Accessible in Theory, Inaccessible in Practice: A User-Centered Evaluation of Disability Inclusion in Humanitarian WASH Facilities in Gaza Displacement Camps

Accessible in Theory, Inaccessible in Practice: A User-Centered Evaluation of Disability Inclusion in Humanitarian WASH Facilities in Gaza Displacement Camps | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Accessible in Theory, Inaccessible in Practice: A User-Centered Evaluation of Disability Inclusion in Humanitarian WASH Facilities in Gaza Displacement Camps Samer Abuzerr This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8539145/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Persons with disabilities in displacement settings face persistent barriers to safe, dignified, and independent access to water, sanitation, and hygiene (WASH) facilities. Evidence on functional accessibility in conflict-affected Gaza is limited. This study evaluated the objective and perceived accessibility of humanitarian WASH facilities and examined user experiences in Gaza displacement camps. Methods Between 23 September and 26 December 2025, a mixed-methods study was conducted across six displacement camps. A total of 384 participants, including persons with disabilities and caregivers, were recruited. Data collection included structured facility audits, observations of WASH use, and participatory evaluation sessions. Composite accessibility scores were calculated, and qualitative findings were thematically analyzed. Results Most WASH facilities were nominally “accessible,” but structural, operational, and environmental barriers limited functional use. Ramps, handrails, and widened doors were often inadequate or poorly maintained. Privacy and safety constraints disproportionately affected women, girls, and participants requiring assistance. Over 58% relied on caregivers for facility use, and 39–46% reported delayed or reduced hygiene practices. Composite accessibility scores were low in 61.6% of facilities, with bathing spaces scoring worst. Participants identified priority barriers and suggested low-cost, context-appropriate adaptations, including handrails, non-slip surfaces, improved maneuvering space, and participatory design. Despite awareness of disability-inclusive policies, functional inclusion remained limited. Conclusion Persons with disabilities in Gaza displacement camps experience a persistent gap between theoretical accessibility and practical usability of WASH facilities. Integrating structural improvements, operational reliability, and participatory design is critical to ensure inclusive, safe, and dignified WASH services. Disability inclusion WASH displacement camps Gaza Strip humanitarian settings accessibility Introduction Access to safe water, adequate sanitation, and hygiene (WASH) services is a fundamental human right and a critical determinant of health, dignity, and well-being. Globally, an estimated 1 billion persons live with some form of disability, yet persons with disabilities (PWDs) are disproportionately excluded from WASH services due to persisting physical, environmental, and social barriers in both development and humanitarian contexts [ 1 , 2 ]. Despite the growing recognition of disability inclusion within the WASH sector, monitoring systems often fail to capture data disaggregated by disability, leaving the specific barriers faced by PWDs invisible in program design, implementation, and evaluation [ 1 ]. Persons with disabilities frequently face multidimensional barriers to WASH participation, including inaccessible infrastructure, lack of assistive devices, social stigma, and increased dependence on caregivers. These barriers compound other vulnerabilities, such as poverty and displacement, contributing to poorer health outcomes, reduced dignity, and social exclusion [ 2 ]. In humanitarian settings, where infrastructure is disrupted and services are strained, these challenges are further exacerbated, and failure to address the specific needs of PWDs can render nominally “accessible” WASH facilities unusable in practice. The Gaza Strip illustrates an extreme manifestation of these challenges. After prolonged conflict and recurrent cycles of hostilities, the territory’s WASH infrastructure has been severely degraded, with critical systems for water supply and sanitation out of service for vast segments of the population [ 3 – 6 ]. By mid-2025, an estimated 81% of public water and sanitation facilities were reported to be inaccessible to the broader population due to direct damage, restrictions on movement, and operational constraints imposed by ongoing hostilities [ 3 ]. UNICEF and other humanitarian agencies have documented acute shortages of safe drinking water and widespread reliance on inadequate or intermittent supplies, significantly increasing the risk of waterborne disease and hygiene-related health complications [ 7 ]. These conditions are particularly dire for persons with disabilities. Prior to the recent escalation of conflict, the Palestinian Central Bureau of Statistics estimated that approximately 58,000 individuals with disabilities resided in the Gaza Strip [ 8 ]. Since the onset of intensified hostilities in late 2023, government and civil society reports indicate that between 33,000 and 44,000 new disability cases have arisen, alongside widespread loss of assistive devices and rehabilitation services due to infrastructure destruction [ 8 ]. Children are disproportionately affected; more than 15% of children in Gaza were reported to have a disability in 2025, and many have been displaced or lost access to essential services [ 9 ]. These compounding crises—environmental, infrastructural, and social—have intensified the exclusion of PWDs from basic services, magnifying their vulnerability within the broader humanitarian emergency. Despite these intersecting vulnerabilities, little is known about how WASH facilities in displacement camps—where hundreds of thousands have sought shelter—meet (or fail to meet) the needs of persons with disabilities. Humanitarian guidelines emphasize the importance of disability-inclusive WASH programming, yet few empirical studies have examined how such facilities are experienced by users with diverse functional limitations [ 1 , 10 , 11 ]. Existing literature from other crisis contexts highlights that superficial compliance with accessibility standards does not necessarily translate into functional access for PWDs, owing to factors such as poor maintenance, overcrowding, and contextual barriers that audits alone cannot capture [ 2 ]. This gap underscores the need for user-centered evaluation approaches that integrate both objective and experiential dimensions of accessibility. This study therefore investigates disability inclusion in humanitarian WASH facilities within Gaza displacement camps, exploring the degree to which infrastructure that is “accessible in theory” is actually “accessible in practice” to persons with disabilities and caregivers. By combining quantitative accessibility audits with structured observations and rich qualitative narratives, the research aims to illuminate the realized accessibility of WASH services, identify key barriers to equitable use, and propose context-specific recommendations for enhancing inclusion in crisis-affected environments. Methods Study Design This study employed a cross-sectional mixed-methods design to evaluate disability inclusion in humanitarian water, sanitation, and hygiene (WASH) facilities in displacement camps in the Gaza Strip. The design integrated quantitative accessibility audits and structured observations with qualitative user-centered methods, including in-depth interviews and participatory evaluation. This approach was selected to capture both objective measures of physical accessibility and subjective lived experiences of use, dignity, and autonomy, which are often inadequately reflected in infrastructure-only assessments [ 1 , 12 ]. The study was conducted between 23 September and 26 December 2025, a period characterized by large-scale internal displacement, intermittent service provision, and heavy reliance on humanitarian WASH facilities. Study Setting The study was carried out in six displacement camps across the Gaza Strip, including both formal collective shelters and informal displacement sites. Camps were purposively selected to ensure variation in: Geographic location (north, central, and southern Gaza), Camp size and population density, Duration of establishment, Implementing agency responsible for WASH service provision (UN agencies, international NGOs, and local NGOs). All selected camps had communal WASH facilities serving large displaced populations, including shared latrines, bathing spaces, and water collection points. Study Population The study population included: Persons with disabilities (PWDs) residing in the selected displacement camps, including individuals with: Physical or mobility impairments, Visual or hearing impairments, Intellectual disabilities, Psychosocial disabilities. Primary caregivers of PWDs, when individuals were unable to participate directly due to age, cognitive impairment, or communication barriers. Disability status was identified using an adapted version of the Washington Group Short Set of Questions on Disability, widely recommended for humanitarian and development settings to assess functional limitations rather than medical diagnoses [ 1 ]. Eligibility Criteria Inclusion criteria were: Residence in the selected displacement camp for at least three months, Self-identified disability or caregiving responsibility for a person with a disability, Willingness and ability to provide informed consent (or caregiver-mediated consent where appropriate). Individuals experiencing acute medical emergencies at the time of data collection were excluded to avoid undue burden. Sampling Strategy A stratified purposive sampling strategy was employed. At the camp level, six displacement camps were selected to reflect diversity in WASH infrastructure typology and management. Within each camp, participants were recruited through collaboration with camp management committees, humanitarian partners, and community focal points for disability inclusion. Efforts were made to ensure representation across disability types, gender, and age groups. In total, approximately 384 persons with disabilities and caregivers participated across all study components. Data Collection Methods The semi-structured interview guide was specifically developed for this study to explore user experiences of accessibility, dignity, privacy, safety, and autonomy in relation to communal WASH facilities. The guide captured perceived barriers, coping strategies, psychosocial impacts, and gender- and disability-specific concerns. It was used alongside structured facility accessibility audits, structured observations, and participatory evaluation activities to enable triangulation of objective and subjective data. The interview guide is provided as Supplementary File 1. 1. Accessibility Audits of WASH Facilities A structured WASH accessibility audit tool was developed based on: UNICEF disability-inclusive WASH guidance, Sphere Humanitarian Standards, Universal design principles. Audits were conducted for all major communal WASH facilities in each camp, including latrines, bathing facilities, and water points. The audit assessed five core domains: Physical access (ramps, steps, gradients, door widths), Internal usability (turning space, grab bars, seating), Safety (floor conditions, lighting, privacy), Communication and signage (visibility, contrast), Hygiene usability (handwashing station height, water flow control). Each domain was scored using predefined criteria, allowing the generation of facility-level accessibility scores. 2. Structured Observations Structured observations were conducted to document actual use of WASH facilities by PWDs. Observations focused on: Time required to access and use facilities, Level and type of assistance required, Safety incidents or near-miss events, Avoidance or alternative practices (e.g., delayed use, open defecation). Observations were conducted discreetly over multiple time periods to minimize reactivity and capture routine practices. 