Cultural and socio-economic conditions as factors contributing to chronic stress in sub-Saharan African communities

Maternal stress and hair cortisol among pregnant women following hurricane Florence

Natural disasters represent major stressors, resulting in psychological distress and physiological responses such as increased cortisol. During pregnancy, this impacts not only maternal well-being, but also fetal development. In 2018, Hurricane Florence caused extensive damage across the eastern United States. Studies indicated that compared to married pregnant women, unmarried pregnant women had higher risk of distress. Here we assess hair cortisol among a subsample of participants, and variations based on marital status.

METHODS

We analyzed multiple stress measures among 37 participants who were pregnant during Hurricane Florence. We used questionnaires modeled on previous studies to assess hardship associated with the hurricane, psychological distress, sociodemographic characteristics, social support, and food security. We analyzed cortisol concentrations in proximal and distal hair sections, representing stress around the time of the disaster (distal) and 3-4 months following the disaster (proximal). We used linear regression to test relationships between hair cortisol and self-report stress measures, and variations based on marital status.

RESULTS

Self-report measures of distress and hardship were similar among married and unmarried participants. Mean cortisol levels in distal and proximal sections were higher among unmarried participants. Controlling for confounding variables, hardship was not associated with hair cortisol. Distress predicted cortisol in distal sections (β = .482, p = .018), with a trend for proximal sections (β = .368, p = .055). Marital status was a significant predictor of distal (β = .388, p = .027) and proximal (β = .333, p = .047) hair cortisol, explaining 8.6%-11.7% of unique variance.

CONCLUSIONS

Preexisting and intersecting risk factors likely place unmarried pregnant individuals at risk of stress during and following a disaster.

Cross-sectional relation of long-term glucocorticoids in hair with anthropometric measurements and their possible determinants: A systematic review and meta-analysis

BACKGROUND

Long-term glucocorticoids (HairGC) measured in scalp hair have been associated with body mass index (BMI), waist circumference (WC), and waist-hip-ratio (WHR) in several cross-sectional studies. We aimed to investigate the magnitude, strength, and clinical relevance of these relations across all ages.

METHODS

We performed a systematic review and meta-analysis (PROSPERO registration CRD42020205187) searching for articles relating HairGC to measures of obesity. Main outcomes were bivariate correlation coefficients and unadjusted simple linear regression coefficients relating hair cortisol (HairF) and hair cortisone (HairE) to BMI, WC, and WHR.

RESULTS

We included k = 146 cohorts (n = 34,342 individuals). HairGC were positively related to all anthropometric measurements. The strongest correlation and largest effect size were seen for HairE-WC: pooled correlation 0.18 (95%CI 0.11-0.24; k = 7; n = 3,158; I²  = 45.7%) and pooled regression coefficient 11.0 cm increase in WC per point increase in 10-log-transformed HairE (pg/mg) on liquid-chromatography-(tandem) mass spectrometry (LC-MS) (95%CI 10.1-11.9 cm; k = 6; n = 3,102). Pooled correlation for HairF-BMI was 0.10 (95%CI 0.08-0.13; k = 122; n = 26,527; I²  = 51.2%) and pooled regression coefficient 0.049 kg/m² per point increase in 10-log-transformed HairF (pg/mg) on LC-MS (95%CI 0.045-0.054 kg/m² ; k = 26; n = 11,635).

DISCUSSION

There is a consistent positive association between HairGC and BMI, WC, and WHR, most prominently and clinically relevant for HairE-WC. These findings overall suggest an altered setpoint of the hypothalamic-pituitary-adrenal axis with increasing central adiposity.

The embodiment of water insecurity: Injuries and chronic stress in lowland Bolivia

