Community hygiene norm violators are consistently stigmatized: Evidence from four global sites and implications for sanitation interventions

Acculturation of hygiene norms among immigrants to Sweden

Hygiene norms in Sweden are generally loose compared to most other countries. Does this looseness affect the hygiene norms among people who immigrate to Sweden from other countries? In a study of hygiene norms among immigrants to Sweden, the change in the physical environment and material living conditions, acculturation to Swedish culture and norms, and selection effects were all expected to lead immigrant hygiene norms to be closer to Swedish looseness. However, in a sample of 447 immigrants from 12 different countries, immigrants reported hygiene norms that were even stricter than those found in their countries of origin. We propose an explanation based on a combination of uncertainty about prevailing hygiene norms and the social risk and stigma associated with being perceived as unhygienic. We conclude that acculturation processes may rely on mechanisms that are domain specific.

Gender dynamics of community-led total sanitation interventions in Mpwapwa District, Tanzania

ABSTRACTGender equity is an important element of health promotion and is vital to ensuring that the benefits and burdens of participation in health promotion activities are fairly distributed. Yet, the gendered consequences of participatory interventions are often overlooked. This is particularly relevant for water and sanitation initiatives, given that women are generally responsible for maintaining domestic hygiene and procuring water. This study uses a qualitative approach to assess the gender dynamics of participation in community-led total sanitation (CLTS) activities in Mpwapwa District, Tanzania. We used semi-structured interviews and focus-group discussions to investigate men's and women's involvement in health promotion initiatives and their key motivators for and challenges to participation. We interviewed 77 community members from four villages and analysed the responses using qualitative content analysis. The study supports the notion that participation reinforces gender inequity and reproduces gendered norms due to activity-specific participation, women's passive participation within activities, and their limited opportunities for decision-making. However, there were also indications that participation provided a platform to increase the status of women, prioritise women's needs and demand a stronger position in decision making within the household and the community. CLTS organisers should, therefore, harness the opportunity to address gender inequalities within the community.

How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq

This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq–a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

A Structured Review of Emotional Barriers to WASH Provision for Schoolgirls Post-Disaster

Pubescent girls face unique emotional barriers to returning to school after a disaster concerning water, sanitation and hygiene (WASH). This paper explores themes of WASH, gender violence, the lack of dignity and sense of shame arising from inadequate WASH facilities for girls in disaster settings. We conducted a structured literature review of 126 sources to investigate the emotional constraints facing pubescent girls concerning WASH in schools in Indonesia, a region prone to frequent disasters. Findings are synthesised into four major themes: psychological experiences of WASH, challenges faced by girls in schools, barriers to inclusive WASH provision and how to create a holistic approach to WASH. Key conclusions include the need for interdisciplinary research, cross sectoral collaboration, more evidence and research in Indonesia, especially regarding menstrual hygiene management, improved toilet design to reduce the physical barriers linked to emotional barriers and inclusive design for those with disabilities.

Global Water, Sanitation, and Hygiene Approaches: Anthropological Contributions and Future Directions for Engineering

Anthropologists contribute key insights toward a comprehensive understanding of water, sanitation, and hygiene (WASH) as a multidimensional, multiscalar, and culturally embedded phenomenon. Yet, these insights have yet to be sufficiently operationalized and implemented in WASH development and wider WASH access-related paradigms. Ensuring WASH security requires a comprehensive approach to identifying both human health risk and environmental impact of WASH-related programs and strategies. It requires an understanding of how sanitation is integrated into households and communities and how individuals within particular cultural contexts practice sanitation and hygiene. This work facilitates that goal by outlining the major contributions of anthropology and allied social sciences to WASH, as well as outlining key considerations for future work and collaboration. We identify six major themes that, if applied in future engineering approaches, will more equitably integrate stakeholders and multiple vantage points in the successful implementation of WASH projects for marginalized and diverse groups. These include a critical understanding of previous approaches, culturally aware interventions, capacity building that considers (un)intended impact, co-created technology, collaboration between fields such as anthropology and engineering, and challenge-ready initiatives that respond to historic and emergent social and environmental inequity.

