench press pull-ups 1 min push-ups and multi-stage shuttle run test). A two&ndash factor analysis of variance evaluated differences in the physical fitness variables between and within playing positions over the competition season.

Feltrin, Rebeca Buzzo 1984. "Entre o campo e o laboratório : a construção da menopausa dentro de um hospital-escola brasileiro." [s.n.], 2012. http://repositorio.unicamp.br/jspui/handle/REPOSIP/286853.

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Dental Hygiene Theses & Dissertations

Theses and dissertations published by graduate students in the Department of Dental Hygiene, College of Health Sciences, Old Dominion University, since Fall 2016 are available in this collection. Backfiles of all dissertations (and some theses) have also been added.

In late Fall 2023 or Spring 2024, all theses will be digitized and available here. In the meantime, consult the Library Catalog to find older items in print.

Theses/Dissertations from 2023 2023

Thesis: The Prevalence of Burnout in Saudi Arabia Dental Hygienists , Nouf Hamad Aldayel

Thesis: Dental Hygiene Students Reported Physiological Symptoms Associated With Wearing an N95 Respirator Mask , Peyton Shea Butler

Thesis: Cheiloscopy Examination and Classification of Lip Prints With and Without Parafunctional Oral Habits: A Cross-Sectional Observation Study , Emily Smith Regan

Theses/Dissertations from 2022 2022

Thesis: Dental Hygienists’ Practices, Attitudes, and Confidence in Providing Care to Child Patients with Autism Spectrum Disorder (ASD) , Fatimah Abdulrahman Alshehri

Thesis: Disaster Victim Identification Competencies: A Comparison of Dental Hygiene and Dental Assistant Students , Samantha Clara Vest

Theses/Dissertations from 2021 2021

Thesis: Use of an Innovative Simulated-Virtual Training to Improve Dental Hygiene Students’ Self-Reported Knowledge, Attitudes, and Confidence in Providing Care to Child Patients with Autism Spectrum Disorder , Kimberly Frances Cenzon

Thesis: The Effects of Sitting and Standing Hygiene on Posture in Dental Hygiene Students , Taylor Shay Kace

Theses/Dissertations from 2020 2020

Thesis: Attitudes of Virginia Dental Hygienists Toward Dental Therapists , Helene Mesina Burns

Thesis: Attitudes of Virginia Dentists Toward Dental Therapists , Adaira Latrece Howell

Theses/Dissertations from 2019 2019

Thesis: Current Barriers to Dental Care of Virginia Children With Autism Spectrum Disorder (ASD) , Sfair Alkhthami

Thesis: Workplace Bullying: A National Survey of Dental Hygienists , Savannah Dawn Sundburg

Theses/Dissertations from 2018 2018

Thesis: Self-Reported Oral health Assessment and Attitudes Toward Oral Health for Adults With Cystic Fibrosis , Ahmed Ali Almuntashiri

Thesis: Current Radiation Safety Practices of United States Dental Hygienists , Kimberly Lintag

Theses/Dissertations from 2016 2016

Thesis: Dental Hygiene Alternative Practice Models: Preparedness and Confidence of 2015 Graduates , Futun Nasser Alkhalifah

Thesis: The Effect of Magnification Loupes on Posture During Instrumentation by Dental Hygienists , Emily Anne Ludwig

Thesis: A Study of Visible Tattoos in Entry-Level Dental Hygiene Education Programs , Kathryn R. Search

Thesis: The Effects of Instrument Handle Design on Forearm Muscle Activity During Scaling by Dental Hygienists , Jessica Rae Suedbeck

Theses/Dissertations from 2015 2015

Thesis: The Perception and Employability of Dental Hygienists with Visible Tattoos , Christina Lynn Cox

Thesis: Dental Consumers' Perceptions of Dental Hygienists with Visible Tattoos , Amanda Brooke Verissimo

Theses/Dissertations from 2014 2014

Thesis: Knowledge, Attitudes, and Barriers Toward Evidence-Based Practice Among Oral Health Professionals in Saudi Arabia , Sukainah Abdulwahab Almeedani

Thesis: Disaster Preparedness & Response: A Survey of U.S. Dental Hygienists , Brenda Tallon Bradshaw

Theses/Dissertations from 2013 2013

Thesis: Fluorescent Technology Versus Visual and Tactile Examination in the Detection of Oral Lesion: A Pilot Study , Hadeel Mohammed Ayoub

Thesis: Comparing Velscope VX and Traditional Oral Exams in Shisha (Hookah) Smokers: A Pilot Study , Amanda E. Kimball

Thesis: Use of Immersive Visualization for the Control of Dental Anxiety During Dental Hygiene Treatment , Carmelo Padrino-Barrios

Theses/Dissertations from 2011 2011

Thesis: Jordanian Dentists' Knowledge and Implementation of Eco-Friendly Dental Office Strategies , Sabha Mahmoud Al Shatrat

Thesis: Effects of Low Temperature Atmospheric Pressure Plasma on Tooth Whitening , Denise Michelle Claiborne

Thesis: Magnification Loupes in U.S. Entry-Level Dental Hygiene Programs , Leslie McHaney Congdon

Theses/Dissertations from 2009 2009

Thesis: Effects of Low-Temperature Atmospheric Pressure Plasma on Streptococcus Mutans , Margaret Farrer Lemaster

Thesis: Bactericidal Effects of Low Temperature Atmospheric Pressure Plasma on Porphyromonas Gingivalis , Arwa Mahasneh

Theses/Dissertations from 2008 2008

Thesis: Bisphenol A Blood and Saliva Levels Prior to and After Dental Sealant Placement in Adults , Joyce Marie Downs

Thesis: In Vitro Comparison of 360° Unirotational Disposable Prophylaxis Angles Versus 90° Reciprocating Disposable Prophylaxis Angles on Spatter During Rubber Cup Polishing , Kelly Marie Schulz

Theses/Dissertations from 2007 2007

Thesis: Effects of Five Different Finger Rest Positions on Arm Muscle Activity During Scaling by Dental Hygiene Students , Mary Elizabeth Cosaboom

Thesis: Bactericidal Effects of Cold Plasma Technology on Geobacillus stearothermophilus and Bacillus cereus Microorganisms , Angela Dawn Morris

Thesis: Vital Tooth Whitening Effects on Oral Health-Related Quality of Life in Older Adults , Ann Michelle Poindexter

Thesis: Effects of Tooth Whitening Use on Oral Health Interests and Values in Adults , Katie Jo Ballantyne Sargent

Theses/Dissertations from 2006 2006

Thesis: In Vitro Evaluation of the Reciprocating Disposable Prophylaxis Angle Versus the Rotating Disposable Prophylaxis Angle in Extrinsic Stain Removal Effectiveness , Inma LaCross

Thesis: Vital Tooth Whitening: Effects on Tooth Color Satisfaction, Beliefs About Dentofacial Appearance, and Self-Esteem in Older Adults , Kelly Marie Seeber

Thesis: Effectiveness of Chlorhexidine-Coating in Controlling Bacterial Quantity on Toothbrush Filaments , Lisa A. Turner

Theses/Dissertations from 2005 2005

Thesis: Predictors of Student Success in an Entry-Level Baccalaureate Dental Hygiene Program , Mohammad J. Alzahrani

Thesis: Use of Miswak Versus Toothbrushes: Oral Health and Behaviors of Jordanian Adults , Reem Saleem Tubaishat

Theses/Dissertations from 2004 2004

Thesis: Effects of Ultrasonic and Hand-Activated Scaling on Tactile Sensitivity in Second Year Dental Hygiene Students in a Clinical Setting , Miranda Beeson

Thesis: The Effects of Universal and Rotating Ultrasonic Inserts on Wrist Movement, Scaling Time Efficiency, and Cumulative Trauma Risk in Dental Hygienists , Christine Colavita Hawn

Theses/Dissertations from 2003 2003

Thesis: Sulphur By-Product: A Potential Indicator of Early Dental Plaque-Induced Gingival Disease Activity , Aleksandra Pavolotskaya

Thesis: Effects of Ultrasonic Scaling and Hand-Activated Scaling on Tactile Sensitivity in Dental Hygiene Students , Danielle Leigh Ryan

Thesis: The Comparative Effects of 0.12% Chlorhexidine and an Herbal Oral Rinse on Dental Plaque-Induced Gingivitis , Elizabeth N. Southern

Theses/Dissertations from 2002 2002

Thesis: Effects of Daily Oral Care with 0.12% Chlorhexidine Gluconate and a Standard Oral Care Protocol on the Development of Nosocomial Pneumonia in Intubated Patients- A Pilot Study , Michelle Lynn Bopp

Thesis: Managerial and Administrative Competencies for Dental Hygiene Program Administrators , Kelly Gale Tanner

Theses/Dissertations from 2001 2001

Thesis: The Effects of Occupational Ultrasonic Noise Exposure on Hearing in Dental Hygienists: A Pilot Study , Jennifer S. Dunning

Thesis: A Scanning Electron Microscopy Comparison of the Effects of the Arkansas Stone and the Ida-Hone Ceramic Stone on Curet Sharpness and Root Smoothness , Marian Gayle Rubino

Thesis: Sulphur By-Product: A Potential Indicator of Early Dental Plaque-Induced Gingival Disease Activity: A Pilot Study , Hui Zhou

Theses/Dissertations from 1999 1999

Thesis: Cultural Adaptability of Students Attending Culturally Diverse and Non-Culturally Diverse Dental Hygiene Programs , Katrina White Magee

Thesis: Sexual Harassment in the Virginia Dental Hygiene Profession , Anne Pennington

Theses/Dissertations from 1998 1998

Thesis: Oral Health Knowledge, Attitudes, and Behaviors of Qatari People , Najat Abdrabbo J. Saleh Al-Salahi

Thesis: A Needs Assessment for a Distance Education Baccalaureate Degree Completion Program for Associate Degree Level Dental Hygienist , Joan Gugino Ellison

Thesis: Course Selection Factors Deemed Important by Dental Hygienists Prior to and After the Initiation of Mandatory Continuing Education in the Commonwealth of Virginia , Melissa Lynn Sainsbury

Theses/Dissertations from 1997 1997

Thesis: Oral Health Assessment of Renal Transplant Recipients Undergoing Immunosuppressant Therapy , Coral Diaz

Thesis: The Effects of Procedural Explanation in Lessening Anxiety During Dental Hygiene Care , Michelle Leigh Sensat

Theses/Dissertations from 1996 1996

Thesis: The Cultural Adaptability of Dental Hygiene, Medical Laboratory Sciences, Nursing and Physical Therapy Faculty , Irene Mary Connolly

Thesis: Relationship Between Design Marketing Strategies and Toothbrush Purchases by Consumers , Cynthia Lynn Garvin

Thesis: Comparison of Curriculum Content on Behavioral Strategies for Managing Anxious Clients in Associate and Baccalaureate Degree Dental Hygiene Programs in the United States , Darnyl Marie King

Thesis: The Oral Health Status of Individuals on Renal Dialysis , Kimberley Naugle

Theses/Dissertations from 1995 1995

Thesis: The Relationship Between Levels of Dentist Supervision and the Ability of Dental Hygienists in Nontraditional Settings to Provide Care , Julie Ann Dunphy

Thesis: Effectiveness of DNA Probe Technology in Distinguishing Among Gingival Health, Mild-Moderate Periodontitis, and Severe Periodontitis in Human Oral Sites , Juliana J. Kim

Theses/Dissertations from 1994 1994

Thesis: Effects of a Commercial Sodium Bicarbonate Toothpaste on Composite Restorative Material , Maggie Jackson

Thesis: Regulation of Dental Hygienists: Its Effect on Disciplinary Action and Opinions of Regulatory Board Members in the United States and Canada , Jodie A. Mueller

Theses/Dissertations from 1993 1993

Thesis: Factors Influencing Dental Hygiene Job Retention in the Private Practice Setting , Kristin A. Hamman

Theses/Dissertations from 1991 1991

Thesis: Promoting Careers in Dental Hygiene: The Dental Hygienist's Role , Taline Dadian

Thesis: Preventative Oral Health Services Provided by Nurses' Aides to Nursing Home Residents , Deborah Lewis Hardy

Thesis: Effects of Ultrasonic Scaling and Hand Scaling on Root Typography , Kim Lee Herremans

Thesis: Short-Term Effects of the Poliswab R on Supramarginal Bacterial Plaque Removal and Gingival Health in a Spinal Cord Unit Population , Beth Elaine McKinney

Thesis: Faculty Standardization of Dental Hygiene Instrumentation Skill Evaluation: A Calibration Exercise , Diane-Marie Smela

Theses/Dissertations from 1990 1990

Thesis: Survey of Virginia Dental Practices to Determine Compliance With the Standards of Risk Management Theory , Joanne Schade Boyce

Thesis: Dental Hygiene Manpower Distribution in Virginia , Christine Ann Nielsen

Theses/Dissertations from 1988 1988

Thesis: Survey of Attitudes of Licensed Dental Hygienists Toward Continuing Education in a State with Mandatory Continuing Education Versus a State without Mandatory Continuing Education , Katharine Reeves Behroozi

Thesis: Job Satisfaction Among Three Different Dental Hygiene Occupational Settings , Ruth Halstead Hull

Theses/Dissertations from 1987 1987

Thesis: The Antimicrobial Effectiveness of Isopropyl Alcohol, Phenylphenol, and Nonphenal Oxyethylene Iodine Complex on Dental Operatory Surfaces , Maureen Anne Lawless

Thesis: The Effectiveness of Oral Health Computer Assisted Instruction on Increasing the Oral Hygiene Status of Children , Claudia Ann Michalak

Thesis: Clinical Effects of Daily Rotary Electric Toothbrushing on the Presence of Gingivitis and Supragingival Dental Plaque , Laura Jean Mueller

Theses/Dissertations from 1986 1986

Thesis: Effects of Air Polishing and Rubber Cup Polishing on Enamel Abrasion , April Kee

Thesis: Effectiveness of a Hydrogen Peroxide, Sodium Chloride, Sodium Bicarbonate Dentifrice Upon Microbiota Associated with Periodontitis , Jill M. Modi

Thesis: Clinical Effectiveness of Listerine R and Viadent R Mouthrinses on Bacterial Plaque and Gingivitis , Debra Pizzola Powell

Theses/Dissertations from 1985 1985

Thesis: The Short Term Effect of a Dental Health Fair on Children's Attitudes Toward Plaque Control, Fluorides, Nutrition, and Receiving Dental Treatment , Sue Nell Bethea

Thesis: Clinical Effectiveness of Hydrogen Peroxide-Sodium Bicarbonate Paste on Human Periodontitis Treated With and Without Scaling and Root Planing , Sylvia M. Lyne

Theses/Dissertations from 1984 1984

Thesis: Admissions Criteria as Predictors of Students' Successful Completion of a Dental Hygiene Program , M. Linda Brown

Thesis: Orthodontists' Attitudes Toward Expanding Career Opportunities for the Dental Hygienist in Orthodontics , Julie A. Foster

Thesis: A Survey of Burnout Among Dental Hygiene Educators , Sandra Boggs Ricks

Theses/Dissertations from 1982 1982

Thesis: Old Dominion University Master of Science in Dental Hygiene Degree Program: Graduate and Employer Survey , Deborah Blythe Bauman

Thesis: Dental Hygiene Students' Perceptions About the Behavioral Characteristics of the Effective Clinical Teacher , Frances Gaby Carson

Thesis: Aseptic Techniques Currently Used in Dental Hygiene Clinics Within Accredited Dental Hygiene Programs , Jan Shaner Greenlee

Thesis: Pedodontists' Attitudes Toward Pit and Fissure Sealants as a Preventative Oral Service , Kathern Rheanice Hamlin

Theses/Dissertations from 1981 1981

Thesis: Effects of the Dental Hygiene Curriculum on Student Creativity , Linda Kathryn Martin

Thesis: Relationship Between the Empathy Levels of Dental Hygiene Students and Their Teachers , Claudia Hudak Sanderlin

Theses/Dissertations from 1980 1980

Thesis: Dental Hygiene Students' Perceptions of Themselves and the Typical Dental Hygienist in Regard to Feminism , Christine M. Berg

Thesis: Effectiveness of Dental Plaque Charts in Motivating Adolescents Toward Improved Oral Hygiene and Oral Health , Lee Ann Branscome

Thesis: Vocational Interests of Dental Hygiene Professionals , Renee Johnson

Thesis: Short-Term Effect of Preventative Oral Health Services on Drug Rehabilitation Clients' Self Concept , Susan Elizabeth Jones

Thesis: Oral Health Care Services Available to Mentally Retarded Individuals in Public Residential Facilities , Marilynn Mattox

Thesis: Use of Disclosing Tablets and Signs of Gingival Bleeding for Improving the Oral Health and Oral Hygiene Status of Adult Dental Clients , Susan Elaine Thompson

Theses/Dissertations from 1979 1979

Thesis: Effect of the Rubber-Cup Prophylaxis and the Self-Administered Prophylaxis on the Oral Hygiene Performance of the Pedodontic Patient , Kay Diane Edwards

Thesis: Measuring Empathy in Female Hygiene Students , Patricia R. Mason

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Global Water, Sanitation and Hygiene (WASH)
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About Global Hygiene

At a glance.

Hygiene refers to practices that can lead to good health and cleanliness, such as bathing with soap and water.
Keeping hands clean is one of the most important ways to prevent the spread of illness.
In many areas, lack of access to clean water and soap makes hygiene difficult.

Hand hygiene is one of the most effective ways to prevent the spread of germs. As of 2023, globally there were:

2.3 billion people who did not have access to a handwashing facility with water and soap at home
670 million people who did not have access to a handwashing facility at all
462 million children who did not have access to handwashing facilities at schools

Diarrheal and Respiratory Diseases

In many resource-limited settings, diarrheal disease is the leading cause of death among children . A 2018 review of data showed that teaching communities to wash hands with soap and water reduced diarrhea by 30%. This means promoting hygiene practices could prevent an estimated 1 million deaths from diarrheal diseases.

Respiratory diseases are also common in resource-limited settings. In 2016, nearly 300 million people got sick and almost 2 million died due to lower respiratory infections alone. While more systematic evidence is needed, many studies show that washing hands can lower the number of respiratory diseases generally, especially in childcare settings and schools.

People often spread diarrheal and respiratory diseases to each other through dirty hands. Diarrheal diseases can also be spread through the fecal-oral route (when germs from poop get into the mouth). Handwashing can stop the spread of many germs that cause disease and is key to preventing the spread of diseases in all parts of the world. However, access to soap and water is limited in many resource-limited settings.

Hygiene Challenges and Resources

In resource limited places, the biggest challenge to good hygiene is not having access to water.

About 2 billion people do not have access to safely managed drinking water services, of which 800 million people do not have access to an improved water source and lack safe drinking water.
Worldwide, 1.4 million deaths per year are attributed to diseases spread through unsafe water, poor sanitation, and lack of hygiene.
An estimated 2.3 billion people do not have access to a handwashing facility with water and soap at home, and 670 million people lack access to a handwashing facility at all.

Successful handwashing programs teach and promote hygiene practices that resonate with local social and cultural norms. Educating people about water use and improving access to water are crucial steps these programs take to enhance water resources in areas with limited resources. Still, hygiene challenges persist as a significant issue for millions.

Global Water, Sanitation, and Hygiene (WASH)

Global access to safe water, adequate sanitation, and proper hygiene can reduce illness and death from disease.

Open access
Published: 08 May 2024

The digital transformation in pharmacy: embracing online platforms and the cosmeceutical paradigm shift

Ahmad Almeman ORCID: orcid.org/0000-0002-6521-9463 1

Journal of Health, Population and Nutrition volume 43 , Article number: 60 ( 2024 ) Cite this article

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In the face of rapid technological advancement, the pharmacy sector is undergoing a significant digital transformation. This review explores the transformative impact of digitalization in the global pharmacy sector. We illustrated how advancements in technologies like artificial intelligence, blockchain, and online platforms are reshaping pharmacy services and education. The paper provides a comprehensive overview of the growth of online pharmacy platforms and the pivotal role of telepharmacy and telehealth during the COVID-19 pandemic. Additionally, it discusses the burgeoning cosmeceutical market within online pharmacies, the regulatory challenges faced globally, and the private sector’s influence on healthcare technology. Conclusively, the paper highlights future trends and technological innovations, underscoring the dynamic evolution of the pharmacy landscape in response to digital transformation.

Introduction

Digital technology is driving a massive shift in the worldwide pharmacy industry with the goal of improving productivity, efficiency, and flexibility in healthcare delivery. In the pharmacy industry, implementing digital technologies like automation, computerization, and robotics is essential to cutting expenses and enhancing service delivery [ 1 ]. With a predicted 14.42% annual growth rate, the digital pharmacy market is expanding significantly and is expected to reach a market volume of about $35.33 billion by 2026. This expansion reflects the pharmacy industry’s growing reliance on and promise for digital technologies [ 2 ].

Pharmacy services have always been focused on face-to-face communication and paper-based procedures. However, the drive for more effective, transparent, and patient-centered healthcare is clear evidence of the growing need for digital transformation. Breakthroughs like mobile communications, cloud computing, advanced analytics, and the Internet of Things (IoT) are reshaping the healthcare sector. These breakthroughs have the potential to greatly improve patient care and service delivery, as demonstrated in other industries including banking, retail, and media [ 3 ].

In the pharmacy industry, a number of significant factors are hastening this digital transition. Important concerns include the desire for cost-effectiveness, enhanced patient care, and more transparency and efficiency in medication development and manufacture. This change has been made even more rapid by the COVID-19 pandemic, which has highlighted the necessity for digital solutions to address the difficulties associated with providing healthcare in emergency situations [ 4 ].

In terms of specific technologies being adopted, artificial intelligence (AI) and machine learning are playing a pivotal role. The McKinsey Global Institute estimates that AI in the pharmaceutical industry could generate nearly $100 billion annually across the U.S. healthcare system. The use of AI and machine learning enhances decision-making, optimizes innovation, and improves the efficiency of research and clinical trials. This results in more effective patient care and a more streamlined drug development process [ 5 ].

The digital transformation in the pharmacy sector represents a pivotal shift in the delivery and experience of healthcare services. This evolution is more than a transient trend; it’s a fundamental alteration in the healthcare landscape [ 6 ]. The adoption of digital technologies is reshaping aspects of healthcare, including patient engagement and medication adherence, leading to enhanced healthcare outcomes. Research indicates that digital tools in pharmacy practices have resulted in more individualized and efficient patient care. Telehealth platforms, exemplified by companies like HealthTap, are being increasingly incorporated by pharmacies to augment patient care via technological solutions. The contribution of digital health technology to medication adherence is notable, employing a variety of tools such as SMS, mobile applications, and innovative devices like virtual pillboxes and intelligent pill bottles. These advancements are pivotal in addressing the critical issue of medication nonadherence in healthcare. Furthermore, digital health tools are empowering pharmacists with expanded clinical responsibilities, particularly in the management of chronic diseases like diabetes, where apps and smart devices provide essential features such as blood glucose tracking and medication reminders. This comprehensive integration of digital health into pharmacy practice signifies a transformative era in healthcare delivery and patient management [ 7 ].

Online platforms are being used increasingly by the pharmaceutical sector and educational institutions to improve efficiency, flexibility, and accessibility. The telepharmacy program at CVS Pharmacy is an example of how telepharmacy services, which provide remote counseling and prescription verification, bring pharmaceutical care to underprivileged communities [ 8 ]. Prescription accuracy and drug management are enhanced by e-prescribing software like Epic’s MyChart and digital health apps like Medisafe [ 9 ; 10 ]. Blockchain technology is also being investigated for transparent and safe supply chain management. Continuous learning and professional networking are made possible in education by Virtual Learning Environments (VLEs) like Moodle [ 11 ], simulation software like SimMan 3G Plus [ 12 ], Continuing Professional Development (CPD) platforms like the American Pharmacists Association [ 13 ], and online conference platforms, as shown in Fig. 1 . While these platforms offer significant benefits like enhanced access and cost-effectiveness, they also present challenges, including addressing the digital divide and ensuring the quality and credibility of online services to maintain professional standards and patient safety.

In this review, we summarized the digital transformation in the pharmacy sector, emphasizing the integration of online platforms and the emerging significance of cosmeceuticals. We discussed the global shift towards digital healthcare, including telehealth and online pharmacy services, and how these changes have been accelerated by the COVID-19 pandemic. The paper also examined the impact of digital technologies on pharmacy practice and education, with a focus on telepharmacy services, e-prescribing software, and digital health apps. Additionally, it addresses the challenges and opportunities presented by this transformation, including regulatory and safety concerns, and the need for continuous professional development in the digital era.

Comprehensive overview of different platforms in the pharmaceutical industry and education illustrating purposes and exemplary cases

The global impact of online pharmacy platforms

In recent years, the landscape of pharmacy practice and education has undergone a significant transformation, driven by technological advancements and catalyzed by the global COVID-19 pandemic. A study highlighting the increasing consumer trust in online medication purchases pre, during, and post-pandemic reveals a shift in consumer behavior towards online pharmacies [ 14 ]. This trend underscores a greater reliance on these platforms, where the perceived benefits significantly outweigh the perceived risks, indicating a positive reception and growing trust in digital healthcare solutions.

The adoption of telehealth, including telepharmacy, exemplifies this shift. In the United States, patient adoption of telehealth services surged from 11% in 2019 to 46%, with healthcare providers expanding their telehealth visits [ 15 ]. This shift is a reflection of how adaptable the healthcare sector is to digital platforms and how customer acceptance is increasing. The epidemic has also served as a catalyst, hastening the creation and uptake of online telepharmacy services throughout the world. The “new normal” has forced the addition of new platforms to support established sources of health information. The creation and evaluation of an online telepharmacy service in the Philippines during the pandemic serves as an example of this, demonstrating how quickly the global pharmacy industry adopted digital solutions. These services are essential for providing and elucidating pharmaceutical information within the context of primary healthcare delivery; they are not merely supplementary [ 16 ].

Simultaneously, pharmacist-led companies such as MedEssist and MedMehave, innovated digital platforms to facilitate services like flu shots or COVID-19 tests, reflecting a move towards customer-centric, digital-first services [ 17 ]. This transition enhances convenience and access to care but also introduces significant regulatory challenges. As the growth of online medicine sales disrupts traditional pharmacy markets, navigating these challenges becomes crucial for maintaining patient safety, quality standards, and fostering a trustworthy online healthcare environment [ 18 ].

Parallel to the practice changes, educational platforms for pharmacy have also evolved, especially under the impetus of the pandemic. These platforms have integrated a mix of traditional and student-centered teaching methodologies, including remote didactic lectures and on-site experiential training. The implementation of blended learning approaches, which combine remote lectures with on-site laboratory classes, reflects a broader educational trend towards hybrid models. This approach aims to leverage the advantages of both online and traditional methods, offering a more flexible and potentially more effective educational experience [ 19 ].

It takes more than just implementing new tools to integrate educational technology into pharmacy education, it also requires understanding how these technologies affect instruction and student learning. To effectively improve the educational experience, their utilization must have a purpose. There is an increasing amount of scholarly interest in this field, as evidenced by systematic reviews of the effects of new technologies on undergraduate pharmacy teaching and learning [ 20 ]. These digital platforms will probably become more significant in the future of pharmacy education, helping to mold the profession and guaranteeing that pharmacists are equipped to fulfill the ever-changing demands of the healthcare system. This development is indicative of a larger trend in the healthcare industry toward a more flexible, patient-focused, and technologically advanced environment [ 21 ].

Digital transformation in global healthcare

The recent advancements in digital transformation within global healthcare are significantly reshaping the landscape of healthcare and pharmacy services. These transformations are largely driven by the integration of digital technologies, which are redefining the tools and methods used in health, medicine, and biomedical science, ultimately aiming to create a healthier future for people worldwide [ 22 ]. In a 2018 report [ 23 ], Amazon’s potential entry into the $500 billion U.S. pharmacy market, the second-largest retail category, through mail-order and online pharmacies was highlighted as a significant industry disruptor. With licenses in at least 12 states in the US and a strategy focused on bypassing middlemen, Amazon’s historical success positions it to transform the pharmacy landscape, promising enhanced efficiency and cost savings for consumers.

One of the critical areas identified in recent research is the establishment of five priorities of e-health policy making: strategy, consensus-building, decision-making, implementation, and evaluation. These priorities emerged from stakeholders’ perceptions and are crucial for the effective integration and adoption of digital health technologies [ 24 ]. This holistic approach is increasingly relevant for scholars and practitioners, suggesting a focus on how multiple stakeholders implement digital technologies for management and business purposes in the healthcare sector [ 25 ]. The deployment of technological modalities, encompassed within five distinct clusters, can facilitate the development of a digital transformation model. This model ensures operational efficiency through several dimensions: enhanced operational efficacy by healthcare providers, the adoption of patient-centered methodologies, the integration of organizational factors and managerial implications, the refinement of workforce practices, and the consideration of socio-economic factors [ 25 ].

Studies focusing on value creation through digital means suggest healthcare as a consumer-centric realm ripe for center-edge transformations, characterized by self-service and feedback cycles. These transformations are vital in addressing inherent tensions between patients and physicians, steering the focus towards value co-creation and service-dominant logic [ 26 ]. Participatory design and decision-making approaches are emphasized for enhancing health information technology’s performance and institutional healthcare innovation. Such approaches are particularly crucial in developing national electronic medical record systems and improving chronic disease treatment through electronic health records. Additionally, telehealth research integrates patients’ perceptions, contributing to the understanding of technology, bureaucracy, and professionalism within healthcare [ 27 ].