Water is critical to health and wellbeing. Studies have theorized that problems with water can become embodied, yet few studies have quantified this. Therefore, we first sought to understand the lowland Bolivian water environment of Tsimane' forager-horticulturalists. We assessed the water environment holistically, using objective measures of water quality and water services (Joint Monitoring Programme's drinking water services ladder) and subjective measures, including perceived water safety and water insecurity experiences [Household Water Insecurity Experiences Scale (HWISE)]. We tested how water service levels, perceived water safety, and water fetching frequency were associated with HWISE scores using Tobit regression models among 270 households. We then tested if and how water becomes embodied via self-reported water-related injury and a chronic stress biomarker, hair cortisol concentration (HCC). Results demonstrated that, compared with households using surface water, households with basic water services had HWISE scores 1.59-pts lower (SE = 0.29; P < 0.001). Ingestion of water perceived to be "bad" and more daily water-fetching trips were associated with higher HWISE scores. Twenty percent of households reported prior water-related injuries, with women most commonly injured. In logistic regressions, each point higher HWISE score was associated with 28% (95%CI:1.16-1.41; P < 0.001) higher odds of injury. Basic water services compared to surface water was associated with 48% lower odds (OR = 0.52; 95%CI:0.33-0.82; P = 0.005) of injury. Finally, using linear regressions among 332 adults, HWISE scores were not associated with HCC. Past water-related injury was associated with higher HCC (Beta = 0.31; SE = 0.09; P = 0.029) among women, but not men. Relying on unimproved water services compared to surface was associated with 46.2% higher HCC for women (Beta=0.38; SE=0.14; P=0.048) and 55.3% higher HCC for men (Beta=0.44; SE=0.15; P=0.044), respectively. Overall, our findings demonstrate that water insecurity can become embodied through water-related injuries and elevated HCC. Improving water service levels through an equity lens may help ameliorate water insecurity and its accompanying negative health effects.

Diverse Health, Gender and Economic Impacts from Domestic Transport of Water and Solid Fuel: A Systematic Review

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

Acute relaxation during pregnancy leads to a reduction in maternal electrodermal activity and self-reported stress levels

BACKGROUND

Prenatal maternal stress can have adverse effects on birth outcomes and fetal development. Relaxation techniques have been examined as potential countermeasures. This study investigates different relaxation techniques and their effect on self-reported stress levels and physiological stress levels in pregnant women.

METHODS

In this cross-sectional study, 38 pregnant women in their 30th to 40th gestational week were assigned to one of three, 20-min lasting relaxation groups: listening to music (N = 12), following a guided imagery (N = 12) or resting (N = 12). The intervention, i.e., acute relaxation (music, guided imagery or resting) took place once for each study participant. Study inclusion criteria were age over 18 years, German speaking, singleton and uncomplicated pregnancy during the 30th and 40th week of gestation. The stress levels were determined during the study. Current stress level during the study was assessed by a visual analogue scale. Chronic stress levels were assessed by the Trier Inventory of Chronic Stress and the Pregnancy Distress questionnaire. Multivariate analyses of covariance were performed and dependent measures included stress levels as well as physiological measures, i.e., cardiovascular activity (electrocardiogram) and skin conductance levels.

RESULTS

All three forms of relaxation led to reduced maternal stress which manifested itself in significantly decreased skin conductance, F(3,94) = 18.011, p = .001, η_p² = .365, and subjective stress levels after the interventions with no significant group difference. Post-intervention stress ratings were further affected by gestational age, with less subjective relaxation in women later in gestation, F (1, 34)=4.971, p = .032, η_p² = .128.

CONCLUSION

Independent of relaxation technique, single, 20-min relaxation intervention (music, guided imagery or resting) can significantly reduce maternal stress. Notably, women at an earlier stage in their pregnancy reported higher relaxation after the intervention than women later in gestation. Hence, gestational age may influence perceived stress levels and should be considered when evaluating relaxation or stress management interventions during pregnancy.

TRIAL REGISTRATION

Not applicable.

Maternal Sociodemographic Factors and Antenatal Stress

Antenatal stress has been associated with adverse birth outcomes such as fetal growth restriction, low birth weight, and preterm birth. Understanding key determinants of stress in a vulnerable pregnant population has the potential of informing development of targeted cost-effective interventions to mitigate against these adverse birth outcomes. We conducted a secondary analysis of data from 150 pregnant women attending antenatal care services at a rural referral hospital in Kenya. The participants completed a sociodemographic and clinical questionnaire, the Cohen’s Perceived Stress Scale (PSS) and gave a hair sample for cortisol and cortisone analysis. The association between selected sociodemographic predictors (age, parity, marital status, maternal education, household income, polygyny, and intimate partner violence) and outcomes (hair cortisol, hair cortisone, and PSS score) was examined using univariate, bivariate and multivariate models. We found a negative association between PSS scores and household income (β = −2.40, p = 0.016, 95% CI = −4.36, −0.45). There was a positive association of the ratio of hair cortisone to cortisol with Adolescent age group (β = 0.64, p = 0.031, 95% CI = 0.06, 1.22), and a negative association with Cohabitation (β = −1.21, p = 0.009, 95% CI = −2.11, −0.31). We conclude that household income influenced psychological stress in pregnancy. Adolescence and cohabitation may have an influence on biological stress, but the nature of this effect is unclear.