3. User-Centered Qualitative Evaluation In-Depth Interviews Semi-structured in-depth interviews (IDIs) were conducted with PWDs and caregivers to explore: Perceived accessibility versus formal design features, Experiences of dignity, privacy, and safety, Physical and emotional burden associated with WASH use, Perceived gaps between humanitarian standards and lived realities. Interviews were conducted in Arabic by trained researchers experienced in disability-sensitive and trauma-informed approaches. Reasonable accommodations, including caregiver support and alternative communication methods, were provided as needed. User Journey Mapping Participants were guided to narrate step-by-step experiences of: Fetching water, Using sanitation facilities, Managing personal hygiene. These narratives were translated into user journey maps highlighting barriers, delays, and points of dependence on others. This method enabled visualization of how accessibility challenges accumulate across the WASH use pathway. 4. Participatory Evaluation Workshops Participatory workshops were held in each camp with PWDs, caregivers, and selected WASH actors. Preliminary findings were presented and discussed to: Validate emerging themes, Identify priority accessibility gaps, Co-develop practical recommendations for humanitarian actors. Participatory evaluation methods were used to enhance contextual relevance and ensure that findings reflected user priorities rather than external assumptions. Data Analysis Quantitative Analysis Accessibility audit scores and structured observation data were analyzed using descriptive statistics, including frequencies, medians, and interquartile ranges. Comparisons were conducted across facility types and camps to identify patterns of inclusion and exclusion. Interview transcripts, observation notes, and workshop discussions were analyzed using thematic analysis. Coding followed an iterative process combining inductive themes with deductive categories informed by: Rights-based approaches to disability, The International Classification of Functioning, Disability and Health (ICF), Disability-inclusive WASH frameworks. To enhance rigor, a subset of transcripts was double-coded by two researchers, and discrepancies were resolved through discussion. Findings from quantitative and qualitative components were integrated through methodological triangulation. This enabled comparison between formal accessibility features (“accessible in theory”) and actual user experiences (“accessible in practice”), strengthening interpretive validity. Ethical Considerations Ethical approval for the study was obtained from the University College of Science and Technology Institutional Review Board (UCST-IRB/2/2026). All participants provided informed consent prior to participation. For individuals with intellectual or communication impairments, consent was obtained from caregivers alongside participant assent where feasible. Additional safeguards included confidential handling of all data, trauma-informed interviewing techniques, the right to withdraw at any time without consequence, and referral to humanitarian services where unmet needs were identified. Results Characteristics of Study Participants and Study Sites A total of 384 participants, including persons with disabilities and their primary caregivers, were recruited from six displacement camps in the Gaza Strip. Participants were aged 6–79 years (median 34, IQR 21–52), with 26.8% under 18 years. Slightly more than half were women (52.6%), reflecting both gender distribution and caregiver roles. Most participants (71.4%) had been displaced for over six months, and 32.0% had experienced repeated displacement, often increasing reliance on communal WASH facilities. Participants reported diverse disabilities, with mobility impairments most common (41.7%), followed by visual (18.5%), hearing (14.3%), intellectual (13.0%), and psychosocial (12.5%) impairments. Many had multiple functional limitations. Using Washington Group domains, 62.2% had severe or very severe limitations, especially in walking/climbing and self-care. Over half (54.9%) used assistive devices, though many reported them as damaged, unavailable, or unsuitable. Dependence on caregivers was high, with 58.6% requiring partial or full assistance to use WASH facilities, particularly among those with mobility or intellectual disabilities, children, and older adults. The six camps included three formal collective shelters and three informal sites, housing 4,000–18,000 people each. A total of 112 communal WASH facilities were assessed, including latrines, bathing spaces, and water points; latrines were most common. Facilities, mostly constructed during emergency response phases, were generally less than a year old (67.9%) but showed signs of rapid deterioration due to overcrowding, limited maintenance, and intermittent water supply. WASH services were managed by UN agencies, international NGOs, and local NGOs (Table 1 ). Table 1 Socio-Demographic Characteristics and Disability Profile of Study Participants (N = 384) Characteristic n % Age Group < 18 years 103 26.8 18–59 years 211 54.9 ≥ 60 years 70 18.2 Gender Female 202 52.6 Male 182 47.4 Duration of Displacement 6 months 274 71.4 Primary Disability Type * Mobility impairment 160 41.7 Visual impairment 71 18.5 Hearing impairment 55 14.3 Intellectual disability 50 13.0 Psychosocial disability 48 12.5 Severity of Functional Limitation Moderate 145 37.8 Severe/very severe 239 62.2 Use of Assistive Devices Yes 211 54.9 No 173 45.1 Caregiver Dependence Independent 159 41.4 Partially dependent 142 37.0 Fully dependent 83 21.6 *Participants may report more than one disability type. Objective Accessibility of Humanitarian WASH Facilities A total of 68 sanitation facilities, 24 bathing spaces, and 20 water points across six Gaza displacement camps were assessed. While 82.4% of sanitation facilities were nominally reachable, substantial physical barriers were identified. Ramps were present at 41.2% of latrines but only 18.0% met basic usability criteria; in their absence, access relied on steps without handrails. Door widths met minimum standards in 36.8% of latrines, and only 29.4% provided adequate internal space for maneuvering or assisted use. Bathing and personal hygiene facilities showed greater accessibility challenges. Adequate privacy was observed in 45.8%, non-slip flooring in 37.5%, and handrails in 25.0% of facilities. Only 20.8% allowed sufficient space for caregiver assistance, and safety concerns led some participants to avoid using these facilities entirely. Water collection points varied widely in accessibility. Taps were at usable heights in 40.0% of cases, but over half (55.0%) were located more than 50 meters from shelters, often on unstable or slippery ground (35.0% stable). Physical effort and environmental hazards limited independent use, particularly for individuals with mobility or balance impairments. Composite accessibility scores ranged from 18 to 72 out of 100. Overall, 61.6% of facilities were classified as low accessibility, 28.6% moderate, and 9.8% high. Bathing facilities had the lowest median scores, followed by sanitation units, with water points slightly higher but still suboptimal. Scores varied between camps; newer or NGO-supported facilities scored higher, whereas older or overcrowded camps scored lower. Presence of visible accessibility features did not consistently translate into functional usability, highlighting a gap between design intent and practical access (Table 2 ). Table 2 Objective Accessibility of Humanitarian WASH Facilities by Facility Type Accessibility Indicator Sanitation Facilities (n = 68) Bathing Facilities (n = 24) Water Points (n = 20) Accessible ramps present 28 (41.2%) 6 (25.0%) – Ramps meeting usability criteria 12 (18.0%) 3 (12.5%) – Adequate door width 25 (36.8%) 11 (45.8%) – Low/no entry threshold 29 (42.6%) 10 (41.7%) – Sufficient internal maneuvering space 20 (29.4%) 5 (20.8%) – Adequate privacy/enclosure 38 (55.9%) 11 (45.8%) – Non-slip flooring 31 (45.6%) 9 (37.5%) 7 (35.0%) Handrails/grab bars present 22 (32.4%) 6 (25.0%) – Accessible tap height – – 8 (40.0%) Stable surrounding ground surface – – 7 (35.0%) Median accessibility score (IQR) 38 (28–49) 32 (24–41) 44 (35–56) Observed Use of WASH Facilities by Persons with Disabilities Observations revealed substantial time, physical effort, and fatigue associated with WASH activities. Median travel times were 7 minutes (IQR 4–12) for sanitation/bathing and 9 minutes (IQR 6–15) for water collection, longer for participants with mobility impairments or in larger camps. Median completion times were 14 minutes for sanitation and 21 minutes for bathing, particularly prolonged for those requiring assistance or navigating restricted spaces. Over 63% of participants exhibited visible fatigue, including balance difficulties and reliance on walls or fixtures. More than half of WASH activities (58.6%) required caregiver assistance, including lifting/transferring (41.3%), guiding/stabilizing (36.9%), and managing hygiene tasks (44.8%). Caregiving often fell on women and adolescent girls, adding physical and emotional strain due to frequent, intimate assistance under limited privacy. Safety risks were common. Falls or near-falls occurred in 27.9% of visits, slips causing minor injuries in 14.6%, and fear of unaccompanied use was reported by 48.2%, especially among visually impaired and psychosocially vulnerable participants. Avoidance behaviors were widespread. Delayed use of sanitation facilities was reported by 39.3%, reduced bathing/handwashing by 46.1%, and 11.2% resorted to open defecation or improvised solutions. These practices were most frequent among participants with severe mobility impairments or in camps with low accessibility scores (Table 3 ). Table 3 Observed Use, Assistance Needs, and Safety Risks During WASH Activities Among Persons with Disabilities (N = 384) Observational Indicator n % Median time to reach WASH facilities ≤ 5 minutes 118 30.7 6–10 minutes 156 40.6 > 10 minutes 110 28.6 Median time to complete WASH activities ≤ 10 minutes 96 25.0 11–20 minutes 162 42.2 > 20 minutes 126 32.8 Visible physical strain/fatigue observed 242 63.0 Required physical assistance 225 58.6 – Lifting/transferring assistance 158 41.3 – Guiding/stabilizing assistance 142 36.9 – Cleaning/hygiene assistance 172 44.8 Falls or near-falls 107 27.9 Slip-related minor injuries 56 14.6 Fear of using facilities unaccompanied 185 48.2 Delayed use of sanitation facilities 151 39.3 Reduced hygiene frequency 177 46.1 Open defecation or improvised solutions 43 11.2 Participants may report or exhibit more than one outcome. User Experiences of Accessibility, Dignity, and Autonomy Participants acknowledged visible accessibility features—ramps, handrails, and designated units—leading to an initial perception of compliance. About 61.5% noted at least one feature, but only 29.7% believed these were designed to meet actual needs, with many describing them as “visible but not usable,” highlighting a gap between standards and practical use. Despite apparent compliance, multiple barriers limited functional access. Physical barriers—steep ramps, narrow doors, high thresholds, and limited internal space—affected 68.2% of participants. Environmental barriers, including muddy/flooded pathways, poor lighting, and overcrowding, impacted 57.8%, while operational barriers—queues, broken locks, intermittent water, and poor maintenance—affected 62.4%. Dignity and psychosocial impacts were widespread. Loss of privacy was reported by 53.6%, embarrassment by 47.9%, and fear of injury or exposure by 48.2%, especially among previously independent adolescents and adults. Women and girls reported heightened privacy and safety concerns, including challenges managing menstrual hygiene, leading some to avoid facilities entirely. Experiences varied by disability type and gender. Mobility-impaired participants faced the greatest exclusion and reliance on caregivers. Sensory-impaired participants struggled with navigation and environmental unpredictability, while those with intellectual disabilities faced difficulty understanding layouts or social norms. Women, girls, and children with disabilities faced compounded barriers, leading to layered exclusion where disability, gender, and age jointly shaped WASH access (Table 4 ). Table 4 User-Reported Experiences of Accessibility, Dignity, and Psychosocial Impact (N = 384) Experience Category n % Perceived presence of accessibility features 236 61.5 Awareness of disability-inclusive design intent 114 29.7 Reported physical barriers to use 262 68.2 Environmental/contextual barriers 222 57.8 Operational barriers (crowding, maintenance, water shortages) 240 62.4 Loss of privacy during WASH use 206 53.6 Feelings of shame or embarrassment 184 47.9 Fear of injury or exposure 185 48.2 Increased dependence on caregivers 225 58.6 Gender-specific concerns reported (women/girls) 133 34.6 Differential challenges by disability type reported 271 70.6 Participants may report multiple experiences. User Journey Mapping: Pathways of Exclusion User journey mapping revealed multiple points of exclusion across sanitation, water collection, and personal hygiene for persons with disabilities in Gaza displacement camps. Sanitation facilities posed barriers at every stage. Entry was hindered by steep ramps, narrow doorways, and obstructed pathways, often requiring caregiver assistance. Cramped internal space, inadequate handrails, and lack of supportive fixtures limited use, while wet or uneven floors complicated exit. Broken doors, non-functional locks, and slippery surfaces were common points of failure, leading participants to pause or avoid use due to fatigue, fear, or dependence. Water collection was physically demanding, with participants carrying containers above waist height, navigating uneven paths, and queuing. About 44% relied on caregivers or peers, particularly wheelchair users, older adults, and those with upper-limb impairments. Women and adolescent girls disproportionately bore caregiving burdens, increasing fatigue, injury risk, and stress. Personal hygiene and bathing faced privacy and safety constraints. Most communal bathing facilities were overcrowded, poorly enclosed, or lacked functional doors and locks, deterring use, especially among women and adolescents. Over half of participants required caregiver assistance for transfers, bathing, or hygiene tasks. Dependence, limited autonomy, and fear of injury contributed to reduced bathing frequency and use of improvised hygiene practices (Table 5 ). Table 5 User Journey Mapping: Points of Exclusion Across WASH Pathways (N = 384) WASH Pathway Stage Key Barriers / Points of Failure % of Participants Affected Sanitation Facilities Entry Steep/uneven ramps, obstructed pathways, narrow doors 62.0 Use Limited internal space, lack of handrails, non-functional fixtures 58.6 Exit Slippery or uneven floors, steps without support 55.4 Water Collection & Transport Collection High taps, long distances, queuing 66.1 Transport Carrying heavy containers, unstable surfaces 63.5 Reliance on others Lifting/assistance from caregivers or peers 44.0 Personal Hygiene & Bathing Access Overcrowding, poorly enclosed spaces 53.6 Use Need for physical assistance, lack of grab bars 52.1 Safety / Privacy Fear of injury, exposure, dependence on caregivers 48.2 Participatory Evaluation Findings Participatory sessions provided insights into priorities, barriers, and solutions identified by persons with disabilities and caregivers, complementing audits and observations. User-identified barriers included physical obstacles (steep ramps, narrow doors, limited internal space; 68.5%), operational challenges (overcrowding, water shortages, poor maintenance; 61.2%), and privacy/safety concerns (54.7%), particularly for women, girls, and those needing assistance. Mobility challenges, lack of handrails, high thresholds, facility distance, non-functional doors, and water scarcity were consistently ranked as the most severe. Proposed solutions focused on low-cost, locally feasible adaptations, including non-slip surfaces, handrails, widened doors, improved maneuvering space, reduced water distances or mobile carts, queuing modifications, and enhanced maintenance. Participants suggested locally sourced ramps, adjustable platforms, and tactile markings for visually impaired users, emphasizing rapid, context-appropriate improvements. Policy-practice gaps were evident. While 52.3% were aware of disability-inclusive policies, many facilities remained functionally inaccessible, with inadequate monitoring and limited consultation with users. Participants highlighted persistent exclusion despite formal commitments, underscoring the need for accountability and participatory planning to bridge these gaps (Table 6 ). Table 6 Participatory Evaluation Findings: User-Prioritized Barriers and Proposed Adaptations (N = 384) Theme Key Findings % of Participants Reporting / Prioritizing Priority Barriers Physical accessibility gaps (ramps, thresholds, narrow doors) 68.5 Operational barriers (crowding, water shortages, maintenance) 61.2 Privacy and safety concerns 54.7 Proposed Solutions Install non-slip surfaces, handrails, grab bars 62.8 Widen doors and internal space for maneuvering 57.1 Reduce water collection distances / mobile carts 49.5 Queue management and crowd reduction strategies 45.6 Regular maintenance and supervision 51.0 Locally feasible innovations (ramps, tactile markings) 38.7 Policy vs Practice Gap Awareness of inclusion policies 52.3 Experiences of exclusion despite policies 67.9 Participants could report multiple barriers, solutions, or observations. Discussion This study provides a comprehensive, user-centered evaluation of disability inclusion in humanitarian WASH facilities within Gaza displacement camps, highlighting the persistent gap between theoretical accessibility and functional usability. Our findings demonstrate that, while many facilities include nominal accessibility features, structural, operational, and psychosocial barriers continue to restrict independent use, dignity, and autonomy among persons with disabilities. Physical and structural barriers were pervasive across all facility types. Despite ramps, handrails, and wider doors being present in some facilities, many were inadequately constructed, poorly maintained, or obstructed, rendering them unusable. This aligns with prior studies in humanitarian contexts, where the mere presence of accessibility features does not guarantee functional use for persons with disabilities [ 13 , 14 ]. In Gaza, high thresholds, cramped internal spaces, and uneven pathways compounded challenges, particularly for wheelchair users and those with mobility impairments, corroborating previous reports of infrastructure inadequacies in conflict-affected settings [ 15 – 17 ]. Operational and environmental factors significantly affected access. Overcrowding, intermittent water supply, broken locks, and poor drainage limited usability, even in structurally “compliant” facilities. This supports evidence from other displacement contexts, where service reliability and environmental hazards frequently undermine nominal accessibility [ 18 , 19 ]. Notably, participants reported that fear of injury, fatigue, and dependence on caregivers often dictated facility use, highlighting the interplay between infrastructure and psychosocial determinants of accessibility, as emphasized in the conceptual frameworks of inclusive WASH [ 17 ]. Privacy, dignity, and autonomy emerged as critical dimensions of WASH inclusion. Women and girls with disabilities reported heightened concerns, including exposure during menstruation and reliance on caregivers for intimate tasks. These findings are consistent with studies showing that gender and disability intersect to exacerbate exclusion in communal facilities [ 17 , 20 ]. Loss of privacy, feelings of shame, and fear of injury contributed to avoidance behaviors, including delayed use or improvised hygiene practices, with potential public health implications such as reduced handwashing, hygiene-related disease risk, and psychological distress [ 21 , 22 ]. Participatory evaluations reinforced the gap between policy and practice. While many participants were aware of humanitarian inclusion policies, functional implementation lagged. Users highlighted low-cost, context-appropriate solutions—such as locally sourced ramps, tactile markers, and modified queuing—that could improve accessibility with minimal investment. This aligns with evidence suggesting that participatory design and local adaptation are key enablers of inclusive WASH in resource-constrained or conflict-affected settings [ 23 , 24 ]. Our integration of audit, observational, and participatory data identified three primary mechanisms of exclusion: Structural inadequacy – features present but poorly designed or maintained, limiting functionality. Operational constraints – water shortages, crowding, and environmental hazards reducing usability. Dependence and psychosocial barriers – fear, stigma, and reliance on caregivers restricting autonomy. These findings highlight the cumulative nature of exclusion, where interacting structural, environmental, and social factors prevent meaningful access, even when nominal standards are met. Similar patterns have been reported in studies from refugee camps in Jordan, Uganda, and Bangladesh, suggesting that these challenges are not unique to Gaza [ 16 , 17 , 25 ]. The findings have several practical implications: Inclusive design must go beyond nominal compliance, ensuring functional usability across disability types and ages. Simple features like ramps, handrails, or wider doors are insufficient if poorly constructed or maintained. Operational management is critical; adequate water supply, maintenance, and crowd management are essential to translate structural accessibility into functional access. Participatory planning involving persons with disabilities and caregivers can identify feasible, low-cost adaptations that enhance usability, safety, and dignity. Gender-sensitive considerations should be integrated, particularly for communal bathing and sanitation facilities, to address privacy, safety, and menstrual hygiene management. These recommendations are consistent with international guidance on disability-inclusive WASH in humanitarian settings [ 21 , 22 ]. This study benefits from a mixed-methods, user-centered approach, integrating objective audits, direct observation, and participatory evaluations, providing a holistic understanding of WASH accessibility. The large sample size (n = 384) across multiple camps enhances generalizability within the Gaza context. However, limitations exist. First, findings may not fully represent all displacement settings or non-camp populations. Second, observational measures may have introduced some Hawthorne effect, as participants knew they were being observed. Third, reliance on self-reported perceptions may introduce bias, though triangulation with objective audits mitigates this risk. Conclusion Persons with disabilities in Gaza displacement camps face persistent barriers to WASH access, even when facilities nominally meet accessibility standards. Physical, operational, and psychosocial factors converge to limit independence, dignity, and health. Participatory, user-centered approaches can identify feasible adaptations, bridging the gap between policy and practice. Humanitarian agencies should prioritize functional accessibility, operational reliability, and participatory design, ensuring that WASH services are genuinely inclusive for all users. Declarations Ethics approval and consent of participation : The study was approved by the University College of Science and Technology Institutional Review Board (UCST-IRB/4/2026) and was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all adult participants and from caregivers of children or individuals unable to provide consent independently. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study. Data Sharing Statement Datasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines. Consent for publication: Not applicable. This manuscript does not contain any identifying images or other personal or clinical details of participants that compromise anonymity. Competing interests: The author declares no competing interest. Role of the Funder/Sponsor Not applicable. Funding /Support : This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution SA conceptualized the study, designed the methodology, collected and analyzed the data, and wrote the manuscript. Acknowledgement The author thanks all persons with disabilities, caregivers, and community members who generously participated in this study. He also acknowledges the support of local NGOs and humanitarian agencies in facilitating data collection. Data Availability Datasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines. References UNICEF: MAKE IT COUNT: Disability Inclusive WASH Programme. Guidance Note on Disability Inclusive WASH Programme Data Collection, Monitoring and Reporting. United Nations International Children's Emergency Fund. 2020, Retrieved from: https://www.unicef.org/documents/make-it-count-disability-inclusive-wash-programme?utm_source=chatgpt.com Affairs, UNDoEaS. Ensuring access to water and sanitation services for all is a Facebook goal (Goal C6). UN-iLibrary 2019, Retrieved from: https://www.un-ilibrary.org/content/books/9789211065381c010 UNICEF: Thirsty, Hungry, and Unable to Wash. Unprecedented Obstacles Stand Between Gaza’s Families and Enough Safe Water. United Nations International Children's Emergency Fund. 2025, Retrieved from: https://www.unicef.org/sop/stories/thirsty-hungry-and-unable-wash Abuzerr S, Hamdan H, Charafeddine J. A qualitative study on gendered wash insecurity and health outcomes among internally displaced populations in conflict-affected context. BMC Public Health 2025. Abuzerr S. Challenges and Innovations in WASH and Disease Surveillance in Conflict Zones: Lessons from the Gaza Strip. 2025. Abuzerr S, Zinszer K. Addressing limited access to water sanitation and hygiene in Gaza strip shelters during conflict. Discover Public Health. 2025;22(1):21. UNICEF: WASH: water, sanitation and hygiene. Providing clean water to children in the State of Palestine. United Nations International Children's Emergency Fund. 2023, Retrieved from: https://www.unicef.org/sop/what-we-do/wash-water-sanitation-and-hygiene MSD: International Day of Persons with Disabilities: Empowering Persons with Disabilities Is a Collective Responsibility. Ministry of Social Development. 2025, Retrieved from: https://www.mosd.gov.ps/en/single-news/844?utm_source=chatgpt.com Nations U, State of Palestine Tells Committee on Rights of Persons with Disabilities. Percentage of Persons with Disabilities in Gaza Has Increased because of Excessive Use of Force by Israel,. UN 2025, Retrieved from: https://www.ungeneva.org/es/news-media/meeting-summary/2025/08/percentage-persons-disabilities-gaza-has-increased-because?utm_source=chatgpt.com Zinszer K, Abuzerr S. Water, sanitation, and hygiene insecurity and infectious disease outbreaks among internally displaced populations in Gaza: implications of conflict-driven displacement on public health. J Water Sanitation Hygiene Dev. 2024;14(11):1182–92. Abuzerr S, Hamdan H, Charafeddine J. Epidemiological surveillance of waterborne diseases among displaced populations: A cross-sectional study. PLOS Global Public Health. 2025;5(12):e0005527. White S, Kuper H, Itimu-Phiri A, Holm R, Biran A. A qualitative study of barriers to accessing water, sanitation and hygiene for disabled people in Malawi. PLoS ONE. 2016;11(5):e0155043. Namara F, Mendoza H, Tumukunde G, Wafula ST. Access to functional handwashing facilities and associated factors among South Sudanese refugees in rhino camp settlement, northwestern Uganda. J Environ public health. 2020;2020(1):3089063. Faure JC, Faust KM, Kaminsky J. Legitimization of the inclusion of cultural practices in the planning of water and sanitation services for displaced persons. Water. 2019;11(2):359. Mafuta W, Zuwarimwe J, Kamuzhanje J, Mwale M, Chipaike R. Sustainable Conflict Resolution through Community Based Water, Sanitation and Hygiene (WASH) Planning in Fragile and Conflict Situations: The Case of Somalia. J Asian Afr Stud. 2021;56(2):352–63. Richard D, Kiani S. Rapid review of disability and older age inclusion in humanitarian WASH interventions. 2019. Wilbur J, Dreibelbis R, Mactaggart I. Addressing water, sanitation and hygiene inequalities: A review of evidence, gaps, and recommendations for disability-inclusive WASH by 2030. PLoS Water. 2024;3(6):e0000257. House S, Chatterton C. Mapping of support for people living with incontinence in humanitarian contexts, Through the lens of WASH, GBV and ASRH, Main Report. In.: Norwegian Church Aid; 2022. Yates T, Vujcic JA, Joseph ML, Gallandat K, Lantagne D. Efficacy and effectiveness of water, sanitation, and hygiene interventions in emergencies in low-and middle-income countries: a systematic review. Waterlines 2018:31–65. Cavill S, Chuktu N, Farrington M, Hiscock D, Muturi C, Nath P, Staunton M. WASH and older people. SLH Learn Paper 2022, 12. WHO: Progress on household drinking-water, sanitation and hygiene 2000–2024: Special focus on inequalities. World Health Organization. 2025, Retrieved from: https://www.who.int/publications/m/item/progress-on-household-drinking-water--sanitation-and-hygiene-2000-2024--special-focus-on-inequalities UNICEF: Progress on household drinking water, sanitation and hygiene I 2000–2017. United Nations Children’s Fund. 2019, Retrieved from: https://www.unicef.org/media/55276/file/progress-on-drinking-%20water-sanitation-and-hygiene-2019.pdf Wilbur J, Clemens F, Sweet E, Banks LM, Morrison C. The inclusion of disability within efforts to address menstrual health during humanitarian emergencies: A systematized review. Front Water. 2022;4:983789. Win CZ, Dwipayanti NMU, Jawjit W. Application of Integrated Water, Sanitation and Hygiene (WASH) Assessment Tool in Displaced Settings in Rakhine State, Myanmar. Water. 2025;17(10):1476. Huggett C, Da Costa Cruz L, Goff F, Pheng P, Ton D. Beyond inclusion: practical lessons on striving for gender and disability transformational changes in WASH systems in Cambodia and Timor-Leste. H2Open J. 2022;5(1):26–42. Additional Declarations No competing interests reported. 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Globally, an estimated 1\u0026nbsp;billion persons live with some form of disability, yet persons with disabilities (PWDs) are disproportionately excluded from WASH services due to persisting physical, environmental, and social barriers in both development and humanitarian contexts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite the growing recognition of disability inclusion within the WASH sector, monitoring systems often fail to capture data disaggregated by disability, leaving the specific barriers faced by PWDs invisible in program design, implementation, and evaluation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePersons with disabilities frequently face multidimensional barriers to WASH participation, including inaccessible infrastructure, lack of assistive devices, social stigma, and increased dependence on caregivers. These barriers compound other vulnerabilities, such as poverty and displacement, contributing to poorer health outcomes, reduced dignity, and social exclusion [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In humanitarian settings, where infrastructure is disrupted and services are strained, these challenges are further exacerbated, and failure to address the specific needs of PWDs can render nominally \u0026ldquo;accessible\u0026rdquo; WASH facilities unusable in practice.\u003c/p\u003e \u003cp\u003eThe Gaza Strip illustrates an extreme manifestation of these challenges. After prolonged conflict and recurrent cycles of hostilities, the territory\u0026rsquo;s WASH infrastructure has been severely degraded, with critical systems for water supply and sanitation out of service for vast segments of the population [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. By mid-2025, an estimated 81% of public water and sanitation facilities were reported to be inaccessible to the broader population due to direct damage, restrictions on movement, and operational constraints imposed by ongoing hostilities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. UNICEF and other humanitarian agencies have documented acute shortages of safe drinking water and widespread reliance on inadequate or intermittent supplies, significantly increasing the risk of waterborne disease and hygiene-related health complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese conditions are particularly dire for persons with disabilities. Prior to the recent escalation of conflict, the Palestinian Central Bureau of Statistics estimated that approximately 58,000 individuals with disabilities resided in the Gaza Strip [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Since the onset of intensified hostilities in late 2023, government and civil society reports indicate that between 33,000 and 44,000 new disability cases have arisen, alongside widespread loss of assistive devices and rehabilitation services due to infrastructure destruction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Children are disproportionately affected; more than 15% of children in Gaza were reported to have a disability in 2025, and many have been displaced or lost access to essential services [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These compounding crises\u0026mdash;environmental, infrastructural, and social\u0026mdash;have intensified the exclusion of PWDs from basic services, magnifying their vulnerability within the broader humanitarian emergency.\u003c/p\u003e \u003cp\u003eDespite these intersecting vulnerabilities, little is known about how WASH facilities in displacement camps\u0026mdash;where hundreds of thousands have sought shelter\u0026mdash;meet (or fail to meet) the needs of persons with disabilities. Humanitarian guidelines emphasize the importance of disability-inclusive WASH programming, yet few empirical studies have examined how such facilities are experienced by users with diverse functional limitations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Existing literature from other crisis contexts highlights that superficial compliance with accessibility standards does not necessarily translate into functional access for PWDs, owing to factors such as poor maintenance, overcrowding, and contextual barriers that audits alone cannot capture [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This gap underscores the need for user-centered evaluation approaches that integrate both objective and experiential dimensions of accessibility.\u003c/p\u003e \u003cp\u003eThis study therefore investigates disability inclusion in humanitarian WASH facilities within Gaza displacement camps, exploring the degree to which infrastructure that is \u0026ldquo;accessible in theory\u0026rdquo; is actually \u0026ldquo;accessible in practice\u0026rdquo; to persons with disabilities and caregivers. By combining quantitative accessibility audits with structured observations and rich qualitative narratives, the research aims to illuminate the realized accessibility of WASH services, identify key barriers to equitable use, and propose context-specific recommendations for enhancing inclusion in crisis-affected environments.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional mixed-methods design to evaluate disability inclusion in humanitarian water, sanitation, and hygiene (WASH) facilities in displacement camps in the Gaza Strip. The design integrated quantitative accessibility audits and structured observations with qualitative user-centered methods, including in-depth interviews and participatory evaluation. This approach was selected to capture both objective measures of physical accessibility and subjective lived experiences of use, dignity, and autonomy, which are often inadequately reflected in infrastructure-only assessments [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study was conducted between 23 September and 26 December 2025, a period characterized by large-scale internal displacement, intermittent service provision, and heavy reliance on humanitarian WASH facilities.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was carried out in six displacement camps across the Gaza Strip, including both formal collective shelters and informal displacement sites. Camps were purposively selected to ensure variation in:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGeographic location (north, central, and southern Gaza),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCamp size and population density,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDuration of establishment,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImplementing agency responsible for WASH service provision (UN agencies, international NGOs, and local NGOs).