The impact of health information technology (HIT) on operational efficiencies is profound. Empirical studies, such as those by Hong and Lee [ 28 ], Laurenza et al. [ 29 ], and Mazor et al. [ 30 ], demonstrate positive correlations between HIT and patient satisfaction, quality of care, and operational efficiency. However, challenges remain, as Rubbio et al. [ 31 ] highlight deficiencies in resilience-oriented practices for patient safety. Organizational and managerial factors in digital healthcare transformation also receive significant attention. Hikmet et al. [ 32 ] and Agarwal et al. [ 33 ] investigate the role of organizational variables and barriers in HIT adoption, whereas Cucciniello et al. [ 34 ] delve into the interdependence between implementing electronic medical records (EMR) systems and organizational conditions. Further, Eden et al. [ 35 ] and Huber and Gärtner [ 36 ] explore workforce adaptations and the implications of health information systems in hospitals that can increases transparency of work processes and accountability. Lastly, examining healthcare financialization and digital division provides an international perspective, contrasting the regulated environment in the EU with the US’s use of online medical crowdfunding as a potential solution to reduce bankruptcy [ 37 ; 38 ]. Collectively, these studies suggest a comprehensive model where stakeholders leverage digital transformation for management, enhancing operational efficiency in healthcare service providers.

Marques and Ferreira [ 39 ] performed a systematic literature review of digital transformation in healthcare, spanning the period from 1973 to 2018. Utilizing the SMARTER (Simple Multi-attribute Rating Technique Exploiting Ranks) method, 749 potential articles were analyzed, culminating in the prioritization and selection of 53 articles for detailed examination. The literature was organized into seven thematic areas: (1) Integrated management of IT in healthcare, (2) Medical images, (3) Electronic medical records, (4) IT and portable devices in healthcare, (5) Access to e-health, (6) Telemedicine, and (7) Privacy of medical data. It was observed that the predominant focus of research resides in the domains of integrated management, electronic medical records, and medical images. Concurrently, emerging trends were identified, notably the utilization of portable devices, the proliferation of virtual services, and the escalating concerns surrounding privacy. See Fig. 2 for visual representation of multifaceted digital transformation in healthcare.

Visual representation of multifaceted digital transformation in healthcare: a synthesis of provider-patient dynamics, HIT impact, and strategic management. HIT; health information technology, HC; healthcare, EMR; electronic medical records. IT; information technology, Pt.; patient

Telehealth and online pharmacy advancements in pandemic management

In the realm of online pharmacies and telehealth, digital health technologies have been instrumental in managing the COVID-19 pandemic through surveillance, contact tracing, diagnosis, treatment, and prevention. These technologies ensure that healthcare, including pharmacy services, is delivered more effectively, addressing the challenges of accessibility and timely care. The role of telemedicine and e-pharmacies, in particular, has been emphasized in improving access to care worldwide. By enabling remote consultations and drug delivery, these platforms are making healthcare more accessible, especially in regions where traditional healthcare infrastructure is limited or overstretched [ 40 ].

The Canadian Virtual Care Policy Framework advocates for the swift adoption and integration of virtual care, propelled by the COVID-19 pandemic. It emphasizes enhancing access and quality, ensuring equity and privacy, and devising appropriate remuneration models, employing a collaborative, patient-centered approach while addressing digital disparities. During the COVID-19 pandemic, Canadian provinces and territories rapidly adopted virtual health care, leading to 60% of visits being virtual by April 2020, up from 10 to 20% in 2019. However, these implementations were often temporary and not fully integrated into healthcare systems. By August 2020, virtual visits decreased to 40%, with variations across regions, while provinces and territories used temporary billing codes for these services. The framework’s “Diagnostique” provides a thorough analysis of policy enablers and strategies for virtual care, underscoring the need for comprehensive policy and partnership engagement [ 41 ]. In the context of digital transformation in pharmacy, the Hospital News article outlines the application and infrastructure of telepharmacy services in Canada, highlighting the geographical challenges and the early adoption of telepharmacy in certain regions since 2003. It notes the use of various technologies like Medication Order Management, Videoconferencing, and Remote Camera Verification. Although lacking specific quantitative data, the article underscores the necessity for expanded telepharmacy services to ensure uniform care quality across diverse locations [ 42 ].

Similarly, Telehealth offers extensive resources for patients and providers in the United States, emphasizing programs like the Affordable Connectivity Program and Lifeline to facilitate access. The Health Resources and Services Administration enhances telehealth through support services, research, and technical assistance, reflecting a significant outreach impact [ 43 ]. The Office for the Advancement of Telehealth (OAT) under Health Resources and Services Administration (HRSA) works to improve access to quality health care through integrated telehealth services in the US. It supports direct services, research, and technical assistance, with over 6,000 telehealth technical assistance requests sent to Telehealth Resource Centers and approximately 22,000 patients served [ 44 ].

Internationally, In the UK, the National Health Service (NHS) spearheads digital health and care, providing significant innovation opportunities through vast data management. Support for digital health spans various stages, from discovery with organizations like Biotechnology and Biological Sciences Research Council (BBSRC) and Intelligent Data Analysis (IDA) research group, to development with networks such as Catapults and CPRD, and delivery with entities like the Academic Health Science Networks (AHSNs) and DigitalHealth.London. Regulatory bodies like the Medicines and Healthcare products Regulatory Agency (MHRA) and NICE ensure safety and efficacy. The collaborative ecosystem involves academic, healthcare, and industry stakeholders, aiming to enhance health and care services through technology and innovation [ 45 ].

In Australia, the government’s investment of over $4 billion into COVID-19 telehealth measures has facilitated universal access to quality healthcare. This initiative has provided over 85 million telehealth services to more than 16 million patients, with approximately 89,000 healthcare providers engaging in this service delivery. From 1 January 2022, telehealth services, initially introduced in response to COVID-19, will become an ongoing part of Medicare. This will allow eligible patients across Australia continued access to general practice (GP), nursing, midwifery, and allied health services via telehealth, deemed clinically appropriate by the health professional [ 46 ].

European nations such as the Netherlands, Austria, and Italy are at the forefront of implementing cross-organizational patient records, significantly enhancing telehealth communication and facilitating cross-border healthcare. The role of strong government support in advancing telehealth is pivotal. Ursula von der Leyen, the President of the European Commission, has been a prominent advocate for eHealth. She proposed the establishment of a European Health Data Space to streamline health data exchange across member states. France, a leader in telehealth legislation for nearly a decade, has pioneered a public funding scheme for tele-expertise at a national scale. Despite these advancements, challenges like legislative barriers and the lack of consistent political direction continue to impede progress in the telehealth domain [ 47 ].

The Asia-Pacific region anticipates a surge in telehealth adoption driven by digital demand and pandemic-induced behavioral changes, while South East Asia exhibits widespread telehealth growth across healthcare aspects [ 48 ]. The telehealth adoption across the Asia-Pacific region has shown remarkable growth between 2019 and 2021 and is projected to continue rising by 2024. China’s adoption nearly doubled to 47% and is expected to reach 76%. Indonesia’s usage more than doubled to 51%, with a forecast of 72%. Malaysia and the Philippines both anticipate reaching a 70% adoption rate, increasing from 30% to 29%, respectively. India’s adoption is projected to more than double to 68%, while Singapore, which had a significant increase from 5 to 45%, is expected to achieve a 60% adoption rate. This trend indicates a robust uptake of telehealth services in the region [ 48 ].

Global telemedicine and E-pharmacy policy dynamics

In the context of telemedicine and e-pharmacy regulations within South East Asia, a notable distinction emerges with Singapore, Malaysia, and Indonesia being the only countries to have formalized legal frameworks governing both telemedicine practices and the dissemination of electronic information. In these countries, tele-consultation is restricted to patients already under the care of healthcare practitioners or as part of ongoing treatment, specifically in Singapore and Malaysia. Additionally, for scenarios requiring more intensive medical intervention, such as new referrals, emergency cases, or invasive procedures, both Malaysia and Indonesia mandate physical presence and face-to-face consultations, emphasizing a cautious and regulated approach to remote healthcare. In Malaysia, the regulations further stipulate that online prescriptions, excluding narcotics and psychotropic substances, are permissible solely under the continuation of care model, reflecting a judicious use of digital prescription services [ 49 ].

In Central and Eastern Europe (CEE), telemedicine has experienced substantial growth, primarily catalyzed by the COVID-19 pandemic, which necessitated rapid advancements in technology and alterations in healthcare practices. The region’s robust digital infrastructure, coupled with the innovative drive of local companies and the challenges posed by an aging demographic, has significantly contributed to this expansion. According to the European Commission’s Market Study on Telemedicine, the global telemedicine market was projected to grow annually by 14% by 2021, a rate that was likely surpassed due to the pandemic’s impact. More specifically, the Europe Telehealth Market, valued at US $6,185.4 million in 2019, is anticipated to witness an annual growth rate of 18.9% from 2020 to 2030. This trend underscores the increasing reliance on and potential of telemedicine in addressing healthcare needs in the CEE region [ 50 ].

In the Middle East, telehealth and telepharmacy, have seen varied degrees of adoption and progress. Despite attempts to reform healthcare delivery in the region, the progress of telemedicine has been somewhat slow, with certain expectations yet to be fully realized. However, there has been notable development in the use and adoption of these technologies [ 51 ]. In a survey comparing the utilization of digital-health applications in Saudi Arabia and the United Arab Emirates (UAE), it was observed that a higher percentage of Saudi participants have utilized online pharmacy services (48%) compared to the UAE (36%). Conversely, awareness of teleconsultation services without prior use was higher in the UAE (43%) than in Saudi Arabia (35%). Retention data indicates that a significant proportion of users in both countries continue to engage with these services, with 80% of Saudi participants and 71% of UAE participants using teleconsultations at varying frequencies. Notably, a substantial majority of users in Saudi Arabia reported regular use of online pharmacies (90%), slightly higher than the UAE (78%), reflecting robust ongoing engagement with these digital health modalities. Notably, consumer adoption of telehealth products is primarily driven by time savings (48%) and convenience (47%), with 24-hour accessibility and efficacy both influencing 34% of users. Affordability and personal recommendations are also notable factors, while a wide range of options and quality are lesser but relevant considerations [ 52 ].

In response to the COVID-19 pandemic, a cross-sectional study was conducted among 391 licensed community pharmacists in the United Arab Emirates to assess the adoption and impact of telepharmacy services. The study revealed a predominant use of telepharmacy services, particularly via phone (95.6%) and messaging applications (80.0%). The findings highlighted that pharmacies with more pharmacists and those operating as part of a group or chain were more likely to implement a diverse range of telepharmacy services. The study identified significant barriers to telepharmacy adoption in individual pharmacies, including limited time, inadequate training, and financial constraints. There was a noticeable shift in service provision during the lockdown, with an increased reliance on telepharmacy, especially among pharmacies serving 50–100 patients per day. However, a reduction in services such as managing mild diseases and selling health products was observed during the lockdown period. The study concluded that telepharmacy played a pivotal role in supporting community pharmacies during the pandemic, with its expansion facilitated by the UAE’s advanced internet infrastructure, supportive health policies, and widespread digital connectivity [ 53 ]. Collectively, these insights reflect a global shift towards integrating and enhancing telehealth services as a response to emerging healthcare needs and technological advancements.

Unni et al. [ 54 ] provided an extensive review of telepharmacy initiatives adopted globally during the COVID-19 pandemic. Predominantly, virtual consultations were utilized to enable at-risk patients and others to remotely access pharmacists, thereby monitoring chronic illnesses, optimizing medication usage, and providing educational support [ 55 ]. Home delivery of medicines was widely implemented to decrease the necessity for in-person visits and mitigate exposure risks [ 56 ]. Additionally, patient education was prioritized to ensure effective management of health conditions from a distance [ 57 ]. Notably, a network of hospitals in China developed cloud-pharmacy care, allowing patients to consult pharmacists via text and the internet, while Spain utilized information and communication technologies for remote pharmaceutical care [ 58 ; 59 ]. Zero-contact pharmaceutical care, introduced in China, facilitated online medication consultations, eliminating direct contact [ 60 ]. The Kingdom of Saudi Arabia and other regions adapted new e-tools and teleprescriptions to enhance service accessibility [ 61 ]. The U.S. focused on credentialing pharmacists for telehealth to ensure competent service provision, and New Zealand implemented hotline numbers for phone consultations to further reduce physical visits [ 62 ; 63 ]. These initiatives reflect a significant shift towards innovative, technology-driven solutions in pharmaceutical care during a global health crisis. Refer to Fig. 3 for a graphical depiction of the worldwide distribution and applications of telepharmacy initiatives.

The global distribution of telepharmacy programs with an analysis of geographical distribution, technological applications, and associated benefits

Tracing the Private Sector’s Impact on Healthcare’s Technological Transformation

The role of the private sector in the fourth industrial revolution.

The World Economic Forum underscores the private sector’s leading role in digital inclusion and the acceleration of actions pertinent to the Fourth Industrial Revolution. This revolution affects economies, industries, and global issues profoundly, indicating the private sector’s critical role in driving technological advancements and digital platforms that deliver impactful healthcare solutions [ 64 ].

Mapping digital transformation in healthcare

A comprehensive analysis performed by Dal Mas et al. [ 65 ] meticulously maps the intricate terrain of digital transformation in healthcare, spotlighting the private sector’s instrumental role. Initially, the investigation encompassed an extensive array of diverse studies, leading to the identification of five main areas of digital technologies: smart health technologies, data-enabled and data collection technologies, Industry 4.0 tools and technologies, cognitive technologies, and drug & disease technologies. These domains frame the future research pathways, primarily steered by the private sector’s innovative drive. A significant proportion of the literature addresses healthcare broadly, suitable for both private and public sectors, yet a notable segment specifically focuses on the private sector’s endeavors, with a pronounced emphasis on the pharmaceutical domain [ 66 ; 67 ].

Public-private partnerships in healthcare delivery

The highlighted technologies, including digital platforms and telemedicine, exemplify the private sector’s trailblazing contributions to digital healthcare advancements. For instance, public-private partnerships (PPP) in India have emerged as a pivotal model for realizing universal healthcare (UHC), especially against the backdrop of acute healthcare shortages and urban-rural divides. Notably, mega PPP projects have successfully deployed technology-enabled remote healthcare (TeRHC), demonstrating its feasibility and impact in reaching isolated communities. These initiatives, overcoming various challenges, serve as a compelling example for global adoption, underscoring the transformative role of PPP in healthcare delivery [ 68 ].. Furthermore, a considerable majority of the literature in telemedicine underscores the necessity for profound research implications, yet a significant minority suggests policy implications [ 69 ; 70 ], reflecting a complex synergy between the private and public sectors in sculpting the digital healthcare framework [ 71 ]. This synthesis underscores the private sector’s critical influence in propelling the digital transformation in healthcare, charting a course that progressively fuses technological innovation with healthcare provision.

A study highlights Indonesia’s strategic initiatives to capitalize on telehealth business opportunities, driven by the Ministry of Research and Technology’s robust support for Technology-Based Start-up Company schemes [ 72 ]. With a demographic boon of 298 million from 2020 to 2024, escalating non-communicable diseases (71%), and a growing base of 222.4 million JKN participants, the stage is set for transformative growth. Despite a critical shortage of health workers (0.4 doctors per 1000 population), the enthusiasm for telemedicine is evident, with 71% satisfaction in hospital telemedicine and 32 million active telehealth users. The Ministry’s foresight in fostering technology start-ups, exemplified by the TEMENIN platform with its 11 health platforms, is steering Indonesia towards a future where high-quality healthcare is accessible and sustainable.

Lab@AOR: a model for PPPs in healthcare sector

The “Lab@AOR” initiative stands as a paradigmatic example of PPPs effectuating digital transformation within the healthcare sector. This strategic collaboration, between the University Hospital of Marche and Loccioni [ 73 ], a private entity, underscores the capacity of PPPs to navigate intricate challenges, stimulate international cooperation, and contribute to the development of sustainable, patient-centric healthcare solutions. Specifically, Lab@AOR was instituted to confront the nuanced challenges associated with the robotization of healthcare service delivery, highlighting the initiative’s role in fostering technological advancement through public and private sector synergy [ 74 ]. The project illustrates the evolution of Lab@AOR through three main phases: the pioneering stage, where groundwork for collaboration was laid; the nurturing stage, where collaborative exchanges were fostered; and the harvesting stage, wherein the potential of the PPP was fully unleashed. In the pioneering stage, Lab@AOR focused on a critical healthcare service component: the in-hospital preparation of medications for oncological patients. The University Hospital of Marche identified a need for innovation to improve service quality, efficiency, and safety, while Loccioni sought a real-life setting to test and refine its robotized system, APOTECAchemo [ 75 ]. This convergence of needs led to a symbiotic partnership aiming to enhance healthcare delivery through technological advancement.

During the nurturing stage, the partnership expanded the scope of APOTECAchemo to include non-oncological medications and developed additional tools like APOTECAps for manual preparation support. This phase was characterized by intensive collaboration, knowledge sharing, and continuous innovation, demonstrating the dynamic capability of the PPP to adapt and evolve in response to emerging healthcare challenges. The harvesting stage marked the international expansion of Lab@AOR, transforming it from a local initiative to an international community focused on leveraging digitalization and robotization to improve care quality and patient-centeredness. The PPP’s growth was catalyzed by its open perspective and inclusive approach, engaging entities from various cultural and institutional contexts, and fostering a network of 31 nodes across 19 countries and 3 continents.

Advancements in telehealth business models and frameworks

In their investigative study, Velayati et al. [ 76 ] delved into the articulation of emergent business models in telehealth and scrutinized the deployment of established frameworks across a variety of telehealth segments. The research spanned an extensive range of sectors, notably telemonitoring, telemedicine, mobile health, and telerehabilitation, alongside telehealth more broadly. The scope further extended to encompass niche areas such as assisted living technologies, sensor-based systems, and specific fields like mobile teledermoscopy, teleradiology, telecardiology, and teletreatment, presenting a thorough analysis of the telehealth landscape. Within the telemedicine and telehealth services sector, Barker et al. [ 77 ] introduced the Arizona Telemedicine Program (ATP) Model, a quintet-layer approach aimed at efficiently distributing telemedicine services throughout Arizona. Complementing this, Lee and Chang [ 78 ] proposed a four-component model specifically tailored for mobile health (mHealth) services pertaining to chronic kidney disease, focusing on offering a cost-effective platform for disease support and management. In the realm of telemonitoring, Dijkstra et al. [ 79 ] utilized the Freeband Business Blueprint Method (FBBM), which includes service, technological, organizational, and financial domains, to facilitate multiple telemonitoring services. Furthermore, the systemic and economic differences were explored in care coordination through Business to customer (B2C) and business (B2B) models for telemonitoring patients with chronic diseases, with the B2C model’s economic advantages were highlighted [ 80 ].

General telemedicine frameworks also received attention. Lin et al. [ 81 ] constructed a six-component framework analyzing major telemedicine projects in Taiwan, while Peters et al. [ 82 ] developed the CompBizMod Framework in Germany, encompassing value proposition, co-creation, communication and transfer, and value capture, designed to evaluate and enhance competitive advantages in telemedicine. In the specialized field of telecardiology, a comprehensive nine-component sustainable business model was crafted to facilitate mutual benefits for service providers and patients. This model emphasizes the importance of a holistic approach in ensuring the longevity and effectiveness of healthcare delivery within this domain [ 83 ]. Meanwhile, Mun et al. [ 84 ] presented a suite of five teleradiology business models aimed at providing effective, high-quality, and cost-efficient diagnoses.

The teletreatment sector saw innovative models from Kijl et al. [ 85 ], who designed a model for treating patients with chronic pain, focusing on the interrelation of components in the value network and the role of information technology. Complementarily, Fusco and Turchetti [ 86 ] introduced four models for telerehabilitation post-total knee replacement, emphasizing partnerships between care units and equipment suppliers to reduce costs and waiting lists. The mHealth and assisted living technology sector witnessed the introduction of a wearable biofeedback system model by Hidefjäll and Titkova [ 87 ], which employed Alexander Osterwalder’s Business Model Canvas and focused on a comprehensive commercialization process. Additionally, Oderanti and Li [ 88 ] presented a seven-component sustainable business model for assisted living technologies, aimed at encouraging older individuals to invest in eHealth services while reducing the pressure on health systems. These diverse clusters and models reflect the multifaceted nature of telehealth, each tailoring its approach to meet the unique demands of its domain. They collectively aim to optimize service delivery, stakeholder involvement, cost efficiency, and patient care quality, marking significant strides in the ongoing evolution of digital healthcare.

Challenges and biases in healthcare technology

One key aspect is the emergence of novel medical technologies and their potential biases. These biases are often a result of insufficient consideration of patient diversity in the development and testing phases. For example, disparities in the performance of medical devices like pulse oximeters among different racial groups have been observed, potentially due to a lack of diverse representation in clinical trials. This indicates a tendency for the development of healthcare technologies that may not adequately serve all patient populations [ 89 ]. A study on the profitability and risk-return comparison across health care industries highlights the use of return on equity (ROE) as a measure of profitability from a shareholder’s perspective. This measure combines profit margin, asset utilization, and financial leverage. The study analyzed financial data of publicly traded healthcare companies, providing insights into the financial dynamics of the healthcare sector. It revealed that while companies like Pfizer Inc. and UnitedHealth Group reported similar profitability, they had substantial differences in profit margin and asset utilization, indicating diverse financial strategies within the healthcare sector. This study underscores the complexity of financial performance in healthcare, where profitability measures need to be balanced with risk assessment and the broader impact on healthcare provision [ 90 ].

Additionally, an article discusses the benefits, pitfalls, and potential biases in healthcare AI. It emphasizes that as the healthcare industry adopts AI, machine learning, and other modeling techniques, it is seeing benefits for both patient outcomes and cost reduction. However, the industry must be mindful of managing the risks, including biases that may arise during the implementation of AI. Lessons from other industries can provide a framework for acknowledging and managing data, machine, and human biases in AI. This perspective is crucial in understanding how the integration of advanced technologies in healthcare can be influenced by the drive for profitability and efficiency, possibly at the expense of equitable and patient-centered care [ 91 ; 92 ].

Cosmeceuticals in the online pharmacy market

Cosmeceuticals, a term derived from the combination of cosmetics and pharmaceuticals, refer to a category of products that are formulated to provide both aesthetic improvements and therapeutic benefits. These products, typically applied topically, are designed to enhance the health and beauty of the skin, going beyond the mere cosmetic appearance. The exploration of cosmeceuticals in the online pharmacy market reveals a multifaceted and rapidly expanding industry. Bridging the gap between cosmetics and pharmaceuticals, they form a significant portion of the skincare industry. Cosmeceuticals are formulated from various ingredients, with their main categories being constantly discussed and analyzed in the scientific community [ 93 ]. They have taken a considerable share of the personal care industry globally, constituting a significant part of dermatologists’ prescriptions worldwide [ 94 ]. This surge is further fueled by increasing consumer demand for effective and safe products, including anti-aging skincare cosmeceuticals, a need which has been intensified by concerns over pollution, climate change, and the COVID-19 pandemic [ 95 ].

The global cosmeceuticals market is experiencing robust growth. Valued at USD 56.78 billion in 2022, it’s projected to expand to USD 95.75 billion by 2030, with a compound annual growth rate (CAGR) of 7.45%. This growth trajectory is propelled by the innovative integration of bioactive ingredients known for their medical benefits [ 96 ]. Another report confirms this upward trend, indicating the market was worth $45.56 billion in 2021 and is on a path of significant growth to USD 114 billion by 2030. The global disease burden is significantly impacted by various skin diseases, with dermatitis, psoriasis, and acne vulgaris among the most prevalent, contributing 0.38%, 0.19%, and 0.29% respectively. The pervasive nature of these conditions drives a substantial demand for effective treatments, propelling the integration of cosmeceuticals into the online pharmacy market. This integration not only offers convenient access to a range of therapeutic skincare products but also caters to the rising consumer inclination towards self-care and preventive healthcare. As a result, the online availability of cosmeceuticals is not just addressing the immediate needs of individuals suffering from skin conditions but is also reshaping the landscape of personal healthcare by making specialized treatments more accessible and customizable [ 97 ]. See Fig. 4 .

The left panel presents the market share distribution for key segments in the cosmeceuticals industry in 2021, including Skin Care Segment, and Supermarket & Specialty Stores, for Asia Pacific Revenue, with percentages for each category. The right panel displays the market value progression over time from 2021 to the projected value in 2030, with bold numbers indicating the value in billion USD for each year. The lower horizontal bar chart depicts the percentage contribution of various skin diseases to the global disease burden

Several factors are contributing to this expansion of the cosmeceuticals market. The market is driven by innovation in natural ingredients and a significant penetration of internet, smartphone, and social media applications, which attract potential consumer populations and reflect constantly changing consumer behavior [ 98 ]. The cosmeceuticals market’s robust CAGR and revenue share, especially in regions like Asia Pacific, further signify its burgeoning presence and potential within the global market [ 99 ]. Integration into online pharmacies is a key aspect of this market’s evolution, offering easier access to these products for a wider customer base. As the market continues to grow, it’s anticipated that the blend of cosmeceuticals with online pharmaceutical platforms will become increasingly seamless, offering consumers a diverse range of accessible, effective, and beneficial skincare and health products. This integration is likely to be driven by the growing trend of e-commerce and digitalization in healthcare and personal care sectors.

The landscape of online pharmacies, particularly concerning cosmeceuticals, is evolving. While the overall penetration for non-specialty drugs in mail-order and online pharmacies is low, they represent a significant portion of specialty prescription revenues at 37%. Despite this, only 13% of consumers consider these as their primary pharmacy choice, indicating a growing but still emerging market. Strategies are in place to enhance the market appeal of these pharmacies, focusing on speed, convenience, and personalized experiences, such as video telehealth visits, to attract a broader consumer base [ 100 ].

The dissertation “L’Oréal Portugal: A Digital Challenge for the Active Cosmetics Division” authored by Ascenso [ 101 ] provides an in-depth examination of the impact of digital evolution on the Portuguese cosmeceutical sector and its implications for L’Oréal, a significant cosmetics company. It posits that while L’Oréal has foundational digital competencies, the rapidly evolving digital landscape presents a broad spectrum of potential risks and opportunities. The study details the operations of L’Oréal’s Active Cosmetics Division, which manages brands predominantly sold in pharmacies and parapharmacies, and explores the potential repercussions of digitalization on L’Oréal Portugal’s strategic and operational frameworks. Furthermore, the thesis highlights the expanding role of e-pharmacies and the need for legal reforms to facilitate their operation. It discusses the prevalent trends in the cosmetic industry, such as the increasing demand for natural, male-focused, and environmentally friendly products. The dissertation scrutinizes L’Oréal’s strategic pillars, including innovation, acquisition, and regional growth, emphasizing the need for the company to integrate advanced technologies and recalibrate its business methodologies in light of digital progression [ 101 ]. Although L’Oréal has initiated some digital strategies targeting consumers and pharmacies, there’s a recognized need for an intensified focus on digital marketing aimed at clients. An exploratory attempt by L’Oréal to implement an online ordering platform for pharmacies did not meet success, indicating possible industry unreadiness for such advancements. This case study serves as a critical examination of how traditional companies in the pharmaceutical and cosmetics sectors must adapt to the digital age’s challenges and opportunities [ 101 ].

In a collaborative endeavor with L’Oréal, an associated digital agency provided a comprehensive suite of services that encompasses the full management of social media pages, the development of e-commerce websites, the establishment of Customer Relationship Management (CRM) platforms tailored for pharmacies, and the execution of digital campaigns leveraging QR codes, SMS marketing, and newsletters. These digital tools confer a competitive edge, facilitating a deeper comprehension of consumer behavior and the potential to augment value extraction from customer interactions. For the laboratories, particularly those associated with cosmetics, the advantages are twofold: an increase in sell-out figures, thereby enhancing direct sales to end consumers, and a boost in sell-in metrics, reflecting a rise in transactions to pharmacies or wholesalers. The online ordering feature, as noted by João Roma, a manager at La Roche-Posay, could result in a cacophony of processes if laboratories were to individually develop distinct methods. He advocates for the utilization of pre-existing platforms, such as the established e-learning infrastructure, to spearhead ventures into the online marketplace [ 101 ].

A survey conducted specifically for L’Oréal’s e-learning platform, cosmeticaactiva.pt [ 102 ], across the Portuguese landscape garnered responses from 324 participants, comprising 71% general pharmacists, 13% technical assistants, 8% directors, 7% individuals responsible for procurement from laboratories, and 2% beauty/cosmetic advisors. The findings from this survey underscore the pervasive adoption of digital tools within the pharmacy sector: 82% of respondents affirmed the presence of their pharmacies on social media platforms, 80% reported the use of basic management software, 64% indicated the deployment of advanced management systems, 61% were conversant with online ordering systems directed at laboratories, 38% utilized a store locator, 28% had an established website presence, and a smaller segment of 12% offered online shopping facilities.

Another survey conducted within this study to evaluate the significance of dermocosmetic products in pharmacies yielded a mean importance rating of 4.38 out of 5, indicating that a majority of pharmacists consider these products to be highly important to their business operations. Factors critical to the differentiation of a proficient laboratory/supplier were innovation and cost-effectiveness, with mean scores of 1.9 and 2.7 respectively, on a scale from 1 (most important) to 5 (least important). A substantial majority of pharmacists, amounting to 81.8%, perceive their pharmacies as beacons of innovation and modernity. Detailed interviews elucidated that digital tools are indispensable in augmenting sales for cosmeceutical products by catalyzing demand—a dynamic not feasible with medicinal products. These tools are paramount in managing customer loyalty, facilitating enhanced communication with existing clients via online and mobile channels. Despite the challenges posed by digitalization, particularly in the realms of logistics and human resources, the management at L’Oréal is well-equipped to swiftly adapt to the evolving business landscape, as evidenced by the proactive adoption and integration of these digital strategies [ 101 ] as illustrated in Fig. 5 .

