Household sanitation facilities and women's risk of non-partner sexual violence in India

Development and validation of a survey instrument for reusable sanitary products toward sustainable menstrual hygiene

The predominant use of disposable, non-organic menstrual products has significant environmental impacts due to waste and resource depletion. Concerns over the environmental, economic, and health implications of menstrual hygiene management (MHM) have highlighted the need to explore sustainable options like reusable sanitary pads (RSPs). Despite their benefits, the adoption of RSPs is limited by a lack of awareness, availability, cost, and research. This study emphasizes the need for the development of an instrument that can capture the effectiveness, safety, and user satisfaction of RSPs, addressing a significant gap in the literature. Using a convenient sampling method, data were collected through a structured offline survey and the sample comprised 446 South Asian women of reproductive age. The instrument included 15 items designed to measure factors such as comfort, hygiene, convenience, and environmental consciousness. The instrument's reliability and validity are thoroughly assessed using reliability and factor analysis to ensure its effectiveness in capturing the multifaceted dimensions of MHM product choices. The study revealed that the overwhelming majority of women would prefer the option of RSPs that are comfortable, accessible, and easy to use and dispose of. The findings aim to provide a validated tool for manufacturers, policymakers, and researchers to evaluate reusable pads, promoting their broader acceptance and adoption of a sustainable and equitable approach to menstrual hygiene.

The Association between Water, Sanitation, Hygiene, and Child Underweight in Punjab, Pakistan: An Application of Population Attributable Fraction

Background

Access to safe drinking water, sanitation, and hygiene (WASH) facilities is crucial for health and human rights, impacting nutrition and weight.

Methods

Multiple Indicators Cluster Survey (MICS) 2017-18 has been used in this study to examine the association between WASH and underweight, alongside other factors. Analysis included descriptive statistics, association tests, logistic regression, and population-attributable fractions (PAF).

Results

According to results child were 1.8, 1.1 and 1.04 times less likely to be underweight if they had access to improved source of drinking water, improved sanitation and hygiene facilities respectively. The likelihood of child being underweight reduces by 1.4, 1.89, 2.01 and 2.55 times if the household wealth status increases from poorest to second, middle, fourth and richest wealth quintiles, respectively. As the mothers' education level increases from no schooling to primary, middle, secondary, and higher level, the possibility of child being underweight reduces by 1.22, 1.24, 1.60 and 2.01 times, respectively. Moreover, the likelihood of a child being underweight decreases as the education level of the household head improves. If maternal age is less than 20 or more than 35 years the likelihood of the child being underweight is increased by 1.074 and 1.121 times, respectively. A child is 1.1 times more likely to be underweight if birth spacing is less than 2 years. A child's risk of being underweight decreases by 1.1 times if they have not experienced diarrhea. A child who has never been breastfed has 1.3 times higher risk of being underweight. The results of Population Attributable Fraction (PAF) indicate that holding the other factors constant, approximately 36.46% burden of underweight was preventable by access to improved drinking water, sanitation, and hygiene practices.

Conclusion

Comprehensive strategy is needed that focuses on improving access to safe drinking water, sanitation infrastructure, and hygiene behaviors.

Effects of Community-Led Total Sanitation (CLTS) Boosting and Household Factors on Latrine Ownership in Siaya County, Kenya

Community-led total sanitation (CLTS) is a widely used approach for enhancing sanitation practices. However, the impact of boosted CLTS on household latrine ownership has not been adequately evaluated. This study aims to investigate the factors associated with latrine possession among households, with a specific focus on single and CLTS-boosting implementation. A community-based repeated cross-sectional study was conducted in Siaya County, Kenya, involving 512 households at the baseline and 423 households at the follow-up. Data were analyzed using the mixed-effects logistic regression model. At the baseline, latrine possession was significantly associated with CLTS implementation (adjusted OR [aOR]: 3.01; 95% confidence interval [CI]: 1.41-6.44), literacy among households (aOR: 1.83; 95% CI: 1.12-2.98) and higher socioeconomic status (SES) (second level: aOR: 2.48; 95% CI:1.41-4.36, third level: aOR: 3.11; 95% CI: 1.76-5.50, fourth level: aOR: 10.20; 95% CI: 5.07-20.54). At follow-up, CLTS boosting (aOR: 7.92; 95% CI: 1.77-35.45) and a higher SES were associated with increased latrine ownership (second level: aOR: 2.04; 95% CI: 0.97-4.26, third level: aOR: 7.73; 95% CI: 2.98-20.03, fourth level: aOR: 9.93; 95% CI: 3.14-28.35). These findings highlight the significant role played by both single and CLST boosting in promoting universal latrine ownership and empowering vulnerable households to understand the importance of sanitation and open defecation-free practices.

The association between access to key household resources and violence against women

We provide the first comprehensive analysis of the association between two key household resources (drinking water and toilet access) and both non-partner violence (NPV) and intimate partner violence (IPV) experienced by women. We use data from a nationally representative household survey for India obtained from the latest (fourth) round of the National Family Health Survey conducted in 2015-16. We employ logistic regression method and also use inverse-probability-weighted regression adjustment to control for selection bias. We find that NPV decreases with access to drinking water, while IPV decreases with provision of toilets. These results are found to be robust to an alternative method viz. propensity score matching and selection on unobservables using the Rosenbaum bounds approach.

Violence Related to Daily Water and Sanitation Needs in South Africa

There is a critical lack of research on violence experienced by women when meeting their daily water and sanitation needs. This short report describes the cumulative lifetime incidence of exposure to violence when using the toilet or collecting water (water, sanitation, and hygiene [WASH]-related violence) and identifies associated health and behavioral risks. Data from 1,870 participants collected in 2013-2015 from a longitudinal cohort of young women in rural South Africa were included in this analysis. We found that exposure to WASH-related violence was high: 25.9% experienced violence when collecting water or when using the toilet. Those who experienced violence were more likely to report pregnancy, an older partner, unprotected sex, experience of intimate partner violence, engaging in transactional sex, depressive symptoms, and anxiety. Future research should investigate the location and type of violence experienced and examine how WASH-related violence is related to health outcomes to identify gender-centered WASH interventions that reduce violence exposure.

Systematic mapping of gender equality and social inclusion in WASH interventions: knowledge clusters and gaps

INTRODUCTION

Poor access to water, sanitation and hygiene (WASH) services threatens population health and contributes to gender and social inequalities, especially in low-resource settings. Despite awareness in the WASH sector of the importance of promoting gender equality and social inclusion (GESI) to address these inequalities, evaluations of interventions focus largely on health outcomes, while gender equality and other social outcomes are rarely included. This review aimed to collate and describe available research evidence of GESI outcomes evaluated in WASH intervention studies.

METHODS

We applied a systematic mapping methodology and searched for both academic and grey literature published between 2010 and 2020 in 16 bibliographic databases and 53 specialist websites. Eligibility screening (with consistency checking) was conducted according to predetermined criteria, followed by metadata coding and narrative synthesis.

RESULTS

Our evidence base comprises 463 intervention studies. Only 42% of studies measured transformative GESI outcomes of WASH interventions, referring to those that seek to transform gender relations and power imbalances to promote equality. A majority of studies disaggregated outcome data by sex, but other forms of data disaggregation were limited. Most included studies (78%) lacked a specific GESI mainstreaming component in their intervention design. Of the interventions with GESI mainstreaming, the majority targeted women and girls, with very few focused on other social groups or intersectional considerations.

CONCLUSION

The review points to various areas for future primary and secondary research. Given the potential contribution of WASH to GESI, GESI considerations should be incorporated into the evaluation of WASH interventions. Regular collection of data and monitoring of GESI outcomes is needed as well as developing new and testing existing methods for monitoring and evaluation of such data.

Socio-economic and demographic factors influencing open defecation in Haiti: a cross-sectional study

BACKGROUND

Open defecation (OD) remains an important public health challenge in Haiti. The practice poses a significantly high risk of disease transmission. Considering these negative health consequences, this paper aims to identify socio-economic and demographic factors that influence OD practice among households in Haiti.

METHODS

The study used secondary data from 13,405 households from the Haiti Demographic and Health Survey 2016-2017. Descriptive statistics and bivariate analysis were used to find the preliminary results. Further, multivariate analysis was performed to confirm the findings.

RESULTS

Around one quarter (25.3%) of Haitian households still defecate in the open, almost 10% in urban areas, and nearly 36% in rural areas. Multivariate analysis revealed that the age and sex of the household head, household size, number of children aged 1-14 years old in the household, education level, wealth index, access to mass media, place of residence, and region were significant predictors of OD practice among households in Haiti.

CONCLUSION

To accelerate the elimination of OD by 2030 and therefore achieve sustainable open defecation-free status, the government of Haiti and its partners should consider wealth disparities among regions and mobilize mass media and community-based networks to raise awareness and promote education about sane sanitation practices. Furthermore, because the possibilities to build toilets differ between rural and urban areas, specific interventions must be spearheaded for each of these regions. The public program can subsidize individual toilets in rural areas with room to collect dry excreta for the preparation of fertilizers, while in urban areas collective toilets can be built in slums. Interventions should also prioritize households headed by women and young people, two underpriviledged socioeconomic groups in Haiti.

Impact of a sanitation intervention on quality of life and mental well-being in low-income urban neighbourhoods of Maputo, Mozambique: an observational study

OBJECTIVES

Toilet users often report valuing outcomes such as privacy and safety more highly than reduced disease, but effects of urban sanitation interventions on such outcomes have never been assessed quantitatively. In this study, we evaluate the impact of a shared sanitation intervention on quality of life (QoL) and mental well-being.

DESIGN

We surveyed individuals living in intervention and control clusters of a recent non-randomised controlled trial, and used generalised linear mixed regression models to make an observational comparison of outcomes between arms.

SETTING

Low-income unsewered areas of Maputo City, Mozambique.

PARTICIPANTS

We interviewed 424 participants, 222 from the prior trial's intervention group and 202 from the control group.

INTERVENTIONS

The control group used low-quality pit latrines. The intervention group received high-quality shared toilets, with users contributing 10%-15% of capital cost.

OUTCOMES

Our primary outcome was the Sanitation-related QoL (SanQoL) index, which applies respondent-derived weights to combine perceptions of sanitation-related disgust, privacy, safety, health and shame. Secondary outcomes were the WHO-5 mental well-being index and a sanitation Visual Analogue Scale.

RESULTS

The intervention group experienced a 1.6 SD gain in SanQoL compared with the control group. This adjusted SanQoL gain was 0.34 (95% CI 0.29 to 0.38) on a 0-1 scale with control mean 0.49. Effect sizes were largest for safety and privacy attributes. Intervention respondents also experienced a 0.2 SD gain in mental well-being. The adjusted gain was 6.2 (95% CI 0.3 to 12.2) on a 0-100 scale with control mean 54.4.

CONCLUSIONS

QoL outcomes are highly valued by toilet users and can be improved by sanitation interventions. Such outcomes should be measured in future sanitation trials, to help identify interventions which most improve people's lives. Since SanQoL weights are derived from respondent valuation, our primary result can be used in economic evaluation.

Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a cross-sectional analysis

OBJECTIVE

There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa.

METHODS

Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13-21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates.

FINDINGS

A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates.

CONCLUSION

Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms.

TRIAL REGISTRATION NUMBER

NCT01233531; Post-results.

Intimate Partner Violence against Women Living in Inadequate Conditions in Sub-Saharan Africa: A Meta-Analysis of Demographic and Health Survey Data

Intimate partner violence (IPV) against women is a major public health problem and is widespread in sub-Saharan Africa (SSA). However, little is known about its environmental determinants. This study aimed to investigate whether inadequate living conditions are associated with IPV victimization in women in SSA. We analyzed cross-sectional data for 102,714 women in 25 SSA countries obtained from the Demographic and Health Surveys Program. Logistic regression was used to estimate the country-specific effects of inadequate living conditions (housing with at least one of four characteristics of unimproved water, unimproved sanitation, insufficient space, and unfinished materials) on multiple forms of IPV. Random effects meta-analysis was used to combined the country-specific estimates. We found an association between inadequate living conditions and a higher likelihood of experiencing any (OR = 1.12, 95% CI 1.03 to 1.23, p = 0.012), sexual (OR = 1.18, 95% CI 1.05 to 1.34, p = 0.008), emotional (OR = 1.12, 95% CI 1.02 to 1.23, p = 0.023), and physical (OR = 1.15, 95% CI 1.03 to 1.28, p = 0.010) IPV. The associations were stronger for rural and less-educated women. These findings suggest that future research to establish a causal link between living conditions and IPV and to elucidate the underlying pathways is crucial to design IPV interventions in SSA.

Household sanitation access and risk for non-marital sexual violence among a nationally representative sample of women in India, 2015-16

BACKGROUND

Lack of household sanitation, specifically toilet facilities, can adversely affect the safety of women and girls by requiring them to leave their households to defecate alone and at night, leaving them more vulnerable to non-marital sexual violence. This study analyzes the association between household sanitation access and past year victimization from non-marital sexual violence (NMSV) in India.

METHODS

We analyzed 74,698 women age 15-49 from whom information on NMSV was collected in India's National Family Health Survey 2015-16 (NFHS-4). We used multivariable logistic regression to test the relationship between women's household sanitation access and recent NMSV experience, controlling for socioeconomics (SES;e.g., age, marital status, caste, wealth, employment), for the total sample and stratified by rural/urban, given lower access to sanitation and lower NMSV in rural contexts.

RESULTS

We found that 46.2% of households in our sample lacked their own private sanitation facilities (58.0% rural; 24.5% urban) and were forced to openly defecate (37.3%) or walk to a shared sanitation facility (8.9%), and 0.45% of women report NMSV in the last 12 months (0.33% rural; 0.68% urban). Our multivariable model indicated no significant association between having private household sanitation facilities and NMSV for the total sample, but stratified analyses indicate a significant association for rural but not urban women. In rural India, those who lack private household sanitation, compared to those with a household toilet, have significantly greater odds of NMSV (AOR = 2.45; p < 0.05). These findings persist after accounting for demographics including age and marital status, socio-economic factors related to marginalization (e.g., caste, wealth), women's employment, and the overall climate of the state.

CONCLUSION

Findings from this study support prior research suggesting that poor access to sanitation is associated with women's risk for NMSV in rural India. This may be via increased exposure, and/or as a marker for greater vulnerability to NMSV beyond what is explained by other SES indicators. Solutions can include increased access to private household sanitation and more targeted NMSV prevention in rural India.

PROTOCOL: Water, sanitation and hygiene for reducing childhood mortality in low- and middle-income countries

Respiratory tract infections and diarrhoea are the two biggest killers of children in low income contexts. They are closely related to access to, and use of improved water, sanitation and hygiene (WASH). However, there is no high quality systematic review that quantifies the effect of WASH improvements on childhood mortality. Existing systematic reviews of WASH improvements measure effects on morbidity, under the (often implicit) assumption that morbidity is closely correlated with mortality. This is at least partly because the impact evaluations on which they are based are only designed to detect changes in morbidity with statistical precision, whereas mortality is a relatively rare outcome. The proposed review will address this evidence synthesis gap, using the greater statistical power of meta-analysis to pool findings across studies.

Violence against women in urban slums of India: A review of two decades of research

It is estimated that about one-third of women ever experienced violence in their lifetime. India has experienced steady urban growth accompanying increase of urban populations living in slums. Several studies have reported prevalence of various forms of violence in urban slums. To our knowledge, no systematic review has been conducted exclusively reporting violence against women in India's urban slums. The review aims to synthesise the studies of violence against women conducted in the last two decades (2000-2020). We searched PubMed, Scopus and other relevant search engines to identify articles published between years 2000 and 2020, which focused on Indian women slum dwellers' experiences of violence. We included 14 studies, which satisfied the inclusion criteria in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was used to assess the studies. The prevalence of any form of violence against women, as reported in the studies, ranged from 15% to 59.3%. The major risk factors identified were husband's alcohol abuse, women justifying the violence inflicted on then, low educational levels of both women and men, dowry issues, age difference between the spouses and termination of a previous pregnancy. It is evident from the review that urban slum women experience persistent violence.

Community Perceptions of a Multilevel Sanitation Behavior Change Intervention in Rural Odisha, India

While latrine coverage is increasing in India, not all household members use their latrines. Cost-effective, culturally appropriate, and theory-informed behavior change interventions are necessary to encourage sustained latrine use by all household members. We qualitatively examined community perceptions of sanitation interventions broadly, along with specific impressions and spillover of community-level activities of the Sundara Grama latrine use behavior change intervention in rural Odisha, India. We conducted sixteen sex-segregated focus group discussions (n = 152) in three intervention and three nonintervention villages and thematically analyzed the data. We found Sundara Grama was well-received by community members and considered educative, but perceptions of impact on latrine use were mixed and varied by activity. Intervention recruitment challenges prevented some, such as women and households belonging to lower castes, from attending activities. Spillover occurred in one of two nonintervention villages, potentially due to positive relations within and between the nonintervention village and nearby intervention village. Community-level sanitation initiatives can be hindered by community divisions, prioritization of household sanitation over community cleanliness, and perceptions of latrine use as a household and individual issue, rather than common good. Community-centered sanitation interventions should assess underlying social divisions, norms, and perceptions of collective efficacy to adapt intervention delivery and activities.

Multidimensional Benefits of Improved Sanitation: Evaluating 'PEE POWER®' in Kisoro, Uganda

With 2.3 billion people around the world lacking adequate sanitation services, attention has turned to alternative service provision models. This study suggests an approach for meeting the sanitation challenge, especially as expressed in Sustainable Development Goal 6.2, using a toilet technology system, such as Pee Power® that generates electricity using diverted urine as a fuel. A field trial was carried out in a girls' school in Kisoro, Uganda, where the generated electricity was used to light the existing toilet block. The trial was evaluated in terms of social acceptability and user experience using a multidimensional assessment protocol. The results of our assessment show that users felt safer when visiting the toilets at night. Lights provided from the technology also helped with the perceived cleanliness of the toilets. The technology was well accepted, with 97% of the respondents saying that they liked the idea of the Pee Power® technology and 94% preferring it over other facilities on site. This shows how the technology helps meet SDG target 6.2, with its particular focus on vulnerable populations.

Evaluating the declarations of open defecation free status under the Swachh Bharat (‘Clean India’) Mission: repeated cross-sectional surveys in Rajasthan, India

Background

The most ambitious sanitation campaign to end open defecation (OD) in India came to a close on 2 October 2019 and there are limited independent, robust data to measure its success. We aimed to evaluate Rajasthan’s claim of open defecation free status in March 2018 under the Swachh Bharat Mission (SBM) or ‘Clean India Mission’ by measuring OD trends from 2016 to 2018.