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAll selected camps had communal WASH facilities serving large displaced populations, including shared latrines, bathing spaces, and water collection points.\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePersons with disabilities (PWDs) residing in the selected displacement camps, including individuals with:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePhysical or mobility impairments,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eVisual or hearing impairments,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntellectual disabilities,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePsychosocial disabilities.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrimary caregivers of PWDs, when individuals were unable to participate directly due to age, cognitive impairment, or communication barriers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDisability status was identified using an adapted version of the Washington Group Short Set of Questions on Disability, widely recommended for humanitarian and development settings to assess functional limitations rather than medical diagnoses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e were:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eResidence in the selected displacement camp for at least three months,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSelf-identified disability or caregiving responsibility for a person with a disability,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWillingness and ability to provide informed consent (or caregiver-mediated consent where appropriate).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIndividuals experiencing acute medical emergencies at the time of data collection were excluded to avoid undue burden.\u003c/p\u003e\n\u003ch3\u003eSampling Strategy\u003c/h3\u003e\n\u003cp\u003eA stratified purposive sampling strategy was employed. At the camp level, six displacement camps were selected to reflect diversity in WASH infrastructure typology and management. Within each camp, participants were recruited through collaboration with camp management committees, humanitarian partners, and community focal points for disability inclusion.\u003c/p\u003e \u003cp\u003eEfforts were made to ensure representation across disability types, gender, and age groups. In total, approximately 384 persons with disabilities and caregivers participated across all study components.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Methods\u003c/h2\u003e \u003cp\u003eThe semi-structured interview guide was specifically developed for this study to explore user experiences of accessibility, dignity, privacy, safety, and autonomy in relation to communal WASH facilities. The guide captured perceived barriers, coping strategies, psychosocial impacts, and gender- and disability-specific concerns. It was used alongside structured facility accessibility audits, structured observations, and participatory evaluation activities to enable triangulation of objective and subjective data. The interview guide is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Accessibility Audits of WASH Facilities\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA structured WASH accessibility audit tool was developed based on:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUNICEF disability-inclusive WASH guidance,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSphere Humanitarian Standards,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUniversal design principles.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAudits were conducted for all major communal WASH facilities in each camp, including latrines, bathing facilities, and water points. The audit assessed five core domains:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePhysical access (ramps, steps, gradients, door widths),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInternal usability (turning space, grab bars, seating),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSafety (floor conditions, lighting, privacy),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCommunication and signage (visibility, contrast),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHygiene usability (handwashing station height, water flow control).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEach domain was scored using predefined criteria, allowing the generation of facility-level accessibility scores.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Structured Observations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStructured observations were conducted to document actual use of WASH facilities by PWDs. Observations focused on:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTime required to access and use facilities,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLevel and type of assistance required,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSafety incidents or near-miss events,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAvoidance or alternative practices (e.g., delayed use, open defecation).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eObservations were conducted discreetly over multiple time periods to minimize reactivity and capture routine practices.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. User-Centered Qualitative Evaluation\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIn-Depth Interviews\u003c/h3\u003e\n\u003cp\u003eSemi-structured in-depth interviews (IDIs) were conducted with PWDs and caregivers to explore:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePerceived accessibility versus formal design features,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExperiences of dignity, privacy, and safety,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePhysical and emotional burden associated with WASH use,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived gaps between humanitarian standards and lived realities.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eInterviews were conducted in Arabic by trained researchers experienced in disability-sensitive and trauma-informed approaches. Reasonable accommodations, including caregiver support and alternative communication methods, were provided as needed.\u003c/p\u003e\n\u003ch3\u003eUser Journey Mapping\u003c/h3\u003e\n\u003cp\u003e Participants were guided to narrate step-by-step experiences of:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eFetching water,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUsing sanitation facilities,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eManaging personal hygiene.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese narratives were translated into user journey maps highlighting barriers, delays, and points of dependence on others. This method enabled visualization of how accessibility challenges accumulate across the WASH use pathway.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Participatory Evaluation Workshops\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipatory workshops were held in each camp with PWDs, caregivers, and selected WASH actors. Preliminary findings were presented and discussed to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eValidate emerging themes,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIdentify priority accessibility gaps,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCo-develop practical recommendations for humanitarian actors.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipatory evaluation methods were used to enhance contextual relevance and ensure that findings reflected user priorities rather than external assumptions.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative Analysis\u003c/h2\u003e \u003cp\u003eAccessibility audit scores and structured observation data were analyzed using descriptive statistics, including frequencies, medians, and interquartile ranges. Comparisons were conducted across facility types and camps to identify patterns of inclusion and exclusion.\u003c/p\u003e \u003cp\u003eInterview transcripts, observation notes, and workshop discussions were analyzed using thematic analysis. Coding followed an iterative process combining inductive themes with deductive categories informed by:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eRights-based approaches to disability,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe International Classification of Functioning, Disability and Health (ICF),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDisability-inclusive WASH frameworks.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo enhance rigor, a subset of transcripts was double-coded by two researchers, and discrepancies were resolved through discussion.\u003c/p\u003e \u003cp\u003eFindings from quantitative and qualitative components were integrated through methodological triangulation. This enabled comparison between formal accessibility features (\u0026ldquo;accessible in theory\u0026rdquo;) and actual user experiences (\u0026ldquo;accessible in practice\u0026rdquo;), strengthening interpretive validity.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003efor the study was obtained from the University College of Science and Technology Institutional Review Board (UCST-IRB/2/2026). All participants provided informed consent prior to participation. For individuals with intellectual or communication impairments, consent was obtained from caregivers alongside participant assent where feasible. Additional safeguards included confidential handling of all data, trauma-informed interviewing techniques, the right to withdraw at any time without consequence, and referral to humanitarian services where unmet needs were identified.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Study Participants and Study Sites\u003c/h2\u003e \u003cp\u003eA total of 384 participants, including persons with disabilities and their primary caregivers, were recruited from six displacement camps in the Gaza Strip. Participants were aged 6\u0026ndash;79 years (median 34, IQR 21\u0026ndash;52), with 26.8% under 18 years. Slightly more than half were women (52.6%), reflecting both gender distribution and caregiver roles. Most participants (71.4%) had been displaced for over six months, and 32.0% had experienced repeated displacement, often increasing reliance on communal WASH facilities.\u003c/p\u003e \u003cp\u003eParticipants reported diverse disabilities, with mobility impairments most common (41.7%), followed by visual (18.5%), hearing (14.3%), intellectual (13.0%), and psychosocial (12.5%) impairments. Many had multiple functional limitations. Using Washington Group domains, 62.2% had severe or very severe limitations, especially in walking/climbing and self-care. Over half (54.9%) used assistive devices, though many reported them as damaged, unavailable, or unsuitable. Dependence on caregivers was high, with 58.6% requiring partial or full assistance to use WASH facilities, particularly among those with mobility or intellectual disabilities, children, and older adults.\u003c/p\u003e \u003cp\u003eThe six camps included three formal collective shelters and three informal sites, housing 4,000\u0026ndash;18,000 people each. A total of 112 communal WASH facilities were assessed, including latrines, bathing spaces, and water points; latrines were most common. Facilities, mostly constructed during emergency response phases, were generally less than a year old (67.9%) but showed signs of rapid deterioration due to overcrowding, limited maintenance, and intermittent water supply. WASH services were managed by UN agencies, international NGOs, and local NGOs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-Demographic Characteristics and Disability Profile of Study Participants (N\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge Group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;59 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of Displacement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary Disability Type\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHearing impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntellectual disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeverity of Functional Limitation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere/very severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of Assistive Devices\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregiver Dependence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartially dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully dependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Participants may report more than one disability type.