Results from Ascenso [ 101 ] survey assessing digital challenges for L’Oréal in the Portuguese cosmeceutical sector. Digital Tools Usage in Pharmacies (upper left) : the bar chart showing the percentage of respondents using various digital tools in pharmacies. Suppliers’ Choosing Factors (upper right) : the bar chart displaying the mean scores of factors that distinguish a good laboratory/supplier. General Pharmacists Opinion (lower left) : A line chart illustrating the mean ratings of pharmacists’ opinions on whether the pharmaceutical sector is modern, changing, conducive to innovations, adapted to consumer needs, and more developed than other sectors. Importance of Digital Development Tools for Pharmacies (lower right) : A vertical bar chart demonstrating the mean scores for the importance of different digital development tools for pharmacies

The digital transformation strategies, exemplified by companies like L’Oréal, extend beyond the mere targeting of end consumers, encompassing the perspectives of various stakeholders, including retailers. This broadened focus reflects a holistic and integrated approach to digital marketing and customer engagement, indicative of a larger trend within the market. The significance of digital channels in facilitating comprehensive customer interaction and brand development is increasingly recognized. The distinction of organizations such as L’Oréal in their digital initiatives highlights the competitive advantage that can be garnered through innovative digital strategies.

The receptiveness of industry professionals, such as pharmacists, to emerging digital trends, along with the readiness of companies to engage in non-face-to-face sales models, marks a paradigm shift in traditional sales and distribution methods. This shift is reflective of a broader market trend where digital platforms are becoming integral to the customer journey. Furthermore, the potential for online sales in specialized sectors, such as dermocosmetics, and the benefits that organizations derive from the technological advancement of their client base, underscore an escalating acknowledgment of e-commerce and digital tools as crucial elements of a business strategy. This trend, with L’Oréal as a prime example, emphasizes the broader market movement towards digital transformation, not merely as an option but as a necessity for maintaining relevance and competitiveness in an ever-evolving market landscape.

The global regulatory landscape for cosmeceuticals

Sophisticated regulatory legislation and enforcement mechanisms characterize many developed countries such as the USA, EU Member States, Canada, and Japan. These nations, along with influential organizations like the World Health Organization (WHO), significantly shape international market rules and regulations due to their market size and regulatory capacity [ 103 ]. The WHO is particularly noted for its crucial role in setting global standards, with a focus on developing and promoting international standards related to food, biological, pharmaceutical, and similar products [ 104 ]. In contrast to pharmaceuticals, the cosmetic industry necessitates a more advanced international regulatory framework due to consumers’ extensive exposure to these products. The distinction between cosmetics and pharmaceuticals varies significantly across different countries, with the USA employing a voluntary registration system for cosmetics and the EU and Japan requiring mandatory product filings prior to marketing [ 105 ]. Concerns over the safety of pharmaceutical and cosmetic products are highlighted, with an increasing consumer focus on “natural, ecological, and clean” products [ 106 ]. However, the lack of a regulatory framework for these categories underscores the need for more advanced regulations to mitigate health risks.

Intergovernmental cooperation is emphasized, with the US and EU portrayed as dominant players in the pharmaceutical and cosmetic industries, respectively. Regulatory capacity, which is essential for defining, implementing, and monitoring market rules, varies among countries and markets. This capacity depends on several factors, including staff expertise, statutory sanctioning authority, and the degree of centralization of regulatory authority [ 103 ]. The regulatory systems of the EU and US are explored, focusing on their unique approaches to medicine authorization and regulation. The European Medicines Agency (EMA) in the EU and the Food and Drug Administration (FDA) in the US serve as pivotal regulatory bodies [ 107 ; 108 ]. The EMA’s centralized procedure and the FDA’s premarket approval process are detailed, along with subsequent postmarket regulatory procedures. For instance, EU and US cosmetic regulations are compared, revealing differences in their approaches and the evolution of the EU’s regulatory landscape through various amendments and directives. In particular, directive 76/768/EC has been superseded by Regulation (EC) N° 1223/2009, serving as the principal regulatory framework for finished cosmetic products in the EU market. This regulation enhances product safety, optimizes the sector’s framework, and eases procedures to promote the internal cosmetic market. Incorporating recent technological advancements, including nanomaterials, it maintains an internationally acknowledged regime focused on product safety without altering existing animal testing prohibitions [ 109 ].

The Eurasian Economic Union’s (EAEU) regulatory framework for medicines and medical devices is detailed, including the legal framework established for regulating the circulation of these products. The conformity assessment methods, such as the EAC Declaration and the State Registration process, are required for manufacturers to demonstrate their products’ compliance with the standards [ 110 ]. Armenia is also part of the EAEU’s legal framework, which aims to unify regulations for the production and registration of pharmaceuticals and medical products by 2025. This unification is expected to reduce administrative costs for manufacturers and improve medicinal products for patients. Despite significant developments in the cosmetics industry, Armenia does not have an extensive regulatory framework for it. Prior to joining the EAEU, the only regulation concerning cosmetic products was the Order of the Minister of Health of the Republic of Armenia on “Hygiene Requirements of the Production and Safety of Perfume-Cosmetic Products.” Since joining the EAEU, Armenia has unified its national legislation with EAEU regulations, but there are challenges and gaps in the direct applicability of the EAEU’s technical regulations in the country [ 111 ].

In the context of the necessity for clear regulatory framework stems from two reasons. Firstly, cosmeceuticals - products straddling cosmetics and drugs - demand intensified regulatory attention. Examples include the 2007 FDA seizure of Jan Marini’s Age Intervention Eyelash, which contained the drug ingredient bimatoprost, and products boasting human stem cell cultured media, which claim rejuvenating effects but may pose safety risks due to minimal oversight [ 112 ]. A noted 1450% increase in FDA warnings (from 4 to 62 letters) between 2007 and 2011 and 2012–2017, with 8 targeting stem cell ingredient promotions, underscores the growing concern [ 113 ]. The FDA’s limited capacity to identify and assess potential drug-adulterated cosmetics raises concerns.

The second aspect focuses on the necessity for a more comprehensive and unbiased scientific and medical perspective in the FDA’s ingredient review process. The Personal Care Products Safety Act proposes a balanced committee formation including industry, consumer, and medical representatives, yet advocates for the inclusion of specialized professionals like chemists, dermatologists, toxicologists, and endocrinologists. Specific ingredients like diazolidinyl urea and quarternium-15, although effective antimicrobials, are flagged for potential skin allergy risks and formaldehyde release. The preservative 4-methylisothiazolinone, banned in Europe for rinse-off products, is noted for increasing allergic contact dermatitis cases in the US [ 114 ]. The lag in US cosmetic regulation compared to the EU is acknowledged, with the Personal Care Products Safety Act considered a significant advancement, albeit in need of further refinement [ 115 ].

The importance of consumer safety in the global regulatory landscape for cosmeceuticals, particularly for products that blur the line between cosmetics and pharmaceuticals, is a critical issue due to several key factors. Firstly, the cosmeceutical market is expanding rapidly, driven by new ingredients promising various skincare benefits like anti-aging and photoprotection. This growth necessitates clear regulatory guidelines to ensure that these products are safe and their claims are clinically proven. The FDA, for instance, differentiates between cosmetics and cosmeceuticals based on their intended use, particularly if a product is marketed as a cosmetic but functions in a way that affects the structure of the human body, classifying it as a cosmeceutical [ 116 ].

Secondly, the legal and regulatory distinctions between drugs and cosmetics are significant. Drugs are subject to FDA approval based on their intended use in treating diseases or affecting the body’s structure or function, whereas cosmetics are not. This difference becomes crucial when products are marketed with drug-like claims but are not regulated as drugs, potentially leading to consumer safety issues. For example, botanical cosmeceuticals, which contain natural ingredients like herbal extracts, need thorough evaluation to ensure consistency in therapeutic effects [ 117 ]. Additionally, cosmeceutical manufacturers must be careful with marketing and advertising claims to avoid legal implications. Misleading claims can lead to lawsuits and regulatory actions, as seen in past cases where companies faced consequences for unfounded product claims. Moreover, the FDA advises cosmeceutical manufacturers to follow Good Manufacturing Practices (GMP) to reduce the risk of misbranding or mislabeling. These guidelines include production practices and specific warning statement guidelines, emphasizing the importance of substantiating the safety of these products [ 118 ].

The global regulatory landscape for online pharmacy

Online pharmacies pose various risks to consumers, including the potential health hazards from counterfeit or substandard medications and the inappropriate use of prescription drugs. The regulatory landscape for these pharmacies varies significantly across nations, with some countries like the United States implementing specific laws, while others, such as France, have instituted outright bans [ 119 ]. The European Union, for instance, has implemented a mandate effective from 1 July 2015, which requires member states to adhere to legal provisions for a common logo specific to online pharmacies. This is coupled with an obligation for national regulatory authorities to maintain a registry of all registered online medicine retailers, as detailed by the European Medicines Agency [ 120 ]. Furthermore, the sale of certain medications online within the EU is permissible, contingent upon the registration of the pharmacy or retailer with respective national authorities [ 121 ]. Additionally, the Council of Europe’s MEDICRIME Convention introduces an international treaty that criminalizes the online sale of counterfeit medicinal products, enforcing prosecution irrespective of the country in which the crime is perpetrated [ 122 ].

Switzerland presents a unique stance, where Swissmedic strongly advises against the online purchase of medicines due to the high risk of illegal sourcing and poor quality. However, Swiss mail-order pharmacies with a valid cantonal license to operate a mail-order business are exempted from this advisory [ 123 ]. The Swiss Mail-Order Pharmacists Association and its affiliates, such as Zur Rose AG and MediService AG, actively advocate for a modern and equitable regulation of mail-order medicine sales [ 124 ]. The legislative framework is further bolstered by the Federal Act on Medicinal Products and Medical Devices, which regulates therapeutic products to guarantee their quality, safety, and efficacy [ 125 ]. In the Middle East, community pharmacy practice is predominantly governed by national Ministries of Public Health or equivalent governmental entities, with most community pharmacies being privately owned [ 126 ]. The region’s involvement in the Global Cooperation Group, which encompasses various international regulatory bodies like the EMA and USFDA, signifies a collaborative approach towards drug regulatory affairs in the MENA region [ 127 ]. Despite these advances in regulatory collaboration, it is notable that currently no specific regulations have been detected for online purchases from online pharmacies in the Middle East, highlighting a significant area for potential regulatory development. Furthermore, a notable transition is observed in pharmacy education across several Middle Eastern nations, with an inclination towards introducing Pharm.D degrees to replace traditional pharmacy degrees, reflective of evolving educational standards in the pharmaceutical field [ 128 ]. This shift in education parallels the need for updated regulatory frameworks, especially in the context of the burgeoning online pharmacy sector.

Furthermore, Australia permits the sale of both Prescription-Only Medicines (POMs) and Over-the-Counter (OTC) medications online, provided that brick-and-mortar pharmacies comply with all relevant laws and practice standards [ 129 ]. In contrast, South Korea maintains a stringent stance, prohibiting the online sale of both POMs and OTC medicines, with sales confined exclusively to physical stores registered with the Regulatory Authority (RA) [ 130 ]. China, Japan, Russia, Singapore, and Malaysia exhibit a more selective regulatory framework. China and Russia allow the online sale of OTC medicines only, with China imposing additional restrictions on third-party e-commerce platforms and Russia having introduced a draft law in December 2017 to formalize this practice [ 131 ; 132 ]. Japan permits the online sale of certain OTC medicines, explicitly excluding specific substances such as fexofenadine and loratadine [ 133 ]. Similarly, Singapore and Malaysia endorse the online sale of specific OTC medicines only, adopting a “buyers beware” approach to caution consumers about the associated risks [ 134 ; 135 ]. Lastly, the legal landscapes in India and Indonesia remain ambiguous. India’s RA has effectively banned the online sale of medicinal products, yet this prohibition lacks legislative backing. Indonesia, too, grapples with unclear regulations, leaving the legal status of online pharmacies indeterminate [ 136 ].

In response to these risks, several initiatives have been developed to guide and certify online pharmacies. In the United States, LegitScript offers certification to online pharmacies that comply with criteria such as appropriate licensing and registration [ 137 ]. Similarly, the Verified Internet Pharmacy Practice Sites (VIPPS) program, accredited by the National Association of Boards of Pharmacy, ensures pharmacies adhere to licensing requirements in the states where they dispense medications [ 138 ]. Internationally, the Health On the Net Foundation has introduced the HONcode, an ethical standard for health websites globally. This code certifies sites that provide transparent and qualified information. However, due to the absence of international harmonization, the HONcode’s certification is limited to US and Canadian pharmacies verified by VIPPS [ 139 ]. The lack of a harmonized international approach presents significant challenges. Consumers do not have access to a comprehensive, global repository of all certified pharmacies. The diverse certification schemes are not well articulated or interconnected, leading to consumer unawareness about their significance or existence. Moreover, enforcing standards across different legal jurisdictions is complex without a unified agreement. To enhance consumer protection, it is imperative to develop and promote a standardized, minimal international code of conduct for online pharmacies. Such a code would unify requirements and allow all initiatives to clarify their roles under a common framework. Adequate oversight in the borderless online pharmacy market can only be achieved through collaborative efforts. To visualize the infographic of the global regularity landscape for the online pharmacy see Fig. 6 .

Comprehensive representation of the regulatory landscape for global online pharmacies, detailing international and national initiatives, certification programs, and conventions aimed at minimizing risks associated with the purchase of medications via online platforms

Technological innovations and Future trends in global pharmacy

The global pharmacy sector is undergoing a transformative shift, driven by the rapid advancement of technological innovations. As the world becomes increasingly digital, the integration of cutting-edge technologies like Artificial Intelligence (AI) and blockchain is setting the stage for a new era in pharmaceutical care and management. These advancements promise to revolutionize the industry by enhancing efficiency, accuracy, and security, ultimately leading to improved patient outcomes and a more streamlined healthcare experience [ 140 ].

Walgreens, in partnership with Medline, a telehealth firm, has developed a platform for patient interaction with healthcare professionals via video chat. AI’s role extends to inventory management in retail pharmacies, allowing pharmacists to predict patient needs, stock appropriately, and use personalized software for patient reminders. Although not all inventory management software in retail pharmacies utilizes AI, some, like Blue Yonder’s software developed for Otto group, demonstrate the potential of AI in predicting product sales with high accuracy, thus enhancing supply chain efficiency [ 141 ; 142 ]. At the University of California San Francisco (UCSF) Medical Center, robotic technology is employed to improve patient safety in medication preparation and tracking. This technology has prepared medication doses with a notable error-free record and surpasses human capabilities in accuracy and efficiency. It prepares both oral and injectable medicines, including chemotherapy drugs, freeing pharmacists and nurses to focus on direct patient care. The automated system at UCSF receives electronic medication orders, with robotics handling the picking, packaging, and dispensing of individual doses. This system also assembles medications on bar-coded rings for 12-hour patient intervals and prepares sterile preparations for chemotherapy and intravascular syringes [ 143 ].

In the realm of global pharmacy, blockchain technology emerges as a pivotal force, driving advancements across various facets of healthcare and pharmaceuticals. At the forefront of its application is the enhancement of supply chain transparency [ 144 ]. Blockchain’s immutable ledger ensures the provenance and legitimacy of medical commodities, offering an unprecedented level of visibility from manufacturing to distribution. This is particularly vital in areas plagued by counterfeit drugs, where systems like MediLedger are instrumental in verifying the legality and essential details of medicines [ 145 ].

The utility of blockchain extends to the implementation of smart contracts — scripts processed on the blockchain that bolster transparency in medical studies and secure patient data management [ 146 ]. These contracts find extensive use in advanced medical settings, as evidenced by a blockchain-based telemonitoring system for remote patients and Dermonet, an online platform for dermatological consultation [ 147 ].