Methods

We used publicly available data from Performance Monitoring and Accountability 2020, a representative survey with two-stage stratified cluster sampling. Enumeration areas were the primary sampling units selected by the probability proportional ­to ­size method. The repeated cross-sectional surveys independently collected household water and sanitation data in Rajasthan (n=20 485). Among households reporting toilet access, the data were pooled across the four rounds for an observational analysis using logistic regression. The primary outcome measure was regular OD among households with access to toilet facilities.

Findings

Between October 2016 and July 2018 main OD practices in rural Rajasthan households decreased from 63.3% (95% CI 57.0% to 69.6%) to 45.8% (95% CI 38.4% to 53.2%) and in urban households from 12.6% (95% CI 6.0% to 19.1%) to 9.4% (95% CI 4.0% to 14.7%). Households with regular OD occurring despite access to a toilet made up 21.7% (95% CI 16.9% to 26.6%) of rural and 12.1% (95% CI 3.6% to 20.7%) of urban Rajasthan as of July 2018. The multivariate logistic regression revealed that factors related to water stress and sanitation sharing were associated with household members regularly practising OD.

Conclusions

These data highlight the importance of a continued focus on constructing toilets that are affordable with low water requirements during the next phase of SBM. An independent survey that can provide robust estimates of OD is needed to monitor progress of toilet construction and use.

Planning and communicating prototype tests for the Nano Membrane Toilet: A critical review and proposed strategy

Urban sanitation in growing cities of the Global South presents particular challenges. This led to the Bill & Melinda Gates Foundation’s Reinvent The Toilet Challenge, which sparked the development of various non-sewered sanitation technologies like the Nano Membrane Toilet. Complex disruptive technologies like this entail an extensive product development process, including various types of prototype tests. While there is an abundance of literature discussing how to build prototypes, and the optimal number of tests, there has been little focus on how to plan and conduct tests, especially in a development endeavour of this complexity. Four approaches to testing are reviewed, and their strengths and weaknesses compared. A visualised testing strategy is proposed that encompasses the entire product development process and can be used to plan and communicate prototype tests for the Nano Membrane Toilet to ultimately achieve compliance with international standards.

Planning and communicating prototype tests for the Nano Membrane Toilet: A critical review and proposed strategy

Urban sanitation in growing cities of the Global South presents particular challenges. This led to the Bill & Melinda Gates Foundation's Reinvent The Toilet Challenge, which sparked the development of various non-sewered sanitation technologies like the Nano Membrane Toilet. Complex disruptive technologies like this entail an extensive product development process, including various types of prototype tests. While there is an abundance of literature discussing how to build prototypes, and the optimal number of tests, there has been little focus on how to plan and conduct tests, especially in a development endeavour of this complexity. Four approaches to testing are reviewed, and their strengths and weaknesses compared. A visualised testing strategy is proposed that encompasses the entire product development process and can be used to plan and communicate prototype tests for the Nano Membrane Toilet to ultimately achieve compliance with international standards.

Non-Partner Violence in Sub-Saharan Africa and the Built Environment: A Multicountry Analysis of the Effects of Sanitation, Water Access, and Urban Settings

This multicountry study used Demographic and Health Surveys (DHS) data from 138,097 women to explore the relationship between non-partner violence (NPV) and sanitation, water, and urbanization in sub-Saharan Africa (SSA). One out of 15 women reports having experienced physical and/or sexual violence by a non-partner during the previous 12 months; within the region, prevalence ranges from 2.3-11.3%. Explanatory models of NPV improve in 11 of the 20 countries when the built environment variables are included. The results suggest that sanitation and water access are associated with risk of NPV in a number of countries in the region, particularly in urban settings.

Field testing of a prototype mechanical dry toilet flush

A prototype of a non-fluid based mechanical toilet flush was tested in a semi-public, institutional setting and in selected peri-urban households in eThekwini municipality, Republic of South Africa. The mechanism's functionality and users' perception of the flush were assessed. User perception varied depending on background: Users accustomed to porcelain water flush toilets were open to, yet reserved about the idea of using a waterless flush in their homes. Those who commonly use Urine Diversion Dehydration Toilets were far more receptive. The user-centred field trials were complemented by a controlled laboratory experiment, using synthetic urine, -faeces, and -menstrual blood, to systematically assess the efficiency of three swipe materials to clean the rotating bowl of the flush. A silicone rubber with oil-bleed-effect was found to be the best performing material for the swipe. Lubrication of the bowl prior to use further reduced fouling. A mechanical waterless flush that does not require consumables, like plastic wrappers, is a novelty and could - implemented in existing dry toilet systems - improve acceptance and thus the success of waterless sanitation.