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eObjective Accessibility of Humanitarian WASH Facilities\u003c/h2\u003e \u003cp\u003eA total of 68 sanitation facilities, 24 bathing spaces, and 20 water points across six Gaza displacement camps were assessed. While 82.4% of sanitation facilities were nominally reachable, substantial physical barriers were identified. Ramps were present at 41.2% of latrines but only 18.0% met basic usability criteria; in their absence, access relied on steps without handrails. Door widths met minimum standards in 36.8% of latrines, and only 29.4% provided adequate internal space for maneuvering or assisted use.\u003c/p\u003e \u003cp\u003eBathing and personal hygiene facilities showed greater accessibility challenges. Adequate privacy was observed in 45.8%, non-slip flooring in 37.5%, and handrails in 25.0% of facilities. Only 20.8% allowed sufficient space for caregiver assistance, and safety concerns led some participants to avoid using these facilities entirely.\u003c/p\u003e \u003cp\u003eWater collection points varied widely in accessibility. Taps were at usable heights in 40.0% of cases, but over half (55.0%) were located more than 50 meters from shelters, often on unstable or slippery ground (35.0% stable). Physical effort and environmental hazards limited independent use, particularly for individuals with mobility or balance impairments.\u003c/p\u003e \u003cp\u003eComposite accessibility scores ranged from 18 to 72 out of 100. Overall, 61.6% of facilities were classified as low accessibility, 28.6% moderate, and 9.8% high. Bathing facilities had the lowest median scores, followed by sanitation units, with water points slightly higher but still suboptimal. Scores varied between camps; newer or NGO-supported facilities scored higher, whereas older or overcrowded camps scored lower. Presence of visible accessibility features did not consistently translate into functional usability, highlighting a gap between design intent and practical access (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObjective Accessibility of Humanitarian WASH Facilities by Facility Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessibility Indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSanitation Facilities (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBathing Facilities (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWater Points (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessible ramps present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRamps meeting usability criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate door width\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow/no entry threshold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (42.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSufficient internal maneuvering space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate privacy/enclosure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (55.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-slip flooring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (45.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandrails/grab bars present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccessible tap height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStable surrounding ground surface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian accessibility score (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (28\u0026ndash;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (24\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (35\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eObserved Use of WASH Facilities by Persons with Disabilities\u003c/h2\u003e \u003cp\u003eObservations revealed substantial time, physical effort, and fatigue associated with WASH activities. Median travel times were 7 minutes (IQR 4\u0026ndash;12) for sanitation/bathing and 9 minutes (IQR 6\u0026ndash;15) for water collection, longer for participants with mobility impairments or in larger camps. Median completion times were 14 minutes for sanitation and 21 minutes for bathing, particularly prolonged for those requiring assistance or navigating restricted spaces. Over 63% of participants exhibited visible fatigue, including balance difficulties and reliance on walls or fixtures.\u003c/p\u003e \u003cp\u003eMore than half of WASH activities (58.6%) required caregiver assistance, including lifting/transferring (41.3%), guiding/stabilizing (36.9%), and managing hygiene tasks (44.8%). Caregiving often fell on women and adolescent girls, adding physical and emotional strain due to frequent, intimate assistance under limited privacy.\u003c/p\u003e \u003cp\u003eSafety risks were common. Falls or near-falls occurred in 27.9% of visits, slips causing minor injuries in 14.6%, and fear of unaccompanied use was reported by 48.2%, especially among visually impaired and psychosocially vulnerable participants.\u003c/p\u003e \u003cp\u003eAvoidance behaviors were widespread. Delayed use of sanitation facilities was reported by 39.3%, reduced bathing/handwashing by 46.1%, and 11.2% resorted to open defecation or improvised solutions. These practices were most frequent among participants with severe mobility impairments or in camps with low accessibility scores (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObserved Use, Assistance Needs, and Safety Risks During WASH Activities Among Persons with Disabilities (N\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservational Indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMedian time to reach WASH facilities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian time to complete WASH activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisible physical strain/fatigue observed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRequired physical assistance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Lifting/transferring assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Guiding/stabilizing assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Cleaning/hygiene assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFalls or near-falls\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSlip-related minor injuries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFear of using facilities unaccompanied\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelayed use of sanitation facilities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReduced hygiene frequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpen defecation or improvised solutions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants may report or exhibit more than one outcome.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eUser Experiences of Accessibility, Dignity, and Autonomy\u003c/h2\u003e \u003cp\u003eParticipants acknowledged visible accessibility features\u0026mdash;ramps, handrails, and designated units\u0026mdash;leading to an initial perception of compliance. About 61.5% noted at least one feature, but only 29.7% believed these were designed to meet actual needs, with many describing them as \u0026ldquo;visible but not usable,\u0026rdquo; highlighting a gap between standards and practical use.\u003c/p\u003e \u003cp\u003eDespite apparent compliance, multiple barriers limited functional access. Physical barriers\u0026mdash;steep ramps, narrow doors, high thresholds, and limited internal space\u0026mdash;affected 68.2% of participants. Environmental barriers, including muddy/flooded pathways, poor lighting, and overcrowding, impacted 57.8%, while operational barriers\u0026mdash;queues, broken locks, intermittent water, and poor maintenance\u0026mdash;affected 62.4%.\u003c/p\u003e \u003cp\u003eDignity and psychosocial impacts were widespread. Loss of privacy was reported by 53.6%, embarrassment by 47.9%, and fear of injury or exposure by 48.2%, especially among previously independent adolescents and adults. Women and girls reported heightened privacy and safety concerns, including challenges managing menstrual hygiene, leading some to avoid facilities entirely.\u003c/p\u003e \u003cp\u003eExperiences varied by disability type and gender. Mobility-impaired participants faced the greatest exclusion and reliance on caregivers. Sensory-impaired participants struggled with navigation and environmental unpredictability, while those with intellectual disabilities faced difficulty understanding layouts or social norms. Women, girls, and children with disabilities faced compounded barriers, leading to layered exclusion where disability, gender, and age jointly shaped WASH access (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUser-Reported Experiences of Accessibility, Dignity, and Psychosocial Impact (N\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived presence of accessibility features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of disability-inclusive design intent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReported physical barriers to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnvironmental/contextual barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperational barriers (crowding, maintenance, water shortages)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoss of privacy during WASH use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeelings of shame or embarrassment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of injury or exposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased dependence on caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender-specific concerns reported (women/girls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferential challenges by disability type reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants may report multiple experiences.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eUser Journey Mapping: Pathways of Exclusion\u003c/h2\u003e \u003cp\u003eUser journey mapping revealed multiple points of exclusion across sanitation, water collection, and personal hygiene for persons with disabilities in Gaza displacement camps.\u003c/p\u003e \u003cp\u003eSanitation facilities posed barriers at every stage. Entry was hindered by steep ramps, narrow doorways, and obstructed pathways, often requiring caregiver assistance. Cramped internal space, inadequate handrails, and lack of supportive fixtures limited use, while wet or uneven floors complicated exit. Broken doors, non-functional locks, and slippery surfaces were common points of failure, leading participants to pause or avoid use due to fatigue, fear, or dependence.\u003c/p\u003e \u003cp\u003eWater collection was physically demanding, with participants carrying containers above waist height, navigating uneven paths, and queuing. About 44% relied on caregivers or peers, particularly wheelchair users, older adults, and those with upper-limb impairments. Women and adolescent girls disproportionately bore caregiving burdens, increasing fatigue, injury risk, and stress.