Cortisol and socioeconomic status in early childhood: A multidimensional assessment

The hypothalamic-pituitary-adrenal (HPA) axis is sensitive to early life stress, with enduring consequences for biological stress vulnerability and health (Gunnar & Talge, 2008). Low socioeconomic status (SES) is associated with dysregulation of the stress hormone cortisol in early childhood. However, a mechanistic understanding of this association is lacking. Multidimensional assessment of both SES and cortisol is needed to characterize the intricate relations between SES and cortisol function in early childhood. We assessed parent-reported family income, parent education, occupational prestige, neighborhood risk, food insecurity, and household chaos for 12-month-old infants (N = 90) and 3.5-year-old children (N = 91). Hair cortisol concentration (HCC) was obtained from parent and child, indexing chronic biological stress, and diurnal salivary cortisol was measured in the children. Controlling for parent HCC, parent education uniquely predicted infant and child HCC and, in addition, neighborhood risk uniquely predicted infant HCC. Household chaos predicted bedtime salivary cortisol concentration (SCC) for both infants and children, and infant daily cortisol output. Food insecurity was associated with flattened cortisol slope in 3.5-year-old children. Parental sensitivity did not mediate relations between SES and cortisol. Results highlight the utility of SES measures that index unpredictable and unsafe contexts, such as neighborhood risk, food insecurity, and household chaos.

Association of differential symptoms of stress to hair cortisol and cortisone concentrations among pregnant women in Kenya

Objectives: The purpose of this study was to characterize the stress experienced by pregnant women in Kenya and assess the relationship between perceived stress and stress-related biomarkers of cortisol and cortisone.Background: Kenyan women are exposed to multiple stressors that may result in chronic stress. However, antenatal stress has not been examined and characterized in Kenya; nor has the relationship between pregnant women's self-reported stress and stress biomarkers been established.Methods: One hundred and fifty women were recruited between 22 and 28 weeks gestation. Participants completed the Perceived Stress Scale (PSS) and a sociodemographic questionnaire. Hair samples were obtained for analysis of cortisol and cortisone. Factor analysis was used to extract unique clusters of stress symptoms from items in the PSS. Regression models were computed to examine relationships of stress to cortisone and cortisol, controlling for obstetric risk.Results: Mean age of the women was 25 years (SD = 5, ±16-41). Their degree of perceived stress and cortisol/cortisone concentrations both indicated moderate levels of stress. There was no association between general perceived stress and either hair cortisol or cortisone. However, factor analysis of the PSS identified three clusters of stress symptoms and one cluster - a woman's negative frame of mind regarding life and inefficacy in handling its problems - was associated with higher levels of cortisone (β= -.231, p = 0.011).Conclusions: Specific stress symptoms may have unique relationships to specific biomarkers and be more useful in assessment than general perceived stress. Assays of both hair cortisol and cortisone might enable a more comprehensive assessment of glucocorticoid activity and better prediction of health risks from stress.Lay summaryUnderstanding stress among rural pregnant Kenyan women may help in addressing risks during pregnancy that lead to adverse birth outcomes. Findings suggest that a woman's tendency to think negatively about life and to doubt her ability to handle life's problems are symptoms of stress that may contribute to higher levels of stress hormones. Assessing women's specific symptoms of stress and different stress hormones during pregnancy may more effectively identify women who need intervention to reduce their health risk.

Water insecurity and urban poverty in the Global South: Implications for health and human biology

OBJECTIVES

Over half of the world's population (4 billion people) experience severe water scarcity at least one month per year, while half a billion people experience severe water scarcity throughout the year. Despite progress from national and global interventions, a staggering proportion of the Global South remains water insecure. Rapid urban growth and associated demographic changes, climate change, and governance failure have also fostered the growth and expansion of urban informal settlements and slums where widespread poverty and environmental hazards exacerbate the impact of water insecurity on health. This article reflects on the interactions between water insecurity and urban poverty in the Global South across four categories of health outcomes: gastrointestinal diseases, mosquito-borne diseases, injuries, and mental illness. These examples highlight the mechanisms through which urban poverty exacerbates the adverse health effects of water insecurity.