Sanitation in Rural India: Exploring the Associations between Dwelling Space and Household Latrine Ownership

In 2017, the Joint Monitoring Programme estimated that 520 million people in India were defecating in the open every day. This is despite efforts made by the government, Non-Governmental Organizations (NGOs), and multilaterals to improve latrine coverage throughout India. We hypothesize that this might be because current interventions focus mostly on individual-level determinants, such as attitudes and beliefs, instead of considering all possible social determinants of latrine ownership. Given this, we ask two questions: what is the association between the amount of dwelling space owned by households in rural India and their likelihood of toilet ownership and what proportion of the variation in household latrine ownership is attributable to villages and states? We used multilevel modeling and found significant associations between the amount of household dwelling space and the likelihood of latrine ownership. Furthermore, considerable variation in latrine ownership is attributable to villages and states, suggesting that additional research is required to elucidate the contextual effects of villages and states on household latrine ownership. Thus, sanitation interventions should consider household dwelling space and village and state context as important social determinants of latrine ownership in rural India. Doing so could bolster progress towards Sustainable Development Goal (SDG) 6.

Health and social impacts of open defecation on women: a systematic review

BACKGROUND

The significance of sanitation to safeguard human health is irrefutable and has important public health dimensions. Access to sanitation has been essential for human dignity, health and well-being. Despite 15 years of conjunctive efforts under the global action plans like Millennium Development Goals (MDGs), 2.3 billion people have no access to improved sanitation facilities (flush latrine or pit latrine) and nearly 892 million of the total world's population is still practicing open defecation.

METHODS

The study provides a systematic review of the published literature related to implications of open defecation that goes beyond the scope of addressing health outcomes by also investigating social outcomes associated with open defecation. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was used to frame the review, empirical studies focusing upon open defecation in women aged 13-50 in low and middle income countries were included in the review. Research papers included in the review were assessed for quality using appropriate critical appraisal tools. In total 9 articles were included in the review; 5 of these related to health effects and 4 related to social effects of open defecation.

RESULTS

The review identified 4 overarching themes; Health Impacts of open defecation, Increased risk of sexual exploitation, Threat to women's privacy and dignity and Psychosocial stressors linked to open defecation, which clearly present a serious situation of poor sanitation in rural communities of Lower-Middle Income Countries (LMICs). The findings of the review identified that open defecation promotes poor health in women with long-term negative effects on their psychosocial well-being, however it is a poorly researched topic.

CONCLUSION

The health and social needs of women and girls remain largely unmet and often side-lined in circumstances where toilets in homes are not available. Further research is critically required to comprehend the generalizability of effects of open defecation on girls and women.

PROSPERO REGISTRATION

CRD42019119946 . Registered 9 January 2019 .

Sanitation Interventions in India: Gender Myopia and Implications for Gender Equality

In India, sanitation interventions have been, by and large, myopic to the gender dimensions of sanitation and hygiene. As a result, women’s sanitation and hygiene needs and vulnerabilities have not received adequate attention. While the legal and policy framework related to sanitation highlights some of the concerns of women, implementation at the local level has almost completely neglected them, raising serious concerns from a gender equality point of view. Using a gender perspective, this article takes a critical look at the existing legal and policy framework in India pertaining to sanitation.

Drivers of women's sanitation practices in informal settlements in sub-Saharan Africa: a qualitative study in Mathare Valley, Kenya

Despite evidence suggesting women are disproportionately affected by the lack of adequate and safe sanitation facilities around the world, there is limited information about the factors that influence women's ability to access and utilize sanitation, especially in sub-Saharan Africa. The purpose of this study was to explore factors influencing women's sanitation practices in informal settlements in Nairobi, Kenya. Information from 55 in-depth interviews conducted in 2016 with 55 women in Mathare Valley Informal Settlement in Nairobi was used to carry out cross-case, thematic analysis of women's common sanitation routines. Women identified neighborhood disorganization, fear of victimization, lack of privacy, and cleanliness/dirtiness of facilities as important factors in the choices they make about their sanitation practices. This suggests that future sanitation-related interventions and policies may need to consider strategies that focus not only on toilet provision or adoption but also on issues of space and community dynamics.

Exploring the relationship between sanitation and mental and social well-being: A systematic review and qualitative synthesis