\u003c/p\u003e \u003cp\u003ePersonal hygiene and bathing faced privacy and safety constraints. Most communal bathing facilities were overcrowded, poorly enclosed, or lacked functional doors and locks, deterring use, especially among women and adolescents. Over half of participants required caregiver assistance for transfers, bathing, or hygiene tasks. Dependence, limited autonomy, and fear of injury contributed to reduced bathing frequency and use of improvised hygiene practices (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUser Journey Mapping: Points of Exclusion Across WASH Pathways (N\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWASH Pathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Barriers / Points of Failure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e% of Participants Affected\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSanitation Facilities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEntry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSteep/uneven ramps, obstructed pathways, narrow doors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited internal space, lack of handrails, non-functional fixtures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSlippery or uneven floors, steps without support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eWater Collection \u0026amp; Transport\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh taps, long distances, queuing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCarrying heavy containers, unstable surfaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReliance on others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLifting/assistance from caregivers or peers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePersonal Hygiene \u0026amp; Bathing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOvercrowding, poorly enclosed spaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeed for physical assistance, lack of grab bars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSafety / Privacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFear of injury, exposure, dependence on caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eParticipatory Evaluation Findings\u003c/h2\u003e \u003cp\u003e Participatory sessions provided insights into priorities, barriers, and solutions identified by persons with disabilities and caregivers, complementing audits and observations.\u003c/p\u003e \u003cp\u003eUser-identified barriers included physical obstacles (steep ramps, narrow doors, limited internal space; 68.5%), operational challenges (overcrowding, water shortages, poor maintenance; 61.2%), and privacy/safety concerns (54.7%), particularly for women, girls, and those needing assistance. Mobility challenges, lack of handrails, high thresholds, facility distance, non-functional doors, and water scarcity were consistently ranked as the most severe.\u003c/p\u003e \u003cp\u003eProposed solutions focused on low-cost, locally feasible adaptations, including non-slip surfaces, handrails, widened doors, improved maneuvering space, reduced water distances or mobile carts, queuing modifications, and enhanced maintenance. Participants suggested locally sourced ramps, adjustable platforms, and tactile markings for visually impaired users, emphasizing rapid, context-appropriate improvements.\u003c/p\u003e \u003cp\u003ePolicy-practice gaps were evident. While 52.3% were aware of disability-inclusive policies, many facilities remained functionally inaccessible, with inadequate monitoring and limited consultation with users. Participants highlighted persistent exclusion despite formal commitments, underscoring the need for accountability and participatory planning to bridge these gaps (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipatory Evaluation Findings: User-Prioritized Barriers and Proposed Adaptations (N\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% of Participants Reporting / Prioritizing\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePriority Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical accessibility gaps (ramps, thresholds, narrow doors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperational barriers (crowding, water shortages, maintenance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivacy and safety concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eProposed Solutions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstall non-slip surfaces, handrails, grab bars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWiden doors and internal space for maneuvering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduce water collection distances / mobile carts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQueue management and crowd reduction strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegular maintenance and supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocally feasible innovations (ramps, tactile markings)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePolicy vs Practice Gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness of inclusion policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiences of exclusion despite policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants could report multiple barriers, solutions, or observations.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comprehensive, user-centered evaluation of disability inclusion in humanitarian WASH facilities within Gaza displacement camps, highlighting the persistent gap between theoretical accessibility and functional usability. Our findings demonstrate that, while many facilities include nominal accessibility features, structural, operational, and psychosocial barriers continue to restrict independent use, dignity, and autonomy among persons with disabilities.\u003c/p\u003e \u003cp\u003ePhysical and structural barriers were pervasive across all facility types. Despite ramps, handrails, and wider doors being present in some facilities, many were inadequately constructed, poorly maintained, or obstructed, rendering them unusable. This aligns with prior studies in humanitarian contexts, where the mere presence of accessibility features does not guarantee functional use for persons with disabilities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Gaza, high thresholds, cramped internal spaces, and uneven pathways compounded challenges, particularly for wheelchair users and those with mobility impairments, corroborating previous reports of infrastructure inadequacies in conflict-affected settings [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOperational and environmental factors significantly affected access. Overcrowding, intermittent water supply, broken locks, and poor drainage limited usability, even in structurally \u0026ldquo;compliant\u0026rdquo; facilities. This supports evidence from other displacement contexts, where service reliability and environmental hazards frequently undermine nominal accessibility [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Notably, participants reported that fear of injury, fatigue, and dependence on caregivers often dictated facility use, highlighting the interplay between infrastructure and psychosocial determinants of accessibility, as emphasized in the conceptual frameworks of inclusive WASH [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrivacy, dignity, and autonomy emerged as critical dimensions of WASH inclusion. Women and girls with disabilities reported heightened concerns, including exposure during menstruation and reliance on caregivers for intimate tasks. These findings are consistent with studies showing that gender and disability intersect to exacerbate exclusion in communal facilities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Loss of privacy, feelings of shame, and fear of injury contributed to avoidance behaviors, including delayed use or improvised hygiene practices, with potential public health implications such as reduced handwashing, hygiene-related disease risk, and psychological distress [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipatory evaluations reinforced the gap between policy and practice. While many participants were aware of humanitarian inclusion policies, functional implementation lagged. Users highlighted low-cost, context-appropriate solutions\u0026mdash;such as locally sourced ramps, tactile markers, and modified queuing\u0026mdash;that could improve accessibility with minimal investment. This aligns with evidence suggesting that participatory design and local adaptation are key enablers of inclusive WASH in resource-constrained or conflict-affected settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur integration of audit, observational, and participatory data identified three primary mechanisms of exclusion:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStructural inadequacy \u0026ndash; features present but poorly designed or maintained, limiting functionality.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOperational constraints \u0026ndash; water shortages, crowding, and environmental hazards reducing usability.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDependence and psychosocial barriers \u0026ndash; fear, stigma, and reliance on caregivers restricting autonomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThese findings highlight the cumulative nature of exclusion, where interacting structural, environmental, and social factors prevent meaningful access, even when nominal standards are met. Similar patterns have been reported in studies from refugee camps in Jordan, Uganda, and Bangladesh, suggesting that these challenges are not unique to Gaza [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings have several practical implications:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInclusive design must go beyond nominal compliance, ensuring functional usability across disability types and ages. Simple features like ramps, handrails, or wider doors are insufficient if poorly constructed or maintained.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOperational management is critical; adequate water supply, maintenance, and crowd management are essential to translate structural accessibility into functional access.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParticipatory planning involving persons with disabilities and caregivers can identify feasible, low-cost adaptations that enhance usability, safety, and dignity.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGender-sensitive considerations should be integrated, particularly for communal bathing and sanitation facilities, to address privacy, safety, and menstrual hygiene management.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese recommendations are consistent with international guidance on disability-inclusive WASH in humanitarian settings [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study benefits from a mixed-methods, user-centered approach, integrating objective audits, direct observation, and participatory evaluations, providing a holistic understanding of WASH accessibility. The large sample size (n\u0026thinsp;=\u0026thinsp;384) across multiple camps enhances generalizability within the Gaza context. However, limitations exist. First, findings may not fully represent all displacement settings or non-camp populations. Second, observational measures may have introduced some Hawthorne effect, as participants knew they were being observed. Third, reliance on self-reported perceptions may introduce bias, though triangulation with objective audits mitigates this risk.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePersons with disabilities in Gaza displacement camps face persistent barriers to WASH access, even when facilities nominally meet accessibility standards. Physical, operational, and psychosocial factors converge to limit independence, dignity, and health. Participatory, user-centered approaches can identify feasible adaptations, bridging the gap between policy and practice. Humanitarian agencies should prioritize functional accessibility, operational reliability, and participatory design, ensuring that WASH services are genuinely inclusive for all users.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent of participation\u003c/strong\u003e: The study was approved by the University College of Science and Technology Institutional Review Board (UCST-IRB/4/2026) and was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all adult participants and from caregivers of children or individuals unable to provide consent independently. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Sharing Statement\u003c/strong\u003e \u003cp\u003e Datasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable. This manuscript does not contain any identifying images or other personal or clinical details of participants that compromise anonymity.