A systematic scoping review of hygiene behaviors and environmental health conditions in institutional care settings for orphaned and abandoned children Michelle Moffa, Ryan Cronk ⁎, Donald Fejfar, Sarah Dancausse, Leslie Acosta Padilla, Jamie Bartram ⁎ The Water Institute, University of North Carolina, Chapel Hill, NC, United States HIGHLIGHTS • Poor environmental health conditions adversely affect orphan health. • This review describes hygiene behaviors and environmental conditions in or- phanages. • Inadequate water and sanitation and overcrowding are common in orphan- ages. • There are few studies on improving health behaviors and conditions in or- phanages. • Insufficient funding and caregiver ex- pertise on hygiene and health impede improvement. GRAPHICAL ABSTRACT Environmental health and hygiene exposures (blue) and health outcomes (red) in institutions for orphaned and aban- doned children. Arrows represent potential associations as identified in the literature. Darker lines are indicative of the relative number of studies documenting this potential association. abstract article info Article history: Received 26 September 2018 Received in revised form 18 December 2018 Accepted 18 December 2018 Available online 20 December 2018 Editor: Damia Barcelo Background: Adequate hygiene behaviors and environmental health conditions are fundamental to children's health, development, and well-being. They are especially important in institutional care settings for orphaned and abandoned children, a particularly vulnerable population whose basic needs are often not met. Objectives: We systematically reviewed the evidence about hygiene behaviors and environmental health condi- tions in institutional care settings for children and associated health outcomes; interventions to improve these behaviors, conditions, and outcomes; and obstacles to improvement. Methods: PubMed, Web of Science, Scopus, and EBSCOhost were searched for studies in the peer-reviewed and grey literature. Studies were included if they reported primary data on one or more environmental health condi- tion or hygiene behavior in an institutional care setting for orphaned and abandoned children. Results: Forty-five publications reporting on over 500 institutions in 29 countries were included. The most docu- mented concern was poor personal hygiene behaviors followed by inadequate water and sanitation infrastruc- ture and overcrowding. Protozoan, helminthic, viral infections, and diarrheal illness among institutionalized children were the most commonly documented associated health outcomes. Keywords: Alternative care Group home Orphanage Toilets Science of the Total Environment 658 (2019) 1161–1174 ⁎ Corresponding authors at: Department of Environmental Sciences and Engineering and The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, CB #7431, 135 Dauer Drive, Chapel Hill, NC 27599-7431, United States. E-mail addresses: rcronk@live.unc.edu (R. Cronk), jbartram@unc.edu (J. Bartram). https://doi.org/10.1016/j.scitotenv.2018.12.286 0048-9697/© 2018 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv