Disability and dignity: a qualitative systematic review of WASH-related barriers, facilitators and interventions for adults with musculoskeletal disabilities.

Background: Adults with musculoskeletal disabilities (MSDs) including arthritis, spinal cord injuries, amputations, and congenital deformities face significant barriers in accessing water, sanitation, and hygiene (WASH) services. These barriers compromise health, dignity, and independence, particularly in low- and middle-income countries. This systematic review aimed to identify WASH-related barriers and facilitators for adults with MSDs and synthesize existing interventions to promote inclusive WASH access. Methods: This systematic review was conducted following PRISMA 2020 guidelines. We searched MEDLINE, Embase, and CENTRAL databases up to March 1, 2025, using MeSH and free-text terms. Inclusion criteria were primary research studies involving adults (≥18 years) with MSDs, reporting on WASH barriers, facilitators, or interventions. Only qualitative or mixed-methods studies published in English were included. Studies involving children, lacking primary data, or behind paywalls were excluded. Two independent reviewers conducted screening and full-text appraisal using Covidence. Data were extracted using a standardized template, and findings were thematically synthesized. Study quality was assessed using the NIH Quality Assessment Tool. Results: From 5,301 initial records, 19 studies met the inclusion criteria, representing diverse geographical settings. Key barriers included inaccessible infrastructure (e.g., lack of ramps or handrails), stigma, poverty, exclusion from planning, and inadequate menstrual hygiene management. Facilitators included home modifications, affordable technology (e.g., biosand filters), caregiver and community support, gender-sensitive WASH education, and inclusive policies. Interventions ranged from inclusive Community-Led Total Sanitation (CLTS) programs to disability-aware infrastructure designs. Despite progress, participation of adults with MSDs in WASH planning and services remained limited. Conclusion: This review highlights persistent exclusion of adults with MSDs from WASH access. Inclusive design, community engagement, and policy-level integration are essential for achieving equitable WASH services. Future research should evaluate the scalability and effectiveness of low-cost interventions, particularly in resource-constrained settings. However, the findings should be interpreted considering the absence of meta-analysis and formal risk-of-bias assessment.