Geographies of insecure water access and the housing-water nexus in US cities

Safe, reliable, and equitable water access is critical to human health and livelihoods. In the United States, an estimated 471,000 households or 1.1 million individuals lack a piped water connection and 73% of households are located in cities, close to networked supply. In this study, we undertake a nationwide analysis of urban water access in the United States, with the aim of explaining the drivers of infrastructural inequality in the 50 largest metropolitan areas. Drawing on statistical analysis and regression modeling of census microdata at the household scale, our analysis reveals spatial and sociodemographic patterns of racialized, class-based, and housing disparities that characterize plumbing poverty. Among unplumbed households, we show that households headed by people of color are almost 35% more likely to lack piped water as compared to white, non-Hispanic households. Precarious housing conditions are an equally strong predictor: Renter-occupied households in the 50 largest US metros were 1.61 times more likely than owner-occupied households to lack piped water. We argue that insecure domestic water access in the United States should be understood as a housing issue that reflects structural inequalities of race and class, particularly in cities with widening wealth gaps. The article concludes with a call for research and action at the intersection of water provision, housing, and social inequality-a paradigm we call the housing-water nexus.

Water and mental health

There is a well‐established connection among water quality, sanitation, and physical health. The potentially important relationship between water and mental health is considerably less studied. Reviewing evidence from ethnography, geography, folklore, indigenous studies, rural medicine, drought research, and large‐n statistical studies, we argue there is now good theoretical rationale and growing evidence of water insecurity as a possible driver of mental ill‐health. Furthermore, some nascent evidence suggests that emotionally meaningful interactions with water might improve mental health outcomes. Leveraging these literatures, we address the many ways in which mental health outcomes are conceptualized and operationalized in water research, including as emotional distress, perceived stress, depressive symptoms, anxiety symptoms, somatic symptoms, and quality of life. We outline arguments supporting seven possible (and likely interlocking) mechanisms that could explain such a relationship: (a) material deprivation and related uncertainty, (b) shame of social failure, (c) worry about health threats, (d) loss of connections to people and places, (e) frustration around opportunity losses and restricted autonomy, (f) interpersonal conflict and intimate partner violence, and (g) institutional injustice or unfairness. However, we explain that as most existing studies are ethnographic, qualitative, or cross‐sectional, a causal relationship between water and mental ill‐health is yet to be confirmed empirically. More research on this topic is needed, particularly given that poorly understood connections may create barriers to achieving Sustainable Development Goals 3 (health) and 6 (water). We further suggest that tracking mental health indicators may provide unique and as‐yet underappreciated insights into the efficacy of water projects and other development interventions.

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Water insecurity: An agenda for research and call to action for human biology

Water insecurity-the lack of adequate and safe water for a healthy and productive life-is one of the greatest threats facing humans in the coming century. By 2030, half of the world is expected to be living in water-stressed conditions, given current climate change scenarios. A key goal of the UN Water Action Decade and Sustainable Development Goal 6 is to improve water security for the three billion people globally affected, but the future looks grim. For many communities, from Cape Town, South Africa to Flint, United States, the imagined dystopian future of severe water shortages has already arrived-shaped not so much by lack of water, but by aging infrastructure, underfunded utilities, social exclusion, politicized commodification, and environmental racism. Stepping off from my biocultural research in Cochabamba, Bolivia, I discuss how recent research is dramatically advancing our understanding of water insecurity, such as new findings around the biocultural causes and consequences of dehydration, contamination, and water stress. But, much more needs be done to support local communities in creating fair and just water systems. I discuss how human biologists can make crucial contributions toward the advancement of a much-needed science of water insecurity, while highlighting some practical and ethical challenges to advancing a core mission of providing safe, sufficient water to all.