Furthermore, blockchain is revolutionizing patient care through patient-centric Electronic Health Records (EHRs). By decentralizing EHR maintenance, blockchain empowers patients with secure access to their historical and current health records [ 148 ]. Prototypes like MedRec and systems such as MeD Share exemplify how blockchain can provide complete, permanent access to clinical documents and facilitate the sharing of medical data between untrusted parties, respectively, ensuring high information authenticity and minimal privacy risks [ 149 ; 150 ]. In verifying medical staff credentials, blockchain again proves invaluable. Systems like ProCredEx, based on the R3 Corda blockchain protocol, streamline the credentialing process, offering rapid verification while allowing healthcare entities to leverage their existing data for enhanced transparency and assurance about medical staff experience [ 151 ].

The integration of blockchain with Internet of Things devices for remote monitoring marks another leap forward, significantly bolstering data security. By safeguarding the integrity and privacy of patient data collected by these devices, blockchain mitigates the risk of tampering and ensures that only authorized parties can access sensitive information [ 152 ]. Besides, a blockchain-based drug supply chain initiative, PharmaChain, utilizes AI for approaches against drug counterfeit and ensures the drug supply chain is more traceable, visible, and secure. For online pharmacies, this means a more reliable supply chain and assurance of drug authenticity, crucial for maintaining trust and safety [ 153 ].

In response to the COVID-19 pandemic, the PharmaGo platform has emerged as an innovative solution in Sri Lanka, revolutionizing the delivery of pharmacy services. As traditional pharmacies grapple with the challenges of meeting all customer needs in one location, PharmaGo addresses this by providing a comprehensive online pharmaceutical service. It allows customers to access a wide range of medications through a single platform, reducing the need to visit multiple pharmacies. Utilizing image processing technology, pharmacy owners can accurately identify prescribed medicines, while the system’s predictive analytics forecasts future drug demands, enhancing stock management. Additionally, PharmaGo’s AI-powered medical chatbot offers real-time guidance, ensuring a seamless and efficient customer experience. This platform represents a significant advancement in healthcare accessibility and pharmacy service delivery in the pandemic era [ 154 ]. In the same context, ontology-based medicine information system, enhancing search relevance through a chatbot interface was presented by Amalia et al. [ 155 ]. Addressing conventional search engines’ limitations in interpreting data relationships, it employs semantic technology to represent metadata informatively. The ontology as a knowledge base effectively delineates disease-medicine relationships, with evaluations indicating a 90% response validity from the chatbot, offering a robust reference for medical information retrieval and its semantic associations.

Future trends for the digital transformation of in the pharmaceutical sector

Future trends for the digital transformation of pharmacies globally are heavily influenced by the transformative impact of digital technologies on healthcare delivery. The integration of telemedicine, electronic health records, and mobile health applications is pivotal in enhancing patient care. These technologies are instrumental in improving data sharing and collaboration among healthcare professionals, increasing the efficiency of healthcare services. Additionally, they offer significant potential for personalized medicine through data analytics and play a crucial role in patient engagement and self-management of health. The importance of these technologies in creating a more connected and efficient healthcare system is underscored, marking a significant shift in the global healthcare landscape [ 156 ].

In the pharmaceutical sector, the COVID-19 pandemic has catalyzed a significant shift towards Pharmaceutical Digital Marketing (PDM), particularly for over-the-counter drugs. This shift focuses on utilizing online pharmacies and digital platforms for targeted advertising, directly reaching consumers. The trend towards purchasing OTC drugs online has grown, driven by the convenience and efficiency of digital channels. While PDM faces challenges like regulatory constraints and the need for digital proficiency, it offers substantial opportunities in enhancing customer engagement and precise marketing. The future of PDM is poised to be more consumer-centric, integrating advanced technologies like AI, and emphasizing personalized marketing strategies to strengthen brand engagement and customer interaction [ 157 ].

Artificial intelligence holds immense potential to revolutionize the field of pharmacy, offering numerous benefits that can significantly enhance efficiency and patient care. One of the primary applications of AI in this sector is the automation of routine tasks. By utilizing AI, pharmacies can automate critical processes such as prescription processing, checking for drug interactions, and managing inventory. This automation not only streamlines operations but also minimizes the likelihood of human error, thereby increasing the overall efficiency of pharmacies [ 158 ].

Furthermore, AI can play a pivotal role in personalized medication management. This is particularly beneficial for patients with chronic conditions such as diabetes who require careful management of their insulin dosages, as fluctuations in blood sugar levels can lead to serious complications. AI systems can monitor patients continuously, provide timely reminders for medication intake, and dynamically adjust treatment plans based on individual health data. Such personalized management ensures that patients receive optimal care tailored to their specific needs, potentially improving treatment outcomes. Incorporation of AI into electronic health records presents another significant advancement. By integrating AI with EHRs, healthcare providers can access real-time patient data. This integration empowers healthcare professionals to make more informed care decisions, enhancing the quality of patient care. Moreover, it significantly reduces the likelihood of medication errors, a critical concern in healthcare.

Likewise, AI’s capability to analyze extensive patient data is invaluable. It can identify patterns and trends in medication adherence, detect potential drug interactions, and pinpoint adverse drug reactions. These insights are crucial for healthcare professionals and researchers. By understanding these patterns, they can develop more effective medication adherence strategies and support systems, contributing to better patient outcomes and advancing the overall field of pharmaceutical care.

In the expansive realm of chemical space, the pharmaceutical industry faces the continual challenge of identifying new active pharmaceutical ingredients (APIs) for diverse diseases [ 159 ]. High throughput screening (HTS), despite its advancements in recent decades, remains resource-intensive and often yields unsuitable hits for drug development. The failure rate of investigational compounds remains high, with a study citing only a 6.2% success rate for orphan drugs progressing from phase I to market approval [ 160 , 161 ].

Machine learning presents a transformative approach to this challenge. It offers an alternative to manual HTS through in silico methodologies. ML-driven drug discovery boasts several advantages: it operates continuously, surpasses the capacity of manual methods, reduces costs by decreasing the number of physical compounds tested, and early identifies negative characteristics of compounds, such as off-target effects and sex-dependent variability [ 162 ].

A substantial advancement in the realm of machine learning has emerged from major pharmaceutical entities, notably AstraZeneca, in conjunction with research institutions. This progress is evidenced by the development of an innovative algorithm that demonstrates both time efficiency and effectiveness in the sphere of drug discovery. The recent introduction of this algorithm significantly enhances the process of determining binding affinities between investigational compounds and therapeutic targets. It surpasses traditional in silico methods in terms of performance. The application of this algorithm underscores the remarkable potential of machine learning in accelerating the identification and development of novel therapeutic agents [ 163 ].

Moreover, the proficiency of machine learning in managing vast and intricate datasets has rendered it indispensable in research focused on cancer targets, utilizing diverse and extensive datasets. This approach is fundamental in numerous drug discovery initiatives, especially those targeting various forms of cancer. A wide array of ML techniques, ranging from supervised to unsupervised learning, are employed to discern chemical attributes that are indicative of potential therapeutic efficacy against a spectrum of cancer targets. This methodology is crucial in identifying novel compounds that could be effective in cancer treatment, leveraging the rich and complex data available in oncological research [ 164 ].

The digital transformation in the pharmacy sector is significantly reshaping healthcare delivery, driven by the integration of cutting-edge technologies like Artificial Intelligence and blockchain. This transformation is marked by a substantial growth in the digital pharmacy market, with a projected annual growth rate of 14.42%, leading to a market volume of approximately $35.33 billion by 2026.

One major aspect of this transformation is the growing reliance on online pharmacy platforms, largely influenced by the COVID-19 pandemic. Consumer trust in online medication purchases has significantly increased, indicating a shift towards digital healthcare solutions. The adoption of telehealth services, including telepharmacy, has surged, with patient adoption in the United States increasing from 11% in 2019 to 46%. This shift towards digital-first services enhances convenience and access to care but also introduces regulatory challenges, particularly in maintaining patient safety and quality standards in the rapidly evolving online healthcare environment.

The cosmeceuticals market, a segment within online pharmacies, is experiencing robust growth. Cosmeceuticals, which bridge the gap between cosmetics and pharmaceuticals, have become a significant part of the skincare industry. The market, valued at USD 56.78 billion in 2022, is projected to expand to USD 95.75 billion by 2030. This expansion is driven by factors like innovation in natural ingredients and significant penetration of internet, smartphone, and social media applications. Despite the growth, the overall penetration for non-specialty drugs in mail-order and online pharmacies remains low, representing a significant portion of specialty prescription revenues. The evolving landscape of online pharmacies in the cosmeceuticals sector reflects a trend towards more accessible and customizable personal healthcare solutions.

Technological innovations are setting the stage for a new era in pharmaceutical care and management. AI’s role extends to areas like inventory management in retail pharmacies, where it predicts patient needs and enhances supply chain efficiency. Blockchain technology enhances supply chain transparency and legitimizes medical commodities, especially crucial in areas affected by counterfeit drugs. Blockchain also plays a vital role in patient-centric Electronic Health Records and telemonitoring systems. For instance, PharmaGo, an innovative platform developed in response to the pandemic, provides a comprehensive online pharmaceutical service, demonstrating the significant advancements in healthcare accessibility and pharmacy service delivery.

These technological advancements are instrumental in improving data sharing and collaboration among healthcare professionals. They offer significant potential for personalized medicine through data analytics, playing a crucial role in patient engagement and self-management of health. The future trends in the pharmaceutical sector, particularly influenced by the COVID-19 pandemic, indicate a shift towards Pharmaceutical Digital Marketing (PDM) and a more consumer-centric approach. AI’s potential in revolutionizing pharmacy includes automation of routine tasks, personalized medication management, real-time patient data access, and the identification of patterns in medication adherence and potential drug interactions.

Data availability

No datasets were generated or analysed during the current study.

Hole G, Hole AS, McFalone-Shaw I. Digitalization in pharmaceutical industry: what to focus on under the digital implementation process? Int J Pharmaceutics: X. 2021;3:100095.

CAS Google Scholar

Shambhavi. Digital Pharmacy on the rise: transforming the Pharma Sector. Brillio.com; Oct. 2022.

Champagne HA, Leclerc D. O., The road to digital success in pharma [Internet]. https://www.mckinsey.com/industries/life-sciences/our-insights/the-road-to-digital-success-in-pharma# ~:text=Mobile%20communications%2 C%20the%20cloud%2 C%20advanced,media%2 C%20retail%2 C%20and%20banking%20industries, August 1, 2015.

COVID-19 accelerated. digital transformation of the pharma industry by five years: Poll, Available from: http://www.pharmaceutical-technology.com/news/covid-19-accelerated-digital-transformation-of-the-pharma-industry-by-five-years-poll/#:~:text=Digital%20transformation%20in%20the%20pharmaceutical,powerful%20analytics%20than%20ever%20before?cf-view&acf-closed , March 9, 2021.

Raza MA, Aziz S, Noreen M, Saeed A, Anjum I, Ahmed M, Raza SM. Artificial Intelligence (AI) in pharmacy: an overview of innovations. INNOVATIONS Pharm 13 (2022).

Zhang X. Investment analysis based on intrinsic value in the Information Technology and Pharmaceutical sectors for advancements in Digital Healthcare. Finance Econ 1 (2023).

Clark M, Clark T, Bhatti A, Aungst T. The rise of digital health and potential implications for pharmacy practice. J Contemp Pharm Pract. 2017;64:32–40.

Article Google Scholar

Health C, Pharmacy CVS. USA, 2023.

MyChart. Epic’s MyChart software system, USA, 2023.

Medisafe MD, Companion. USA, 2023.

Moodle. Moodle open source learning management system, USA, 2023.

PLUS SG. SimMan 3G PLUS advanced emergency care patient simulators, USA, 2023.

Association AP. American Pharmacists Association, USA, 2023.

Fittler A, Ambrus T, Serefko A, Smejkalová L, Kijewska A, Szopa A, Káplár M. Attitudes and behaviors regarding online pharmacies in the aftermath of COVID-19 pandemic: at the tipping point towards the new normal. Front Pharmacol. 2022;13:1070473.

Article PubMed PubMed Central Google Scholar

Hiskey O. The era of telehealth pharmacy practice. J Am Pharmacists Association. 2022;62:10–1.

Plantado ANR, de Guzman HJd, Mariano JEC, Salvan MRAR, Benosa CAC, Robles YR. Development of an online telepharmacy service in the Philippines and analysis of its usage during the COVID-19 pandemic. J Pharm Pract. 2023;36:227–37.

Article PubMed Google Scholar

Zhang PC. The future of pharmacy is intertwined with digital health innovation. Can Pharmacists Journal/Revue Des Pharmaciens Du Can. 2022;155:7–8.

Miller R, Wafula F, Onoka CA, Saligram P, Musiega A, Ogira D, Okpani I, Ejughemre U, Murthy S, Garimella S. When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries. BMJ Global Health 6 (2021).

Shawaqfeh MS, Al Bekairy AM, Al-Azayzih A, Alkatheri AA, Qandil AM, Obaidat AA, Harbi SA, Muflih SM. Pharmacy students perceptions of their distance online learning experience during the COVID-19 pandemic: a cross-sectional survey study. J Med Educ Curric Dev. 2020;7:2382120520963039.

Lee CY, Lee SWH. Impact of the educational technology use in undergraduate pharmacy teaching and learning–A systematic review. Pharm Educ. 2021;21:159–68.

Strawbridge J, Hayden JC, Robson T, Flood M, Cullinan S, Lynch M, Morgan AT, O’Brien F, Reynolds R, Kerrigan SW. Educating pharmacy students through a pandemic: reflecting on our COVID-19 experience. Res Social Administrative Pharm. 2022;18:3204–9.

Lin B, Wu S. Digital transformation in personalized medicine with artificial intelligence and the internet of medical things. OMICS. 2022;26:77–81.

Article CAS PubMed Google Scholar

Company M. Trends disrupting pharmacy value pools and potential implications for the value chain, 2018.

Stoumpos AI, Kitsios F, Talias MA. Digital Transformation in Healthcare: Technology Acceptance and its applications. Int J Environ Res Public Health. 2023;20:3407.

Kraus S, Schiavone F, Pluzhnikova A, Invernizzi AC. Digital transformation in healthcare: analyzing the current state-of-research. J Bus Res. 2021;123:557–67.

Jefferies JG, Bishop S, Hibbert S. Customer boundary work to navigate institutional arrangements around service interactions: exploring the case of telehealth. J Bus Res. 2019;105:420–33.

Patrício L, Teixeira JG, Vink J. A service design approach to healthcare innovation: from decision-making to sense-making and institutional change. AMS Rev. 2019;9:115–20.

Hong KS, Lee D. Impact of operational innovations on customer loyalty in the healthcare sector. Service Bus. 2018;12:575–600.

Laurenza E, Quintano M, Schiavone F, Vrontis D. The effect of digital technologies adoption in healthcare industry: a case based analysis. Bus Process Manage J. 2018;24:1124–44.