METHODS

The four selected health outcomes were chosen a priori to represent two communicable conditions with well-developed literatures, and two noncommunicable conditions with newer literatures that have emerged over the last decade. We conducted a narrative literature review of scholarly and gray literature appearing between January 2000 and April 2019 using several online scholarly databases.

RESULTS

Gastrointestinal diseases, mosquito-borne diseases, injuries, and mental illness all exemplified the relationship between water insecurity and urban poverty through human biological pathways. For each of the four health categories, we identified frontiers for human biology research contributions to the water-poverty-health nexus.

CONCLUSIONS

We discuss our findings in the context of three crosscutting themes that merit innovative research approaches: stressor interactions and trade-offs, exposure thresholds, and intervention efficacy. We reiterate that the global burden of disease associated with water insecurity cannot be addressed in isolation from efforts to alleviate extreme poverty.

A systematic review of studies utilizing hair glucocorticoids as a measure of stress suggests the marker is more appropriate for quantifying short-term stressors

Quantitating glucocorticoids (GCs) in hairs is a popular method for assessing chronic stress in studies of humans and animals alike. The cause-and-effect relationship between stress and elevated GC levels in hairs, sampled weeks later, is however hard to prove. This systematic review evaluated the evidence supporting hair glucocorticoids (hGCs) as a biomarker of stress. Only a relatively small number of controlled studies employing hGC analyses have been published, and the quality of the evidence is compromised by unchecked sources of bias. Subjects exposed to stress mostly demonstrate elevated levels of hGCs, and these concentrations correlate significantly with GC concentrations in serum, saliva and feces. This supports hGCs as a biomarker of stress, but the dataset provided no evidence that hGCs are a marker of stress outside of the immediate past. Only in cases where the stressor persisted at the time of hair sampling could a clear link between stress and hGCs be established.

Is water carriage associated with the water carrier's health? A systematic review of quantitative and qualitative evidence

Introduction

The work of carrying water falls mainly on women and children, particularly in sub-Saharan Africa and rural areas. While concerns have been raised, how water carriage is associated with health of the water carrier is not clear. The aim of this review is to summarise evidence on whether, and how, water carriage is associated with the water carrier’s health.

Methods

A systematic review of literature was conducted, searching Embase; Medline; Web of Science Social Sciences Citation Index; Web of Science Arts and Humanities Citation Index; International Initiative for Impact Evaluation website; WHO Virtual Health Sciences Library and WHO African index medicus, from inception to 8 November 2017.

Results

Forty-two studies were included. Their ability to demonstrate cause and effect relationships was limited by study design and fair or poor methodological quality. Overall, the studies suggest that water carriage is associated with negative aspects of the water carriers’ health. There is moderate quantitative and strong qualitative evidence that water carriage is associated with pain, fatigue, perinatal health problems and violence against vulnerable people, and inconclusive evidence of an association with stress or self-reported mental health and general health status.

Conclusion

In many circumstances, water carriage is a potential barrier to Sustainable Development Goal (SDG) 6 target ‘universal and equitable access to safe and affordable drinking water for all’ and SDG 3 ‘ensure healthy lives and promote well-being for all at all ages’. Efforts should focus on providing water on premises, and where this is not possible, providing water close to home and reducing risk of gender-based violence.

The Relationship between Household Sanitation and Women's Experience of Menstrual Hygiene: Findings from a Cross-Sectional Survey in Kaduna State, Nigeria