The WHO defines health not as the absence of disease but as a "state of complete physical, mental, and social well-being." To date, public health research on sanitation has focused mainly on the impact of sanitation on infectious diseases and related sequelae, such as diarrhea and malnutrition. This review focuses on the mental and social well-being implications of sanitation. We systematically searched leading databases to identify eligible studies. Qualitative studies were assessed using a 17-point checklist adapted from existing tools, while quantitative studies were assessed using the Liverpool Quality Appraisal Tool. We followed a best-fit framework synthesis approach using six a priori well-being dimensions (privacy, shame, anxiety, fear, assault, and safety), which were examined using line-by-line coding. Two additional dimensions (dignity and embarrassment) inductively emerged during coding for a total of eight well-being outcomes. We then synthesized coded text for each dimension into descriptive themes using thematic analysis. For quantitative studies, we extracted any measures of association between sanitation and well-being. We identified 50 eligible studies covering a variety of populations and sanitation contexts but many studies were conducted in India (N = 14) and many examined the sanitation experience for women and girls (N = 19). Our synthesis results in a preliminary conceptual model in which privacy and safety, including assault, are root well-being dimensions. When people perceive or experience a lack of privacy or safety during open defecation or when using sanitation infrastructure, this can negatively influence their mental and social well-being. We found that perceptions and experiences of privacy and safety are influenced by contextual and individual factors, such as location of sanitation facilities and user's gender identity, respectively. Privacy and safety require thorough examination when developing sanitation interventions and policy to ensure a positive influence on the user's mental and social well-being.

The association between women's sanitation experiences and mental health: A cross-sectional study in Rural, Odisha India

Emerging qualitative research suggests women's sanitation experiences may impact mental health. However, specific associations remain unclear. We aimed to determine if sanitation access and sanitation experiences were associated with mental health among women in rural Odisha, India. Using a cross-sectional design, we evaluated the association between sanitation access and sanitation experiences and selected mental health outcomes. Data were collected from 1347 randomly selected women across four life course stages in 60 rural communities (December 2014-February 2015). Our four primary outcomes included: mental well-being, and symptoms of anxiety, depression, and distress. The primary exposures were (1) access to a functional latrine within the household compound and (2) sanitation insecurity (SI), evaluated using a seven domain measure assessing women's negative sanitation experiences and concerns. We used hierarchical linear modeling to determine associations between the exposures and mental health outcomes, adjusting for covariates (life stage, poverty, current health status, social support). Mean well-being scores were moderate and mean anxiety, depression, and distress scores were above a threshold indicating the potential presence of any of the three conditions. Access to a functional household latrine was associated with higher well-being scores, but not with anxiety, depression or distress. Women's SI domains were associated with all four outcomes: four domains were significantly associated with lower well-being scores, two were significantly associated with higher anxiety scores, three were significantly associated with higher depression scores, and three were significantly associated with higher distress scores, all independent of functional household latrine access. Women in rural Odisha, India may suffer assaults to their well-being and have higher symptoms of anxiety, depression, and distress when urinating and defecating, even if they have an available facility. These findings suggest that sanitation-related interventions should consider how to accommodate women's experiences beyond excreta management to comprehensively impact health.

Risk profile for drowning deaths in children in the Indian state of Bihar: results from a population-based study

BACKGROUND

We report on incidence of drowning deaths and related contextual factors in children from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy (VA).

METHODS

Interviews were conducted for deaths in 1-14 years population that occurred from January 2012 to March 2014 in 109 689 households (87.1% participation) in 1017 clusters representative of the state. The Population Health Metrics Research Consortium shortened VA questionnaire was used for interview and cause of death was assigned using the SmartVA automated algorithm. The annualised unintentional drowning death incidence, activity prior to drowning, the body of water where drowning death had occurred and contextual information are reported.

FINDINGS

The survey covered 224 077 children aged 1-14 years. Drowning deaths accounted for 7.2%, 12.5% and 5.8% of all deaths in 1-4, 5-9 and 10-14 years age groups, respectively. The adjusted incidence of drowning deaths was 14.3 (95% CI 14.0 to 14.7) per 100 000 children, with it being higher in urban (16.1, 95% CI 14.8 to 17.3) areas. Nearly half of the children drowned in a river (5.9, 95% CI 5.6 to 6.1) followed by in a pond (2.8, 95% CI 2.6 to 2.9). Drowning death incidence was the highest while playing (5.1, 95% CI 4.9 to 5.4) and bathing (4.0, 95% CI 3.8 to 4.2) with the former accounting for more deaths in 1-4 years age group. Sixty per cent of children were already dead when found. None of these deaths were reported to the civil registration system to obtain death certificate.

INTERPRETATION

The findings from this large representative sample of children document the magnitude of and variations in unintentional drowning deaths in Bihar. Urgent targeted drowning interventions are needed to address the risk in children. Gross under-reporting of drowning deaths in children in India needs attention.

Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality

BACKGROUND

Community-led total sanitation (CLTS) is a widely applied rural behavior change approach for ending open defecation. However, evidence of its impact is unclear.

OBJECTIVES

We conducted a systematic review of journal-published and gray literature to a) assess evidence quality, b) summarize CLTS impacts, and c) identify factors affecting implementation and effectiveness.

METHODS

Eligible studies were systematically screened and selected for analysis from searches of seven databases and 16 websites. We developed a framework to appraise literature quality. We qualitatively analyzed factors enabling or constraining CLTS, and summarized results from quantitative evaluations.