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests:\u003c/strong\u003e \u003cp\u003eThe author declares no competing interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRole of the Funder/Sponsor\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e \u003cb\u003e/Support\u003c/b\u003e: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSA conceptualized the study, designed the methodology, collected and analyzed the data, and wrote the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe author thanks all persons with disabilities, caregivers, and community members who generously participated in this study. He also acknowledges the support of local NGOs and humanitarian agencies in facilitating data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDatasets are available from the corresponding author upon reasonable request, in accordance with data transparency and ethical guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF: MAKE IT COUNT: Disability Inclusive WASH Programme. Guidance Note on Disability Inclusive WASH Programme Data Collection, Monitoring and Reporting. United Nations International Children's Emergency Fund. 2020, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/documents/make-it-count-disability-inclusive-wash-programme?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/documents/make-it-count-disability-inclusive-wash-programme?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAffairs, UNDoEaS. Ensuring access to water and sanitation services for all is a Facebook goal (Goal C6). \u003cem\u003eUN-iLibrary\u003c/em\u003e 2019, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.un-ilibrary.org/content/books/9789211065381c010\u003c/span\u003e\u003cspan address=\"https://www.un-ilibrary.org/content/books/9789211065381c010\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF: Thirsty, Hungry, and Unable to Wash. Unprecedented Obstacles Stand Between Gaza\u0026rsquo;s Families and Enough Safe Water. United Nations International Children's Emergency Fund. 2025, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/sop/stories/thirsty-hungry-and-unable-wash\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/sop/stories/thirsty-hungry-and-unable-wash\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuzerr S, Hamdan H, Charafeddine J. A qualitative study on gendered wash insecurity and health outcomes among internally displaced populations in conflict-affected context. BMC Public Health 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuzerr S. Challenges and Innovations in WASH and Disease Surveillance in Conflict Zones: Lessons from the Gaza Strip. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuzerr S, Zinszer K. Addressing limited access to water sanitation and hygiene in Gaza strip shelters during conflict. Discover Public Health. 2025;22(1):21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF: WASH: water, sanitation and hygiene. Providing clean water to children in the State of Palestine. United Nations International Children's Emergency Fund. 2023, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/sop/what-we-do/wash-water-sanitation-and-hygiene\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/sop/what-we-do/wash-water-sanitation-and-hygiene\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMSD: International Day of Persons with Disabilities: Empowering Persons with Disabilities Is a Collective Responsibility. Ministry of Social Development. 2025, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mosd.gov.ps/en/single-news/844?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://www.mosd.gov.ps/en/single-news/844?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNations U, State of Palestine Tells Committee on Rights of Persons with Disabilities. Percentage of Persons with Disabilities in Gaza Has Increased because of Excessive Use of Force by Israel,. \u003cem\u003eUN\u003c/em\u003e 2025, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ungeneva.org/es/news-media/meeting-summary/2025/08/percentage-persons-disabilities-gaza-has-increased-because?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://www.ungeneva.org/es/news-media/meeting-summary/2025/08/percentage-persons-disabilities-gaza-has-increased-because?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZinszer K, Abuzerr S. Water, sanitation, and hygiene insecurity and infectious disease outbreaks among internally displaced populations in Gaza: implications of conflict-driven displacement on public health. J Water Sanitation Hygiene Dev. 2024;14(11):1182\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuzerr S, Hamdan H, Charafeddine J. Epidemiological surveillance of waterborne diseases among displaced populations: A cross-sectional study. PLOS Global Public Health. 2025;5(12):e0005527.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite S, Kuper H, Itimu-Phiri A, Holm R, Biran A. A qualitative study of barriers to accessing water, sanitation and hygiene for disabled people in Malawi. PLoS ONE. 2016;11(5):e0155043.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNamara F, Mendoza H, Tumukunde G, Wafula ST. Access to functional handwashing facilities and associated factors among South Sudanese refugees in rhino camp settlement, northwestern Uganda. J Environ public health. 2020;2020(1):3089063.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaure JC, Faust KM, Kaminsky J. Legitimization of the inclusion of cultural practices in the planning of water and sanitation services for displaced persons. Water. 2019;11(2):359.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMafuta W, Zuwarimwe J, Kamuzhanje J, Mwale M, Chipaike R. Sustainable Conflict Resolution through Community Based Water, Sanitation and Hygiene (WASH) Planning in Fragile and Conflict Situations: The Case of Somalia. J Asian Afr Stud. 2021;56(2):352\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichard D, Kiani S. Rapid review of disability and older age inclusion in humanitarian WASH interventions. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilbur J, Dreibelbis R, Mactaggart I. Addressing water, sanitation and hygiene inequalities: A review of evidence, gaps, and recommendations for disability-inclusive WASH by 2030. PLoS Water. 2024;3(6):e0000257.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHouse S, Chatterton C. Mapping of support for people living with incontinence in humanitarian contexts, Through the lens of WASH, GBV and ASRH, Main Report. In.: Norwegian Church Aid; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYates T, Vujcic JA, Joseph ML, Gallandat K, Lantagne D. Efficacy and effectiveness of water, sanitation, and hygiene interventions in emergencies in low-and middle-income countries: a systematic review. Waterlines 2018:31\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavill S, Chuktu N, Farrington M, Hiscock D, Muturi C, Nath P, Staunton M. WASH and older people. SLH Learn Paper 2022, 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO: Progress on household drinking-water, sanitation and hygiene 2000\u0026ndash;2024: Special focus on inequalities. World Health Organization. 2025, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/m/item/progress-on-household-drinking-water--sanitation-and-hygiene-2000-2024--special-focus-on-inequalities\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/m/item/progress-on-household-drinking-water--sanitation-and-hygiene-2000-2024--special-focus-on-inequalities\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF: Progress on household drinking water, sanitation and hygiene I 2000\u0026ndash;2017. United Nations Children\u0026rsquo;s Fund. 2019, Retrieved from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/media/55276/file/progress-on-drinking-%20water-sanitation-and-hygiene-2019.pdf\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/media/55276/file/progress-on-drinking-%20water-sanitation-and-hygiene-2019.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilbur J, Clemens F, Sweet E, Banks LM, Morrison C. The inclusion of disability within efforts to address menstrual health during humanitarian emergencies: A systematized review. Front Water. 2022;4:983789.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWin CZ, Dwipayanti NMU, Jawjit W. Application of Integrated Water, Sanitation and Hygiene (WASH) Assessment Tool in Displaced Settings in Rakhine State, Myanmar. Water. 2025;17(10):1476.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuggett C, Da Costa Cruz L, Goff F, Pheng P, Ton D. Beyond inclusion: practical lessons on striving for gender and disability transformational changes in WASH systems in Cambodia and Timor-Leste. H2Open J. 2022;5(1):26\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Disability inclusion, WASH, displacement camps, Gaza Strip, humanitarian settings, accessibility","lastPublishedDoi":"10.21203/rs.3.rs-8539145/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8539145/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePersons with disabilities in displacement settings face persistent barriers to safe, dignified, and independent access to water, sanitation, and hygiene (WASH) facilities. Evidence on functional accessibility in conflict-affected Gaza is limited. This study evaluated the objective and perceived accessibility of humanitarian WASH facilities and examined user experiences in Gaza displacement camps.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween 23 September and 26 December 2025, a mixed-methods study was conducted across six displacement camps. A total of 384 participants, including persons with disabilities and caregivers, were recruited. Data collection included structured facility audits, observations of WASH use, and participatory evaluation sessions. Composite accessibility scores were calculated, and qualitative findings were thematically analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMost WASH facilities were nominally \u0026ldquo;accessible,\u0026rdquo; but structural, operational, and environmental barriers limited functional use. Ramps, handrails, and widened doors were often inadequate or poorly maintained. Privacy and safety constraints disproportionately affected women, girls, and participants requiring assistance. Over 58% relied on caregivers for facility use, and 39\u0026ndash;46% reported delayed or reduced hygiene practices. Composite accessibility scores were low in 61.6% of facilities, with bathing spaces scoring worst. Participants identified priority barriers and suggested low-cost, context-appropriate adaptations, including handrails, non-slip surfaces, improved maneuvering space, and participatory design. Despite awareness of disability-inclusive policies, functional inclusion remained limited.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePersons with disabilities in Gaza displacement camps experience a persistent gap between theoretical accessibility and practical usability of WASH facilities. Integrating structural improvements, operational reliability, and participatory design is critical to ensure inclusive, safe, and dignified WASH services.\u003c/p\u003e","manuscriptTitle":"Accessible in Theory, Inaccessible in Practice: A User-Centered Evaluation of Disability Inclusion in Humanitarian WASH Facilities in Gaza Displacement Camps","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 18:31:33","doi":"10.21203/rs.3.rs-8539145/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-07T16:49:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78143318193161277021201793898252962474","date":"2026-03-25T20:55:53+00:00","index":"hide","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T13:16:25+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T09:24:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T03:28:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-12T18:28:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-12T18:22:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e95707af-b374-4f2a-b171-4b916817102e","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T18:31:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 18:31:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8539145","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8539145","identity":"rs-8539145","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}