Mazor I, Heart T, Even A. Simulating the impact of an online digital dashboard in emergency departments on patients length of stay. J Decis Syst. 2016;25:343–53.

Rubbio I, Bruccoleri M, Pietrosi A, Ragonese B. Digital health technology enhances resilient behaviour: evidence from the ward. Int J Oper Prod Manage. 2020;40:34–67.

Hikmet N, Bhattacherjee A, Menachemi N, Kayhan VO, Brooks RG. The role of organizational factors in the adoption of healthcare information technology in Florida hospitals. Health Care Manag Sci. 2008;11:1–9.

Agarwal R, Gao G, DesRoches C, Jha AK. Research commentary—the digital transformation of healthcare: current status and the road ahead. Inform Syst Res. 2010;21:796–809.

Cucciniello M, Lapsley I, Nasi G. Managing health care in the digital world: a comparative analysis. Health Serv Manage Res. 2016;29:132–42.

Eden R, Burton-Jones A, Casey V, Draheim M. Digital transformation requires workforce transformation. MIS Q Exec. 2019;18:1–17.

Google Scholar

Huber C, Gärtner C. Digital transformations in healthcare professionals’ work: Dynamics of autonomy, control and accountability. Manage Revue. 2018;29:139–61.

Burtch G, Chan J. Investigating the relationship between medical crowdfunding and personal bankruptcy in the United States: evidence of a digital divide. MIS Quarterly (Forthcoming; 2018.

Seddon JJJM, Currie WL. Healthcare financialisation and the digital divide in the European Union: narrative and numbers. Inf Manag. 2017;54:1084–96.

Marques IC, Ferreira JJ. Digital transformation in the area of health: systematic review of 45 years of evolution. Health Technol. 2020;10:575–86.

Naik N, Hameed B, Sooriyaperakasam N, Vinayahalingam S, Patil V, Smriti K, Saxena J, Shah M, Ibrahim S, Singh A. Transforming healthcare through a digital revolution: a review of digital healthcare technologies and solutions. Front Digit Health. 2022;4:919985.

Canada. Virtual care policy framework, Canada, 2023.

Dhaliwall S. Telepharmacy services in Canada. Canada: Hospital News; 2018.

Telehealth HHSgov. Telehealth services in the United States, USA, 2023.

HRSA. Health Resources & Services Administration, USA, 2023.

UK.digital. health, Digital health and care, UK, 2023.

Australia AT, Services. Australia, 2023.

Imenokhoeva M. Telehealth in the European Union: Improving Access to Healthcare, HIMSS, EU, 2020.

Lucy d’Arville, Boulton A, Kapur V. Asia Pacific, Telehealth Adoption is expected to soar through 2024. BIAN and Company; 2022.

Intan Sabrina M, Defi IR. Telemedicine guidelines in South East Asia—a scoping review. Front Neurol. 2021;11:581649.

Wolf.Theiss. Telemedicine– the future of healthcare in Central and Eastern Europe, 2022.

Al-Samarraie H, Ghazal S, Alzahrani AI, Moody L. Telemedicine in Middle Eastern countries: Progress, barriers, and policy recommendations. Int J Med Informatics. 2020;141:104232.

Mahdi AlBasri H, Elwan P, Georgiev, Ustun A. Growth opportunities for digital health in KSA and UAE. McKinsey: McKinsey; 2022.

Ibrahim OM, Ibrahim RM, Al Meslamani AZ, Al Mazrouei N. Role of telepharmacy in pharmacist counselling to coronavirus disease 2019 patients and medication dispensing errors. J Telemed Telecare. 2023;29:18–27.

Unni EJ, Patel K, Beazer IR. Hung, Telepharmacy during COVID-19: a scoping review. Pharmacy. 2021;9:183.

Leila Shafiee Hanjani JS, Bell, Freeman CR. Undertaking medication review by telehealth. Australian J Gen Pract. 2020;49:826–31.

Bejarano AP, Santos PV, Robustillo-Cortés MdlA, Gómez ES, Rubio MDS. Implementation of a novel home delivery service during pandemic. Eur J Hosp Pharm (2020) ejhpharm–2020.

Elson EC, Oermann C, Duehlmeyer S, Bledsoe S. Use of telemedicine to provide clinical pharmacy services during the SARS-CoV-2 pandemic. Am J Health-System Pharm. 2020;77:1005–6.

Li H, Zheng S, Liu F, Liu W, Zhao R. Fighting against COVID-19: innovative strategies for clinical pharmacists. Res Social Administrative Pharm. 2021;17:1813–8.

Margusino-Framiñán L, Illarro-Uranga A, Lorenzo-Lorenzo K, Monte-Boquet E, Márquez-Saavedra E, Fernández-Bargiela N, Gómez-Gómez D, Lago-Rivero N, Poveda-Andrés JL, Díaz-Acedo R, Hurtado-Bouza JL, Sánchez-Gundín J, Casanova-Martínez C. Morillo-Verdugo, Pharmaceutical care to hospital outpatients during the COVID-19 pandemic. Telepharmacy Farmacia Hospitalaria. 2020;44:61–5.

PubMed Google Scholar

Hua X, Gu M, Zeng F, Hu H, Zhou T, Zhang Y, Shi C. Pharmacy administration and pharmaceutical care practice in a module hospital during the COVID-19 epidemic. J Am Pharmacists Association. 2020;60:431–e4381.

Asseri AA, Manna MM, Yasin IM, Moustafa MM, Roubie FM, El-Anssasy SM, Baqawie SK. Implementation and evaluation of telepharmacy during COVID-19 pandemic in an academic medical city in the Kingdom of Saudi Arabia: paving the way for telepharmacy. World J Adv Res Reviews. 2020;7:218–26.

Segal EM, Alwan L, Pitney C, Taketa C, Indorf A, Held L, Lee KS, Son M, Chi M, Diamantides E, Gosser R. Establishing clinical pharmacist telehealth services during the COVID-19 pandemic. Am J Health-System Pharm. 2020;77:1403–8.

Bukhari N, Rasheed H, Nayyer B, Babar Z-U-D. Pharmacists at the frontline beating the COVID-19 pandemic. J Pharm Policy Pract. 2020;13:8.

Smith RF. The private sector is taking the lead on enabling digital inclusion. Here’s how. in: W.E. Forum, editor, World Economic Forum, 2021.

Dal Mas F, Massaro M, Rippa P, Secundo G. The challenges of digital transformation in healthcare: an interdisciplinary literature review, framework, and future research agenda. Technovation. 2023;123:102716.

Ianculescu M, Alexandru A. Microservices–A Catalyzer for Better Managing Healthcare Data Empowerment. Stud Inf Control. 2020;29:231–42.

López-Martínez F, Núñez-Valdez ER, García-Díaz V, Bursac Z. A case study for a big data and machine learning platform to improve medical decision support in population health management. Algorithms. 2020;13:102.

Ganapathy K, Reddy S. Technology enabled remote healthcare in public private partnership mode: A story from India. Telemedicine, Telehealth and Telepresence: Principles, Strategies, Applications, and New Directions (2021) 197–233.

Gleiss A, Kohlhagen M, Pousttchi K. An apple a day–how the platform economy impacts value creation in the healthcare market. Electron Markets. 2021;31:849–76.

Bonacina S, Koch S, Meneses I, Chronaki C. Can the European EHR exchange format support shared decision making and citizen-driven health science? Public Health and Informatics, IOS; 2021. pp. 1056–60.

Samuel L, TRANSFORMING THE HEALTHCARE SYSTEM: THE PUBLIC-PRIVATE HEALTHCARE DICHOTOMY IN INDIA IN THE ERA OF DIGITAL HEALTH., Proceedings of the International Conference on Public Health, 2020, pp. 18–31.

Antarsih NR, Setyawati SP, Ningsih S, Sulaiman E, Pujiastuti N. Telehealth Business Potential in Indonesia, International Conference on Social, Economics, Business, and Education (ICSEBE 2021), Atlantis Press, 2022, pp. 73–78.

Loccioni LG. Italy, 2023.

Casprini E, Palumbo R. Reaping the benefits of digital transformation through Public-Private Partnership: A service ecosystem view applied to healthcare. Global Public Policy Gov. 2022;2:453–76.

APOTECAchemo. APOTECAchemo Advanced Robotic Chemotherapy Drug Compounding Systems, Italy, 2023.

Velayati F, Ayatollahi H, Hemmat M, Dehghan R. Telehealth business models and their components: systematic review. J Med Internet Res. 2022;24:e33128.

Barker GP, Krupinski EA, McNeely RA, Holcomb MJ, Lopez AM, Weinstein RS. The Arizona telemedicine program business model. J Telemed Telecare. 2005;11:397–402.

Lee Y-L, Chang P. Modeling a mobile health management business model for chronic kidney disease, Nursing Informatics 2016, IOS Press, 2016, pp. 1047–1048.

Dijkstra SJ, Jurriëns JA, van der Mei RD. A business model for telemonitoring services, 14th Annual High Technology Small Firms Conference, HTSF 2006, University of Twente, 2006.

Grustam AS, Vrijhoef HJ, Poulikidis V, Koymans R, Severens JL. Extending the business-to-business (B2B) model towards a business-to-consumer (B2C) model for telemonitoring patients with chronic heart failure. J Bus Models. 2018;6:106–29.

Lin T-C, Chang H-J, Huang C-C. An analysis of telemedicine in Taiwan: a business model perspective. Int J Gerontol. 2011;5:189–92.

Peters C, Blohm I, Leimeister JM. Anatomy of successful business models for complex services: insights from the telemedicine field. J Manage Inform Syst. 2015;32:75–104.

Lin S-H, Liu J-H, Wei J, Yin W-H, Chen H-H, Chiu W-T. A business model analysis of telecardiology service. Telemedicine e-Health. 2010;16:1067–73.

Mun SK, Tohme WG, Platenberg RC, Choi I. Teleradiology and emerging business models. J Telemed Telecare. 2005;11:271.

Kijl B, Nieuwenhuis LJ, Veld RM, Hermens HJ. and M.M. Vollenbroek-Hutten, Deployment of e-health services–a business model engineering strategy. Journal of telemedicine and telecare 16 (2010) 344–353.

Fusco F, Turchetti G, Interactive Business Models for Telerehabilitation after Total Knee Replacement.: Preliminary Results from Tuscany, Bioinformatics and Biomedical Engineering: Third International Conference, IWBBIO 2015, Granada, Spain, April 15–17, 2015. Proceedings, Part II 3, Springer, 2015, pp. 502–511.

Hidefjäll P, Titkova D. Business model design for a wearable biofeedback system, pHealth, 2015, pp. 213–224.

Oderanti FO, Li F. A holistic review and framework for sustainable business models for assisted living technologies and services. Int J Healthc Technol Manage. 2016;15:273–307.

Valbuena VS, Seelye S, Sjoding MW, Valley TS, Dickson RP, Gay SE, Claar D, Prescott HC, Iwashyna TJ. Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study. BMJ 378 (2022).

Bai G, Rajgopal S, Srivastava A, Zhao R. Profitability and risk-return comparison across health care industries, evidence from publicly traded companies 2010–2019. PLoS ONE. 2022;17:e0275245.

Article CAS PubMed PubMed Central Google Scholar

McCall CJ, DeCaprio D, Gartner J. The Measurement and Mitigation of Algorithmic Bias and Unfairness in Healthcare AI Models Developed for the CMS AI Health Outcomes Challenge. medRxiv (2022) 2022.09. 29.22280537.

Hsueh P-YS. Ecosystem of patient-centered research and information System Design, Personal Health Informatics: patient participation in Precision Health. Springer; 2022. pp. 329–51.

Martin KI, Glaser DA. Cosmeceuticals: the new medicine of beauty. Mo Med. 2011;108:60.

PubMed PubMed Central Google Scholar

Pandey A, Jatana GK, Sonthalia S, Cosmeceuticals SP. StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC., Treasure Island (FL) ineligible companies. Disclosure: Gurpoonam Jatana declares no relevant financial relationships with ineligible companies. Disclosure: Sidharth Sonthalia declares no relevant financial relationships with ineligible companies., 2023.

Morganti P, Morganti G, Gagliardini A, Lohani A. From cosmetics to innovative cosmeceuticals—Non-woven tissues as New Biodegradable Carriers. Cosmetics. 2021;8:65.

Article CAS Google Scholar

Market C. Fortune Business Insights., Cosmeceuticals Market, 2023.

LLP SMR. Global Cosmeceuticals Market, A $95.75 Billion Industry Opportunity by 2030., 2022.

R.a. Markets, Global Cosmeceuticals Market - Outlook & Forecast 2023–2028, 2023.

Research SM. Industry Report and Statistics (Facts & Figures) - Number of Users, Price, Demand & Sales Analysis by Product & Distribution Channel, 2021.

Company M. Meeting changing consumer needs: The US retail pharmacy of the future, 2023.

Ascenso FNS. L’Oréal Portugal: a digital challenge for the active cosmetics division, 2016.

cosmeticaactiva. L’Oreal E-Learning Platform in Portugal, 2023.

Bach D, Newman AL. Governing lipitor and lipstick: capacity, sequencing, and power in international pharmaceutical and cosmetics regulation. Rev Int Polit Econ. 2010;17:665–95.

Organization WH. Quality assurance of pharmaceuticals. a compendium of guidelines and related materials: Good manufacturing practices and inspection, 2007.

Rai S, Gupta A, Punetha V. Regulations of Cosmetics across the Globe. Applied Clinical Research. Clin Trials Regul Affairs. 2015;2:137–44.

Natural VLAMBERT. & Organic Living; Say ‘No’ To Chemicals For A Healthy Life. in: Raconteur, editor, 2016.

Agency EM. The European regulatory system for medicines, 2023.

FDA, Food and Drug Adimenstration in the United States of America, 2023.

Cosmetics I, Market. Industry, Entrepreneurship and SMEs, EU, European Commission 2023.

EEU EEU. TECHNICAL REGULATION ON THE SAFETY OF COSMETICS AND PERFUMERY, 2015.

Danghyan L. Armenian regulatory framework of the cosmetics and pharmaceutical industries, and its compliance with international regulations. Whether the existing regulatory framework of cosmetics and pharmaceutical industries complies with international best practice and ensures product safety and consumer protection. American University of Armenia; 2020.

TGA. Australian Public Assessment Report for Bimatoprost, 2017.

Kwa M, Welty LJ, Xu S. Adverse events reported to the US Food and Drug Administration for cosmetics and personal care products. JAMA Intern Med. 2017;177:1202–4.

DeKoven JG, Warshaw EM, Belsito DV, Sasseville D, Maibach HI, Taylor JS, Marks JG, Fowler JF, Mathias CT, DeLeo VA. North American contact dermatitis group patch test results 2013–2014. Dermatitis. 2017;28:33–46.

Janetos TM, Kwa M, Xu S. Regulation of cosmetics. JAMA Intern Med. 2018;178:1000–1.

Daum C. Self-Regulation in the Cosmetic Industry: A Necessary Reality or a Cosmetic Illusion? 2006.

Schaffer S, Reading Our Lips.: The History of Lipstick Regulation in Western Seats of Power, 2006.