DISCUSSION

We included 200 studies (14 quantitative evaluations, 29 qualitative studies, and 157 case studies). Journal-published literature was generally of higher quality than gray literature. Fourteen quantitative evaluations reported decreases in open defecation, but did not corroborate the widespread claims of open defecation-free (ODF) villages found in case studies. Over one-fourth of the literature overstated conclusions, attributing outcomes and impacts to interventions without an appropriate study design. We identified 43 implementation- and community-related factors reportedly affecting CLTS. This analysis revealed the importance of adaptability, structured posttriggering activities, appropriate community selection, and further research on combining and sequencing CLTS with other interventions.

CONCLUSIONS

The evidence base on CLTS effectiveness available to practitioners, policy makers, and program managers to inform their actions is weak. Our results highlight the need for more rigorous research on CLTS impacts as well as applied research initiatives that bring researchers and practitioners together to address implementation challenges to improve rural sanitation efforts. https://doi.org/10.1289/EHP1965.

Understanding and defining sanitation insecurity: women's gendered experiences of urination, defecation and menstruation in rural Odisha, India

BACKGROUND

Research suggests that the lived experience of inadequate sanitation may contribute to poor health outcomes above and beyond pathogen exposure, particularly among women. The goal of this research was to understand women's lived experiences of sanitation by documenting their urination-related, defecation-related and menstruation-related concerns, to use findings to develop a definition of sanitation insecurity among women in low-income settings and to develop a conceptual model to explain the factors that contribute to their experiences, including potential behavioural and health consequences.

METHODS

We conducted 69 Free-List Interviews and eight focus group discussions in a rural population in Odisha, India to identify women's sanitation concerns and to build an understanding of sanitation insecurity.

FINDINGS

We found that women at different life stages in rural Odisha, India have a multitude of unaddressed urination, defecation and menstruation concerns. Concerns fell into four domains: the sociocultural context, the physical environment, the social environment and personal constraints. These varied by season, time of day, life stage and toilet ownership, and were linked with an array of adaptations (ie, suppression, withholding food and water) and consequences (ie, scolding, shame, fear). Our derived definition and conceptual model of sanitation insecurity reflect these four domains.

DISCUSSION

To sincerely address women's sanitation needs, our findings indicate that more is needed than facilities that change the physical environment alone. Efforts to enable urinating, defecating and managing menstruation independently, comfortably, safely, hygienically, privately, healthily, with dignity and as needed require transformative approaches that also address the gendered, sociocultural and social environments that impact women despite facility access. This research lays the groundwork for future sanitation studies to validate or refine the proposed definition and to assess women's sanitation insecurity, even among those who have latrines, to determine what may be needed to improve women's sanitation circumstances.

Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle-income countries

Girls and women experience numerous types of vaginal bleeding. These include healthy reproductive processes, such as menstruation and bleeding after childbirth, but also bleeding related to health conditions, such as fibroids or cancer. In most societies, the management of menstruation is handled covertly, something girls are often instructed about at menarche. The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented. In many societies, cultural taboos frequently hinder open discussion around vaginal bleeding, restricting information and early access to healthcare. Additionally, the limited availability of clean, accessible water and sanitation facilities in many low and middle-income countries augments the challenges girls and women face in conducting daily activities while managing vaginal bleeding, including participating in school or work, going to the market or fetching water. This paper aims to highlight the key vaginal bleeding experiences throughout a woman's life course and the intersection of these bleeding experiences with their access to adequate water and sanitation facilities, information and education sources, and supplies. The aim is to address the silence around girls and women's vaginal bleeding and their related social, physical and clinical management needs across the life course; and highlight critical gaps that require attention in research, practice and policy around this neglected topic of health and gender equality.

Assessing Women's Negative Sanitation Experiences and Concerns: The Development of a Novel Sanitation Insecurity Measure

Lack of access to acceptable sanitation facilities can expose individuals, particularly women, to physical, social, and mental health risks. While some of the challenges have been documented, standard metrics are needed to determine the extent to which women have urination- and defecation-related concerns and negative experiences. Such metrics also are needed to assess the effectiveness of interventions to mitigate them. We developed a sanitation insecurity measure to capture the range and frequency of women's sanitation-related concerns and negative experiences. Research was conducted in rural Odisha, India with women across various life course stages to reflect a range of perspectives. This paper documents the mixed data collection methods and the exploratory and confirmatory factor analyses we employed to arrive at a final measure. The final sanitation insecurity measure includes 50 items across seven factors that reflect the physical environment, the social environment, and individual-level constraints. Most factor scores were significantly higher for unmarried women and for women who lacked access to functional latrines, indicating social and environmental influence on experiences. This measure will enable researchers to evaluate how sanitation insecurity affects health and to determine if and how sanitation interventions ameliorate women's concerns and negative experiences associated with sanitation.