Household water insecurity may influence common mental disorders directly and indirectly through multiple pathways: Evidence from Haiti

Living in poverty significantly elevates risk of common mental disorders, but the underlying mechanisms are poorly specified. The stress of coping with household food insecurity is posed as one fundamental driver. While much less tested, the stress of failing to meet household water needs may also matter. We test (a) a hypothesized direct influence of household water insecurity (as household access to water sources and quality/quantity of water available in the household) on anxiety and depression symptoms. We also test (b) if there are indirect (mediated) effects of these aspects of water insecurity on common mental disorder symptom levels via household food insecurity, and (c) via their association with sanitation insecurity (lack of toilet). Data were collected in Haiti in June-July 2016 from 4,055 geographically-sampled households representing three distinct low-resource communities, purposefully differentiated as urban, town, and rural. We confirm that household water insecurity exerts a direct, strong independent effect on anxiety and depression levels, even once food insecurity and household assets are taken into account. Additionally, household water insecurity appears to have an indirect effect on anxiety and depression levels through its influence on household food insecurity. In the rural community sample, there is also support for the proposition of additional influence of household water on anxiety through its association with lack of sanitation. This Haitian case supports theories posing a central, influential role for household water insecurity as a potential driver of common mental illness in low-resource households via direct and indirect (food insecurity, sanitation) pathways.

Stigma: A biocultural proposal for integrating evolutionary and political-economic approaches

OBJECTIVES

Stigma-the process by which people become socially discredited because they hold a characteristic that is classified as unacceptable or undesirable-has barely been considered in biocultural analyses. Yet, it provides an acute point of articulation for evolutionary and political-economic perspectives on human variation, including the biocultural production of health disparities. To explain the theoretical integration of the two perspectives to stigma, we first lay out some operationalizable definitions of stigma, and review feasible methods to capture them in the field. We then test the roles of predictors suggested from evolutionary (respondent's level of disgust, fear of contagion) and political-economic (respondent's perceived social standing and negative social labeling of those who violate hygiene norms) theories of stigma.

METHODS

We used survey, interview, and behavioral report data from a study of hygiene behaviors at four local community sites in Guatemala, Fiji, New Zealand, and the United States (N = 300). We applied a hierarchical GLMM design that treats site as a random effect.

RESULTS

The independent influences of both variable sets are evident in publicly visible forms of reported hygiene behaviors, specifically the exhibition of clean bodies, clothes, and homes.

CONCLUSION

We propose that the study of stigma provides a productive operationalizable space to engage the promise of the biocultural synthesis to integrate evolutionary and political-economic models of health and human variation.

Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia

Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as "bad women", while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.

The Enabling Environment for Participation in Water and Sanitation: A Conceptual Framework

Participatory approaches are an important component of institutional frameworks for the governance of water resources and services. Studies on public participation in water management provide evidence for the outcomes of public participation and insights into the types of methods and the contexts under which participation can be meaningful. However, participatory processes are complex, and there is no single method by which to interpret, approach and implement them. This paper explores elements from the theory and practice of participation, applied to the management of water resources and water and sanitation services. Based on an in-depth literature review, we analyze the forms of participation in water and sanitation, their outcomes, as well as the contextual factors and procedural elements of participatory processes that affect their success. Contextual factors are those that are largely outside of the control of agencies or participants (e.g., demographics, history, and culture) or those that can only be influenced by management and institutional decisions in the mid- and long-term (e.g., the legal and institutional framework); while procedural elements are those over which agencies and participants have considerable control when designing and executing participatory efforts (e.g., representativeness and inclusivity, access to information, and opportunity to influence). We propose a framework that interrelates and integrates both contextual factors and procedural elements of participation. It, includes three additional aspects that are influenced by, and in turn influence, the context and the process: existing capacities for implementation of meaningful participatory processes, the resources that are allocated to them, and attitudes towards participatory processes. The framework helps conceptualize what we call the enabling environment for active, free, and meaningful participation in the delivery of water and sanitation services. By breaking down the complexities of participation, the framework supports practitioners and decision-makers to better design and implement participatory processes in water resources and water and sanitation services.