Global efforts to improve sanitation have emphasized the needs of women and girls. Managing menstruation is one such need, yet there is scarce research capturing current practices. This study investigated the relationships between household sanitation and women’s experience of menstrual management. Secondary analyses were undertaken on data from 1994 women and girls collected through the Performance Monitoring and Accountability 2020 survey in Kaduna, Nigeria. In multivariable models, women had higher odds of using the main household sanitation facility for menstrual management when they had access to a basic (OR = 1.76 95%CI 1.26–2.46) or limited (OR = 1.63 95%CI 1.08–2.48) sanitation facility, compared to an unimproved facility. Women with no household sanitation facility had higher odds of using their sleeping area (OR = 3.56 95%CI 2.50–5.06) or having no facility for menstrual management (OR = 9.86 95%CI 5.76–16.87) than women with an unimproved sanitation facility. Menstrual management locations were associated with ratings of their characteristics. Safely managed or basic sanitation facilities were not rated more favorably than unimproved facilities in privacy (OR = 1.02 95%CI 0.70–1.48), safety (OR = 1.45 95%CI 0.98–2.15), access to a lock (OR = 0.93 95%CI 0.62–1.37), or soap and water (OR = 1.04 95%CI 0.70–1.56). Women using their sleeping area had more favorable perceptions of their environment. Findings suggest household sanitation influences women’s choices for menstrual management, but that existing indicators for improvement are not sensitive to menstrual needs.

Chronic stress in the mother-infant dyad: Maternal hair cortisol, infant salivary cortisol and interactional synchrony

Stress physiology is shaped by early experience, with enduring effects on health. The relation of chronic maternal physiological stress, as indexed by hair cortisol, to infants' stress systems and to mother-infant interaction quality has not been established. We examined maternal hair and salivary cortisol, six-month-old infants' salivary cortisol, and mother-infant interaction in 121 mother-infant dyads. High maternal hair cortisol was related to higher infant average salivary cortisol concentration. Maternal hair cortisol and bedtime salivary cortisol were both uniquely related to infant bedtime salivary cortisol. Mothers with higher hair cortisol were more intrusive and had lower positive engagement synchrony with their infants. Maternal intrusiveness moderated the association of maternal hair cortisol and infant salivary cortisol, such that maternal hair and infant average salivary cortisol were related only when mothers were more intrusive. Maternal chronic physiological stress may upregulate infants' developing stress systems, particularly in the context of lower mother-infant interaction quality.

Psychosocial impacts of the lack of access to water and sanitation in low- and middle-income countries: a scoping review

The lack of access to safe water and adequate sanitation has implications for the psychosocial well-being of individuals and households. To review the literature on psychosocial impacts, we completed a scoping review of the published literature using Medline, Embase, and Scopus. Fifteen studies met the inclusion criteria and were reviewed in detail. Of the included studies, six were conducted in India, one in Nepal, one in Mexico, one in Bolivia, two in Ethiopia, one in Zimbabwe, one in South Africa, and two in Kenya. Four interrelated groups of stressors emerged from the review: physical stressors, financial stressors, social stressors, and stressors related to (perceived) inequities. Further, gender differences were observed, with women carrying a disproportionate psychosocial burden. We argue that failure to incorporate psychosocial stressors when estimating the burden or benefits of safe water and sanitation may mask an important driver of health and well-being for many households in low- and middle-income countries. We propose further research on water-related stressors with particular attention to unique cultural norms around water and sanitation, short and long term psychosocial outcomes, and individual and collective coping strategies. These may help practitioners better understand cumulative impacts and mechanisms for addressing water and sanitation challenges.

Hair cortisol and its potential value as a physiological measure of stress response in human and non-human animals

There is considerable interest in the potential for measuring cortisol in hair as a means of quantifying stress responses in human and non-human animals. This review updates the rapid advancement in our knowledge of hair cortisol, methods for its measurement, its relationship to acute and chronic stress, and its repeatability and heritability. The advantages of measuring cortisol in hair compared with other matrices such as blood, saliva and excreta and the current theories of the mechanisms of cortisol incorporation into the fibre are described. Hair cortisol as a measure of the physiological response to stress in a variety of species is presented, including correlations with other sample matrices, the relationship between hair cortisol and psychosocial stress and the repeatability and heritability of hair cortisol concentrations. Current standards for the quantification of hair cortisol are critically reviewed in detail for the first time and gaps in technical validation of these methods highlighted. The known effects of a variety of sources of hair cortisol variation are also reviewed, including hair sampling site, sex, age and adiposity. There is currently insufficient evidence to conclude that cortisol concentration in hair accurately reflects long-term blood cortisol concentrations. Similarly, there is a lack of information surrounding the mechanisms of cortisol incorporation into the hair. This review highlights several directions for future research to more fully validate the use of hair cortisol as an indicator of chronic stress.