Lincoln JE. Overview of the us fda gmps: good manufacturing practice (gmp)/quality system (qs) regulation (21 CFR part 820). J Validation Technol. 2012;18:17.

van der Heijden I, Pletneva N, Boyer C. How to protect consumers against the risks posed by the online pharmacy market. Swiss Med Inf 29 (2013).

Agency EM. Buying medicines online, 2015.

Union E. Buying medicine online, 2023.

ISPE. Regulating Online Pharmacies & Medicinal Product E-Commerce, 2019.

Swissmedic. Guideline on medicines and the Internet, 2020.

Kulali H. Online Pharmacy in Switzerland: A Full Guide. 2023, Pharmapidya, 2023.

Swissmedic. Current law, 2019.

El Hajj MS, Mekkawi R, Elkaffash R, Saleh R, Awaisi AE, Wilbur K. Public attitudes towards community pharmacy in Arabic speaking Middle Eastern countries: a systematic review. Res Social Administrative Pharm. 2021;17:1373–95.

DelveInsight. The Regulatory process for drug approval in the MENA region, DelveInsight, 2019.

Sallom H, Abdi A, Halboup AM, Başgut B. Evaluation of pharmaceutical care services in the Middle East Countries: a review of studies of 2013–2020. BMC Public Health. 2023;23:1364.

P.B.o. Australia, Guidelines for Dispensing of Medicines., 2019.

Center KLT. Statutes of the Republic of Korea. Pharmaceutical Affairs Act; 2016.

Goryachev I. Russia Federation: Telemedicine Law in Russia, Mondaq, 2018.

Jing M. China FDA stops online med sales, 2016.

L.a.W. o.J. Ministry of Health, List of Sales Sites for over-the-counter Drugs, 2020.

H.S.A.o, Singapore. Dangers of Buying Health Products Online, 2023.

M.o.H.o. Malaysia, Buying Medicines Online: Beware., 2023.

Ganapathy N. India’s pharmacies do battle with online rivals Straitimes, India, 2017.

LegitScript LS. Industry-Leading Certification, 2023.

NABP. The Verified Internet Pharmacy Practice Sites, 2012.

Boyer C, Baujard V, Geissbuhler A. Evolution of health web certification through the HONcode experience. Stud Health Technol Inf. 2011;169:53–7.

Tagde P, Tagde S, Bhattacharya T, Tagde P, Chopra H, Akter R, Kaushik D, Rahman MH. Blockchain and artificial intelligence technology in e-Health. Environ Sci Pollut Res. 2021;28:52810–31.

Walgreen. Convenient virtual care., 2023.

Group O. Otto Group, 2023.

U.o.C.S, Francisco, New UCSF. Robotic Pharmacy Aims to Improve Patient Safety, 2011.

Narayanaswami C, Nooyi R, Govindaswamy SR, Viswanathan R. Blockchain anchored supply chain automation. IBM J Res Dev. 2019;63:7: 1–7.

Khezr S, Moniruzzaman M, Yassine A, Benlamri R. Blockchain technology in healthcare: a comprehensive review and directions for future research. Appl Sci. 2019;9:1736.

Xia Q, Sifah EB, Asamoah KO, Gao J, Du X, Guizani M. MeDShare: Trust-less medical data sharing among cloud service providers via blockchain. IEEE access 5 (2017) 14757–14767.

Mannaro K, Pinna A, Marchesi M. Crypto-trading: Blockchain-oriented energy market, 2017 AEIT International Annual Conference, IEEE, 2017, pp. 1–5.

Rallapalli S, Minalkar A. Improving Healthcare-Big Data Analytics for. J Adv Inform Technol 7 (2016).

Wang H, Song Y. Secure cloud-based EHR system using attribute-based cryptosystem and blockchain. J Med Syst. 2018;42:152.

Cyran MA. Blockchain as a foundation for sharing healthcare data. Blockchain Healthc Today (2018).

Funk E, Riddell J, Ankel F, Cabrera D. Blockchain technology: a data framework to improve validity, trust, and accountability of information exchange in health professions education. Acad Med. 2018;93:1791–4.

Khan PW, Byun Y. A blockchain-based secure image encryption scheme for the industrial internet of things. Entropy. 2020;22:175.

Gomasta SS, Dhali A, Tahlil T, Anwar MM, Ali ABMS. PharmaChain: Blockchain-based drug supply chain provenance verification system. Heliyon. 2023;9:e17957.

Gamage RG, Bandara NS, Diyamullage DD, Senadeera KU, Abeywardena KY, Amarasena N. PharmaGo-An Online Pharmaceutical Ordering Platform, 2021 3rd International Conference on Advancements in Computing (ICAC), IEEE, 2021, pp. 365–370.

Amalia A, Sipahutar PYC, Elviwani E, Purnamasari F. Chatbot Implementation with Semantic Technology for Drugs Information Searching System. Journal of Physics: Conference Series 1566 (2020) 012077.

Trenfield SJ, Awad A, McCoubrey LE, Elbadawi M, Goyanes A, Gaisford S, Basit AW. Advancing pharmacy and healthcare with virtual digital technologies. Adv Drug Deliv Rev. 2022;182:114098.

Anis MS, Hassali MA. Pharmaceutical marketing of over-the-counter drugs in the current digital era: a review. Pharm Sci Asia 49 (2022).

Khan O, Parvez M, Kumari P, Parvez S, Ahmad S. The future of pharmacy: how AI is revolutionizing the industry. Intell Pharm. 2023;1:32–40.

Moshawih S, Hadikhani P, Fatima A, Goh HP, Kifli N, Kotra V, Goh KW, Ming LC. Comparative analysis of an anthraquinone and chalcone derivatives-based virtual combinatorial library. A cheminformatics proof-of-concept study. J Mol Graph Model. 2022;117:108307.

Moshawih S, Goh HP, Kifli N, Idris AC, Yassin H, Kotra V, Goh KW, Liew KB, Ming LC. Synergy between machine learning and Natural products Cheminformatics: application to the lead Discovery of anthraquinone derivatives. Chemical Biology & Drug Design; 2022.

Wong CH, Siah KW, Lo AW. Estimation of clinical trial success rates and related parameters. Biostatistics. 2019;20:273–86.

Moshawih S, Goh HP, Kifli N, Darwesh MAE, Ardianto C, Goh KW, Ming LC. Identification and optimization of TDP1 inhibitors from anthraquinone and chalcone derivatives: consensus scoring virtual screening and molecular simulations. J Biomol Struct Dynamics (2023) 1–25.

Moore JH, Margreitter C, Janet JP, Engkvist O, de Groot BL, Gapsys V. Automated relative binding free energy calculations from SMILES to ∆∆G. Commun Chem. 2023;6:82.

Moshawih S, Lim AF, Ardianto C, Goh KW, Kifli N, Goh HP, Jarrar Q, Ming LC. Target-based small Molecule Drug Discovery for Colorectal Cancer: a review of Molecular pathways and in Silico studies. Biomolecules. 2022;12:878.

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Almeman, A. The digital transformation in pharmacy: embracing online platforms and the cosmeceutical paradigm shift. J Health Popul Nutr 43 , 60 (2024). https://doi.org/10.1186/s41043-024-00550-2

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Air Force legacy to follow in family footsteps as public health officer

May 13, 2024 | Erin Bluvas, [email protected]

With her elementary school years spent in California and the past 10 in the Midlands, there was a constant theme in Darby Mihelich ’s bicoastal upbringing: service. As members of the United States Air Force, Mihelich’s parents inspired her to pursue a career as a public health officer in the military branch that had become a second home to them all.

“Hearing her stories of duty in Southwest Asia, where she protected personnel from biohazards and provided aid, made a big impact on me,” Mihelich says of her mother, who served as a bioenvironmental engineer. “Despite her frequent deployments, she always stressed the importance of keeping both airmen and civilians safe and healthy.”

My experience at USC has been nothing short of fantastic (and) has provided me with an enriching and dynamic environment to grow academically, socially and personally.

It felt like a natural choice for Mihelich to follow in the footsteps of her two older sisters and attend USC for her bachelor’s degree. The public health major has spent the past four years amassing enriching experiences and lifelong memories.

A two-month Public Health in the Tropics Internship took Mihelich to Kenya, where she worked with HIV-positive mothers and children as a part of the pediatric unit in the School for International Training. She used epidemiology to address factors contributing to malnutrition rates and health promotion to emphasize the importance of the local vaccination and nutritional programs.

“This immersive experience inspired me to join the Maternal and Child Health Student Association , where I've connected with doctoral students and further deepened my involvement in the field,” Mihelich says.

She also traveled to Costa Rica with the Foundation for International Medical Relief of Children, where she helped facilitate access to primary care services, led health education initiatives, taught children vital oral hygiene practices and empowered women through self-defense classes. “These diverse experiences have not only broadened my perspective but have also fueled my passion for making a positive impact in public health,” Mihelich says.

Closer to home, she found joy in her campus life as well as living in the state’s capital city. From the array of available clubs and organizations to energy-charged sport competitions, Mihelich has loved that there are always new interests to explore, events to attend and challenges to tackle.

“My experience at USC has been nothing short of fantastic, and Columbia serves as the ideal setting for college life that caters perfectly to students,” she says. “There’s always something exciting happening on campus, and one of the things I appreciate most is the increasing diversity I've noticed, which has enriched my interactions and broadened my perspectives. USC has provided me with an enriching and dynamic environment to grow academically, socially and personally.”

Her time at the Arnold School played a big role in Mihelich’s college experience as well.

“What I loved most is how expansive the field of public health is – it offers countless opportunities whether you're interested in business, health care, speech pathology, or any other area,” she says. “Public health truly surrounds us and delving into it provides valuable insights into understanding communities and the factors shaping them.”

Public health truly surrounds us and delving into it provides valuable insights into understanding communities and the factors shaping them.

An insider tip from Mihelich: actively engage with professors and build connections with them as these individuals offer not just academic guidance but also real-world insights and networking opportunities that can greatly enhance learning experiences and career prospects. For Mihelich, those mentors were epidemiology professor Anthony Alberg and instructor Kersten Cope .

“Dr. Alberg's expertise in epidemiology has not only deepened my understanding of the field but also inspired me to pursue my passion for it further,” Mihelich says of the department chair, who also helped steer her academic and professional aspirations. “Ms. Cope holds a special place in my heart as one of my favorite professors. Over the years, she has witnessed my growth firsthand and has been a constant source of encouragement and wisdom.”

With support from her mentors, the May graduate has firmed up her next steps. She will enroll in the Master of Public Health in Epidemiology program at George Washington University this fall. Then she’ll return to the family tradition of serving in the U.S. Air Force.

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Carolina Alumni Association honors Southerland and Koch

May 16, 2024

Drs. Janet Southerland and Gary Koch received Carolina Alumni Awards for their exceptional contributions to their respective fields and profound impact on the lives of countless students and colleagues.

Janet Southerland, DDS, PhD, MPH (‘94, health policy and administration), received the Distinguished Service Medal, presented by the Carolina Alumni board of directors. Southerland’s path to success has been paved with perseverance and an unwavering commitment to opening doors for others. She earned 5 degrees from Carolina: bachelor’s degrees in zoology and dental hygiene, a Doctor of Dental Surgery, a Master of Public Health and a Doctor of Philosophy degree in oral biology.

Dr. Janet Southerland (Photographed by Ray Black III)

Today, she serves as the interim dean of Louisiana State University’s School of Dentistry. Previously, she was a professor and dean of the MeHarry Medical College School of Dentistry and the UNC Adams School of Dentistry’s chair of hospital dentistry, chief of oral medicine and director of the Hospital Dental Clinic.

Southerland’s career has been marked by a relentless pursuit of excellence, a commitment to mentoring the next generation of health care professionals and a deep-rooted desire to provide equitable access to health care for underserved communities.

She chairs the Black Alumni Reunion’s Light on the Hill Society scholarship program, ensuring that students from disadvantaged backgrounds can pursue their dreams. Her research focuses on addressing health care disparities in impoverished communities and she has volunteered her time and expertise on medical missions both domestically and internationally.

Gary Koch, PhD (‘68, statistics), on the other hand, has left an indelible mark on the field of biostatistics and the lives of countless students through his unwavering dedication to teaching and mentorship. He received the Faculty Service Award.

Dr. Gary Koch (Photographed by Ray Black III)

For over half a century, Koch has been a pillar of the department of biostatistics at Carolina, mentoring generations of graduate students and shaping the trajectory of their careers.

Renowned for his knowledge and ability to break down complex concepts, Koch’s reputation as an exceptional educator precedes him. He has a knack for finding creative ways to engage his students, whether it’s sketching out equations on napkins at the Carolina Inn or holding impromptu dissertation consultations during halftime at Kenan Stadium.

Koch’s contributions extend far beyond the classroom. He has played a pivotal role in developing analytical methods for working with categorized data, which have had real-world applications in fields ranging from pharmaceutical research to public health. His co-authorship of the manual, “Categorical Data Analysis Using SAS,” – which has been widely used as a textbook – cemented his legacy as a pioneer in his field.

He has served as a faculty member of the UNC Department of Biostatistics since 1967, shortly before his graduation in 1968, and is a professor of biostatistics and director of the Biometric Consulting Laboratory. He is also a member of the editorial boards for Statistics in Medicine and the Journal of Biopharmaceutical Statistics .

In the 1970s, Koch collaborated with fellow statistician and UNC professor Dennis Gillings on what would become the contract research firm Quintiles, which grew into a multibillion-dollar company. But when he had to make a choice — stay in academia or devote his career to developing the business — he chose to continue his collaborations with other researchers and mentor future generations.

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Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh
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Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

Korima Begum

Ariful Haq Kabir

Md Shahgahan Miah

Introduction

Study time and setting

Theoretical framework

Study population and sampling strategy

Data collection procedure

Data analysis

Thematic analysis

Theme 1: Individual and structural factors

Theme 2: Socio-behavioural factors: Perceptions and beliefs

Theme 3: Contextual factors

Theme 4: Factors related to the university

Limitation of the study

Suggested recommendations to improve hygiene and sanitation practices

Supporting information

Funding Statement

Data Availability

Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh

Introduction

Study time and setting

Theoretical framework

Study population and sampling strategy

Data collection procedure

Data analysis

Thematic analysis

Theme 1: Individual and structural factors

Theme 2: Socio-behavioural factors: Perceptions and beliefs

Theme 3: Contextual factors

Theme 4: Factors related to the university

Limitation of the study

Suggested recommendations to improve hygiene and sanitation practices

Supporting information

S2 File. Guideline for focus group discussion.

S3 File. Guideline for key informant interview.

Health, hygiene, and practical interventions, for people who are experiencing homelessness

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Additional Information

Introduction: Water, Sanitation, and Hygiene Insecurities

Gendered Relations in the Household

Gender Division of Household Labor

Washing Utensils and Laundry in Contaminated Water

Water Collection

Gender and Power in the Household

Care and Treatment in Son-Preference Families

Health Care Seeking Behavior

Gendered Presentation of the Body

Gendered Use of Public Space

Menstruation and Cultural Taboos About Menstrual Blood

Human papillomavirus (HPV) infection and reproductive-tract infection (RTI)

Gender-based violence

Hygiene for maternal health

Dehydration and chronic constipation

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