Associations between hair cortisol concentration, income, income dynamics and status incongruity in healthy middle-aged women

A body of research demonstrates that financial disadvantage is associated with general health inequalities and higher mortality rates. Most studies make use of cross-sectional analyses, although income can also be viewed as a dynamic concept. The use of endocrine-markers as proxies for health can provide information about the pathways involved in these associations. Hair cortisol analysis has been developed as a method for assessing sustained cortisol output as it provides an estimate of cumulative cortisol secretion over a prolonged time. The present study assessed income and income trajectory over a 4-year period in 164 working women (aged 26-65) in relation to hair cortisol in a longitudinal design. A negative association between hair cortisol and concurrent income was found (p=0.025) and hair cortisol and changes in income over 4 years (p<0.001), after adjustment for age, BMI, smoking status, hair treatment and country. Status incongruity, a mismatch between educational status and income group, was related to higher cortisol levels compared with status congruity (p=0.009). These findings suggest that psychoneuroendocrinological pathways might partially explain the relationship between lower socio-economic status and adverse health outcomes. Future longitudinal research using hair cortisol analysis is warranted to clarify the time course of social mobility in relation to long-term cortisol, to investigate other underlying psychosocial factors implicated in these associations, and to determine the exact health implications of the neuroendocrine perturbations in individuals with limited economic resources.

Socioeconomic status in children is associated with hair cortisol levels as a biological measure of chronic stress

INTRODUCTION

Low socioeconomic status (SES) may be associated with a high risk of lifestyle-related diseases such as cardiovascular diseases. There is a strong association between parental SES, stress and indicators of child health and adult health outcome. The exact mechanisms underlying this association have not yet been fully clarified. Low SES may be associated with chronic stress, which may lead to activation of the hypothalamic-pituitary-adrenal (HPA)-axis, resulting in a higher circulating level of the stress hormone cortisol. Therefore, chronic stress may mediate the association between low SES and elevated cortisol levels and its adverse outcomes.

AIM

We investigated whether SES was associated with a chronic measure of cortisol exposure in a child population.

METHODS

Cortisol and cortisone were measured in scalp hair in 270 children and adolescents, aged 4-18 years, enrolled through school visits. Neighborhood level SES was based on a score developed by the Netherlands Institute for Social Research using postal codes, and this includes neighborhood measures of income education and unemployment. Maternal and paternal education level were used as indicators of family SES.

RESULTS

Neighborhood level socioeconomic status score was significantly associated with hair cortisol (β=-0.103, p=0.007, 95%CI [-0.179, -0.028]) and hair cortisone (β=-0.091, p=0.023, 95%CI [-0.167, -0.015]), adjusted for age and sex. Additionally, hair cortisol was significantly correlated with maternal education level and hair cortisone was significantly correlated with paternal education level.

CONCLUSION

The results of our study suggest that the widely shown association between low family SES and adverse child health outcomes may be mediated by chronic stress, given the chronically higher levels of cortisol in children and adolescents in families with low SES. It is especially notable that the association between SES and cortisol was already found in children of young age as this can have major consequences, such as increased risk of cardio metabolic diseases in later life.

Sanitation, Stress, and Life Stage: A Systematic Data Collection Study among Women in Odisha, India

Emerging evidence demonstrates how inadequate access to water and sanitation is linked to psychosocial stress, especially among women, forcing them to navigate social and physical barriers during their daily sanitation routines. We examine sanitation-related psychosocial stress (SRPS) across women’s reproductive lives in three distinct geographic sites (urban slums, rural villages, and rural tribal villages) in Odisha, India. We explored daily sanitation practices of adolescent, newly married, pregnant, and established adult women (n = 60) and identified stressors encountered during sanitation. Responding to structured data collection methods, women ranked seven sanitation activities (defecation, urination, menstruation, bathing, post-defecation cleaning, carrying water, and changing clothes) based on stress (high to low) and level of freedom (associated with greatest freedom to having the most restrictions). Women then identified common stressors they encountered when practicing sanitation and sorted stressors in constrained piles based on frequency and severity of each issue. The constellation of factors influencing SRPS varies by life stage and location. Overall, sanitation behaviors that were most restricted (i.e., menstruation) were the most stressful. Women in different sites encountered different stressors, and the level of perceived severity varied based on site and life stage. Understanding the influence of place and life stage on SRPS provides a nuanced understanding of sanitation, and may help identify areas for intervention.